Akweongo et al. Reprod Health (2021) 18:52 https://doi.org/10.1186/s12978-021-01085-z RESEARCH Open Access It’s a woman’s thing: gender roles sustaining the practice of female genital mutilation among the Kassena-Nankana of northern Ghana Patricia Akweongo1* , Elizabeth F. Jackson2, Shirley Appiah‑Yeboah3, Evelyn Sakeah4 and James F. Phillips2,5 Abstract Introduction: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in tradi‑ tions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women’s empowerment and changing gender roles. Methods: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena‑Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. Results: The social systemic influences on FGM/C decision‑making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision‑making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co‑wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. Conclusion: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women’s social networks for offsetting their extended family familial roles in sustaining FGM/C practices. Keywords: Female genital mutilation, Female genital cutting, Social determinants, Gender stratification, Ghana, Sahelian Africa, Harmful traditional practices Introduction zones for this practice than transnational cultural zones. Female circumcision is a deeply rooted custom in many According to the United Nations Children Fund African societal settings. The practice of female geni- (UNICEF), at least two hundred million girls and women tal mutilation (FGM/C) occurs in 28 African countries, are “circumcised” in 31 countries across three continents, although national borders are less relevant to delineating with more than half of these “circumcisions” occurring in African countries [1]. Although the practice has existed for centuries among different groups, beginning in the *Correspondence: pakweongo@ug.edu.gh 1 School of Public Health, University of Ghana, Legon, Ghana 1990s this practice became a matter for international dis- Full list of author information is available at the end of the article cussion [2–4] that continues to the present [5–9]. © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Akweongo et al. Reprod Health (2021) 18:52 Page 2 of 17 The determinants of FGM/C are complex, ranging less clear, however. Instead, international discourse has from socio-cultural norms and economic factors, to assumed the character of exhortations for African gov- health services and hygiene, religion, and gender strati- ernments to take punitive action. In several countries, fication customs amongst others [10]. Gender determi- particularly in Ghana, this perspective has generated reli- nants are typically emphasized by feminist commentators ance on laws that attempt to criminalize the excisor per- who argue that FGM/C is rooted in the need for men to formance of the practice [15]. While laws may have had control women’s sexuality, prevent promiscuity, ensure some impact, and comprise a needed component of pub- premarital virginity, marital fidelity and male sexual sat- lic policy, it is likely that legal sanctions drive the practice isfaction [10]. While this discourse is neither monolithic underground in many settings [16–18], thereby compli- nor unidimensional, FGM/C is widely recognized as a cating efforts to understand the practice and to address consequence of patriarchal oppression and the subjuga- the issue openly in a manner that would lead to sustained tion of women. In concert with this perspective, an advo- social change. As yet, social science has contributed little cate of FGM/C abandonment stated in a formative article to guiding policy and action. Although clarifying social in the 1990s that, “FGM/C is…as a culturally approved dynamics associated with the practice could improve form of violence against women….” [11]. Moreover, its program efforts to eradicate FGM/C, deliberations on practice is known to have detrimental perinatal survival what to do about the practice have been relegated to effects [12, 13]. This finding has fostered a series of rec- essays, critiques or commentaries rather than to empiri- ommendations on what must be done to end the prac- cal research. In particular, there is a dearth of information tice and views about gender roles in sustaining FGM/C. on how sustain the practice gender roles that is derived Although three decades have elapsed since the Hosken from interaction with women and men themselves. As report was disseminated, passages continue to have wide- one writer noted: spread currency nearly three decades later: “Research on female ‘circumcision’ not only has to “To claim- as many African men do (as well as take into account the place of the practice in the cul- male, Western anthropologists)- that women are ture in question but also has to be foregrounded in the ones who perpetuate the operations in societies a multifaceted analysis of the lives of those women where women have never had any choice about any- whose genitals have become the subject of study” thing, least of all their bodies, is ludicrous. Clearly, [19]. it is a matter of sexual politics. As soon as men stop demanding FGM/C as a price for marriage and stop This paper provides qualitative data from field based paying for having their daughters mutilated, the study to explicate the gender dynamics of female cir- operations would stop” [11]. cumcision in the Kassena-Nankana district of northern Ghana, a locality of northern Ghana that is known to It has become the conventional wisdom to attribute have a high FGM/C prevalence [20–23]. Focus group dis- gender stratification as the fundamental exogenous deter- cussions with women and men are employed to illustrate minant of the practice, with many influential observers the gender roles that influence the practice of female cir- concluding that addressing the FGM/C problem requires cumcision in a rural, traditional African setting. It inves- prior social change leading to gender development. In tigates the social, cultural, and physical mechanisms that recent years, the Western media has garnered a plethora sustain female circumcision, with particular attention to of accounts from African women who were subject to the clarifying gender roles in FGM/C decision-making. cruel and inhuman bodily mutilation that FGM/C rep- resents to foster the view that African traditions of male Background dominance and the patriarchal system must change for FGM/C or female circumcision is a generic term for tra- the practice of female circumcision to be eliminated. As ditional practices involving the cutting of female genitalia one respected commentator has noted: leading to the partial or the total removal of the female “In the eyes of many educated people, female genital genitalia or injury to the female genital organ for cultural mutilation is the consequence of a patriarchal and or any other non-therapeutic reasons [6, 24]. Four major polygamous society which has always sought to tame types of FGM/C have been identified [24]. Type 1, also and subdue women” [14]. known as Sunna or “circumcision”, is defined as the par- tial or total removal of the clitoral glands and/or the pre- There is little doubt that feminist discourse on the root puce/clitoral hood. This practice typically represents only causes of FGM/C has correctly identified the underlying a small proportion of women who undergo FGM/C and gender determinants of this harmful practice. Evidence only a few ethnic groups practice it. Type 2 involves the based programmatic implications of this perspective are partial or total removal of the clitoral glans and the labia A kweongo et al. Reprod Health (2021) 18:52 Page 3 of 17 minora, with or without removal of the labia majora. among the Nankam, Kassem, and Builsa ethnic groups Type 2 is also known as clitoridectomy or excision. that comprise nearly all of the population of the district. WHO estimates that about 85 percent of women who A 1995 survey of households in the district revealed that undergo FGM/C have experienced excision [7]. Type 3 77% of 5275 randomly selected women of reproduc- also known as infibulation is the narrowing of the vaginal tive age had undergone FGM/C. In 1995–1996, a clinic- opening through the creation of a covering seal. The seal based study of 398 pregnant women seeking prenatal is formed by cutting and repositioning the labia minora, care found that all three types of FGM/C (circumcision, or labia majora, sometimes through stitching, with or excision, and infibulation) are practiced in the Kassena- without removal of the clitoral prepuce and glands. Type Nankana district. The majority of the women (62%) were 4 involves all other harmful procedures to the female circumcised between 15 and 19 years of age, and by age genitalia for non-medical purposes, e.g. pricking, pierc- 20, 80% had already undergone FGM/C [13]. In a more ing, incising, scraping and cauterizing the genital area. recent study, 29% of 5071 deliveries in the Kassena- Though all the four types of FGM/C are associated with Nankana district were FGM/C associated. Additionally, increased health risks, imminent complications can the prevalence of FGM/C was 61.5% was among women include psychological hazards including pain, trauma, who were over 40 years and 14.4% among those less than and severe physical complications, such as bleeding, gen- 20 years [32]. ital tissue swelling, urinary problems infections, or even Among the Kassena-Nankana, FGM/C usually takes death, as well as indirect psychological effects on wom- place after puberty and before marriage to mark the en’s self-image and sexual lives [3, 25]. beginning of womanhood. After the harvest of the FGM/C is prevalent in the three northern regions early millet in August, circumcision is organized at the of Ghana where the Kusasi, Frafra, Kassena, Nankam, clan or village level. Although, age is a consideration in Busanga, Walla, Dagaabas, Builsa and Sisala ethnic determining eligibility for FGM/C, other factors such as groups reside [26]. In the Upper East Region, FGM/C impending marriage, development of breasts, early men- is prevalent in the Bawku Municipality, Pusiga District struation and growth of pubic hair influence the age at and the two Kassena-Nankana districts [23]. Although circumcision. FGM/C is not a cultural practice in the southern parts Religious belief systems are also a factor in FGM/C of the country, migrants from the three northern regions decision-making. Traditional religion among the Kas- and neighboring Sahelian countries sustain the practice it sena-Nankana involves a process whereby an extended in the areas in where they have settled. The national prev- family patriarch consults with a shaman, termed a alence in Ghana at the time of this study was estimated “soothsayer” for the purpose of contacting ancestral spir- to range between 20 and 30 percent, while the combined its to explain the past, interpret the present or forecast prevalence for Upper West and Upper East regions was the future on matters of current concern to his lineage estimated to be 86% [4]. The prevalence of FGM/C in [33]. Often a girl’s father or extended family head con- Ghana was recently estimated by the Ghana Multi-clus- sults with a “soothsayer” to determine if ancestral sprits ter Survey to be 4% of women of reproductive age [5, designate a girl as being ready for circumcision or eligi- 27]. However, marked regional disparities in prevalence ble for exemption from the practice. Thus, the rites of of FGM/C were documented in this study. In the Upper traditional religion may exempt a girl from circumcision East the prevalence of FGM/C was reported at 27.8%; [33]. However, more typically, beliefs about FGM/C are 41% in the Upper West and 2.8% in the Northern Region. embedded in traditional religion in ways that support the Although the practice has declined in recent years, esti- practice. The piligo (in Nankam) and sogo (in Kassim) is mates show that FGM/C persists as a common practice a terra cotta pottery bowl that is broken in the middle [28, 29]. Although the practice is declining nationally, of the funeral procession of a deceased woman by the there are pockets of rural areas where the practice is still daughter. It is first, a sign of farewell to the woman. Sec- prevalent. In rural areas women are three times as likely ondly, it shows that the woman was fertile in her lifetime to have experienced FGM/C than women living in urban and had children. Most importantly, the breaking of the areas [30]. In the Pusiga district of the Upper East region ‘piligo’ (or sogo) is believed it is to enable the deceased of Ghana, 62% women report having undergone FGM/C woman to continue her duties as a woman in the next [31]. world. A woman who does not have a daughter to do this In 1995, the Navrongo Health Research Centre (NHRC) for her is believed to roam in the ancestral world hungry initiated research aimed at describing and understanding and thirsty and is not welcomed by her ancestors. the practice of female circumcision in Kassena-Nankana Discussion of FGM/C in Kassena-Nankana district district of the Upper East Region. Studies of various sub- reveals that adult women and men justify the practice groups in the district revealed that FGM/C is practiced as a mechanism that is believed to instill societal morals Akweongo et al. Reprod Health (2021) 18:52 Page 4 of 17 and values in a young girl before she assumes a larger Categories of potential respondents could be readily role in the community as wife and mother. Tradition- compiled for this study for Demographic Surveillance ally, after the harvest of the early millet in August, girls System (NDSS) at the Navrongo Health Research Centre who are deemed physically mature are organized to (NHRC) system delineates groups of extended families undergo circumcision by an excisor who visits the vari- compounds into clusters that were stratified into zones ous villages. FGM/C is mainly performed on girls rang- from the north, south, east and west sub-districts of the ing in age between four and 14 [34]. Studies suggest that district for random selection, based on NDSS house- most Ghanaian girls who undergo the procedure are were hold enumeration numbers [36–38]. Based on randomly under age five when FGM/C is conducted [26]. However, selected household numbers, Field staff of the NDSS, in some cases, FGM/C is performed on girls immediately known as a Community Key Informants (CKIs) identi- prior to marriage [34]. Elderly women who are present fied the precise location of the selected compounds was at the circumcision ceremony will encourage the young known. NDSS staff visited sample households and invited girls to be brave during the procedure. Afterwards, the members to participate in focus groups according to girls are assembled in one compound under the guid- designated gender and age groups represented by each ance of two or three elderly women who nurse their sores session. This procedure was intended to identify at least while providing education on societal values, norms and one participant per compound. Sample substitution was morals. The girls who have undergone the circumcision unnecessary because all sample compounds yielded one prior to marriage are taught how to cook and how to be a or more individuals who agreed to participate in discus- wife and member of their husband’s extended family [13]. sion sessions. Two focus group discussions comprising At menarche life skills are discussed and the community a male and female group each was held in each commu- members are expected to recognize circumcised young nity. Written and oral informed consent was sought from woman as a person who is allowed to receive marriage participants who participated in the study. A total of 22 proposals. focus groups were selected, each ranging in size from 8 to 10 participants. The interviews were conducted either in Kassim or Nankam, the two main language groups in the Methods district. The interview guides were developed in English The Navrongo Health Research Centre launched an and the translated into the two languages and back trans- experimental study to test hypotheses about means of lated into English to ensure translation accuracy. reducing the incidence of FGM/C through social action Participants for fifteen focus group discussions were and community outreach. The Navrongo program devel- selected based on the following age and sex criteria defin- oped in collaboration with local government and non- ing panels of adolescent boys and adolescent girls (aged governmental organizations to change the behaviors and 20–24); reproductive aged men and women (aged 26–34 attitudes associated with FGM/C through education to and 35–49) and older men and women (aged 50 and all sectors of the community and the provision of liveli- above). This classification was sufficient for represent- hood activities for adolescent girls. A cohort of adoles- ing the experiences and beliefs associated with FGM/C cent girls in six villages were exposed to different social as they differ among age and gender groups. Participants action programs and observed over a five years period of for seven of the focus group discussions were females time [35]. The current study was the component of this selected according to age and marital status categories investigation that provided a baseline appraisal of social defining polygamous unions (aged 25–35 and 35–49) and determinants of FGM/C in study areas. single unions (aged 25–35 and 35–49). There were two Data collection. This paper is based on the analysis adolescent female groups and 2 adolescent male groups of twenty-two focus group discussions with men and (20–24). Female marital status was chosen as a selec- women in 11 communities of the Kassena-Nankana dis- tion criteria based on the assumption that having co- trict of northern Ghana: Mirigu, Paga-Bagtua, Chiana- wives will have an observed effect on circumcision status Katiu, Natugnia, Pungu, Nayagnia, Gomongo, Mayoro, after marriage. There were 11 female groups and 11 male Janania, Gongnia, Chiana-Kayoro. Sessions were con- groups of various ages and marital status. vened prior to the implementation of social interventions A moderator and a note taker were present at each for mobilizing community support for FGM/C eradica- discussion. The moderators’ questions and participants tion. Since open discussions of FGM/C with different answers were recorded on an audiotape. The interview groups in the community is common, focus group dis- guides were pretested in the central zone of the district. cussions (FGDs) were deemed to be an appropriate form The FGDs were conducted to obtain insights on how of eliciting views on the topic from a wide array of social engrained the practice of FGM/C was, social norms gov- groups. erning and sustaining the practice, perceptions of change A kweongo et al. Reprod Health (2021) 18:52 Page 5 of 17 in the practice and the extent of participant’s understand- “…if the man did not support, her daughter could ing of the health risks and law banning the practice of not be circumcised. If your father did not give his FGM/C. Participants were also invited to discuss factors consent, you could not be circumcised…” which could facilitate social action for eradicating the practice. A transcriber, who was not present at the time —Paga Bagtua, woman, aged 25–35, single union of the discussion, described the data from the audiotapes Circumcision is performed in the post harvest season. and translated discussions into English before analysis of In the months preceding the harvest, women consult the transcripts. Data were entered with a conventional with their peers in neighboring compounds to discuss word processor, stored electronically, and dispensed plans for undergoing circumcision for girls in the com- to the research team without labels that could identify munity who are considered ready for the procedure. the participants. Analysis embraced the conventions of After a decision is reached to proceed with circumci- grounded theory analysis whereby verbatim transcripts, sion, girls are informed that circumcision rites will be which were coded by key words, categorized into specific performed. Respondents in all FGD panels of this study themes and utilized for the extraction of key themes [39]. denied that any form of compulsion was employed. Quotes representing these key themes are presented in Instead, they stressed the view that girls are asked to this paper. All quotes chosen were extracted in a man- decide on whether or not to undergo the procedure. It is ner that portrays discussion that was common to all of nonetheless clear from this study that personal agency in the focus group sessions. In the presentation that fol- a girl’s FGM/C decision-making is more an illusion than lows marital status has been noted with each quotation. reality. Instead, powerful social pressure is exercised by Although quotes that are selected are chosen to portray key players: mothers, mother-in-laws, compound heads the general view of the focus group participants, citations and their wives, fathers, husbands, co-wives, peers and do necessarily represent views of all individuals. Care birth attendants. has been taken to ensure anonymity, although coding Once a group of girls have been identified the parents recorded age groups and community where sessions were and community leaders extend an invitation for a local convened. Occasionally words or phrases in parenthesis excisor to circumcise their daughters. Other families are added to clarify the meaning of words and statements from neighboring towns and villages who hear about the of the quotes. arrival of the excisor may also ask that their daughters join the group of girls undergoing the circumcision. Both the mother and the father give the excisor different forms Results of payment. Payment may range from cash to goods. The mother is usually responsible for providing cloth, cala- The FGM/C decision‑making process Both men and women support the notion that there are bash, shea nuts, while the father provides cash, fowls or distinctly different parental roles in the sequence of deci- millet. sion leading to the practice of female circumcision. Typi- “….she provided fibre threads [cloth], calabashes and cally, the mother takes primary initial responsibility for shea-nuts. The man only gives a fowl….” encouraging her daughter to be circumcised: —Paga Bagtu woman, aged 25–35, single union “Your mother would always tell you that your col- leagues are going to get circumcised, so you should “When I have my daughter, I make her get circum- join them. After you have gone, she would then tell cised and all the fines are mine to pay. I will have to your father, and he would get ready with a fowl and give some fowls, guinea fowls, and millet.” millet to pay the practitioner.” —Chiana-Katiu man, aged 35–49 —Mirigu woman, aged 35–49, single union Thus, the father or compound heads play a role in the The role of men initial decision to undergo FGM/C and are sometimes Husbands and fathers each have specific roles to play in asked to permit the circumcision, but the father’s actions female circumcision. Focus group discussions indicated are undertaken in response to decisions taken by women. that fathers rarely exert pressure on their daughters to Once a man is asked to sanction FGM/C, he consults be circumcised. The role of husbands is even less pro- with the soothsayer, and when the consultation is com- nounced than the father’s role. Nonetheless, men play a pleted, the father or compound head informs the girl’s significant role in the decision-making system. mother of the outcome of the consultation. Thus, while Fatherly duties It is evident from the FGD data that men men do not initiate FGM/C decisions, their concurrence are not instigators in the circumcision of their daughters. is essential. As one woman noted: Fathers grant permission for their daughters to undergo Akweongo et al. Reprod Health (2021) 18:52 Page 6 of 17 circumcision, but seldom encourage their daughters to Once a girl has been circumcised, either before or undergo circumcision. When a girl is very young, her after marriage, her father is eligible to receive a full bride father consults with a soothsayer to determine whether wealth payment. or not his daughter should be circumcised. In the ani- mist traditions of the Kassena and Nankana, women are “In the past when an uncircumcised woman got believed to be the property of a lineage and lineal gods married, her parents could not claim her dowry. So are the guiding spirit of all individuals. Women are not if she wanted to get married then she had to get cir- allowed to consult with soothsayers. However, men often cumcised.” seek spiritual guidance in religious séances. A soothsayer —Chiana Katiu woman, aged 26–34 is a spiritual leader who performs traditional rites that are A father of an uncircumcised girl may have no right believed to establish communication with ancestral spir- to bride wealth payments. Still, if a dowry is given to an its. In this course of consultation, a girl may be exempted uncircumcised girl, her brothers may benefit from the from the practice if the soothsayer consultation reveals bride wealth while her parents do not. Since the bride- that she belongs to a god who does not want her to be wealth payments are obligatory if a bride is circumcised, circumcised. When eligible girls are old enough for cir- economic incentives derived from bridewealth undoubt- cumcision, fathers pay fees to the circumciser: edly influence the beliefs and motives of the father and “Men do not insist at all but it is the mothers.” other men in the family.Nonetheless, the economic role of FGM/C in bride- —Natugnia woman, aged 35–49, polygamous union wealth appears to be eroding, as suggested by the focus “If there is pressure on the girls to get circumcised group discussions. It is apparent that circumcision status then I feel it is the mothers because men do not is less of a determining factor in the payment of bride really care about the practice”. wealth fees now that it has been in the past.The risks posed to the man’s extended family by wife’s —Pungu man, aged 26–24 sexual desires Men voiced strong opinions about the Some women reported that fathers had to be consulted relationship between FGM/C and female sexuality. Men before the act, though in some cases, circumcision took often noted that circumcision was a social necessity in place without the father knowing about it. In such cases, the past because wife’s sexual desires were a threat to fathers are asked to pay fees afterwards. A compound harmony in the extended family. head or family head may also be responsible for the cir- cumcision fees for girls in his compound. “What I know is, our grandparents could travel for long without returning, by the time they are back, “It is the compound head who gives the millet and their wives would have had contact with other fowls to be given to the circumcisor…” men. So it was done to reduce the sexual anxiety in women”. —Nayagnia man, aged 35–49 – Nayagnia man, aged 35–49 “Sometimes the compound heads do not even know Such beliefs and FGM/C values may be grounded in that the girls have gone for the circumcision. It is African customs of polygamous marriage and family when they are asked to pay some fees that they get to building that is associated with weak emotional bonds know about it.” between spouses and an element of spousal mistrust —Chiana-Katiu men, aged 35–49 [40–42]. FGM/C is perceived by men as a mechanism Marriage of daughters:It is the responsibility of fathers that is needed to control sexual desires or urges (nyane) to arrange the marriage of daughters. In the tradition of in women, thereby inhibiting sexual rivalry among co- the Kassena-Nankana, a man seeking a husband for his wives. This is because once a woman’s interest in sexual daughter will approach fathers of young men to discuss pleasure and ability to enjoy sex is decreased, she is likely marriage and bridewealth. In the past, circumcision sta- to be unfazed by the sexuality of her co-wives. In keeping tus was an important prerequisite to marriage. However, with this perspective, some men stated that they wanted this has changed: their wives to be circumcised to prevent sexual liaisons between their wives and other men: “[Before]…it is only when the girl is circumcised that she can get married but now the men are impatient “I will like my wife to go through circumcision. There and do not wait for all the customs [FGM/C] to be is the belief that when she is not circumcised, she has done”. ‘nyane’ (sexual urge), sometimes in her that makes her want to sleep with other men.” —Pungu man, aged 26–34 A kweongo et al. Reprod Health (2021) 18:52 Page 7 of 17 —Gomongo adolescent male, aged 20–24 Women, concur with the notion that men do not really Men thus see women’s sexual urges as dangerous care about FGM/C: and destructive to the extended family. So extreme are sentiments about this danger that some men believe “…the men do not care because they are not insulted that unbridled sexual passion can even kill plants. For [if their wife is uncircumcised]. What he needs is the example, an uncircumcised woman’s nyane can cause vagina, and the clitoris does not block his interest, so calabash plants to wither and die: he does not mind whether his wife is circumcised or not.” “I have seen it with my naked eyes before (uncir- cumcised woman crossing a calabash plant and —Gongnia middle-aged man (age unknown) harming it). This is because since she is not circum- While pressure may arise from the husband’s house- cised, she is still a child and she has a lot of nyane hold, the husband himself may not have a direct influence in her, which destroys things.” on his wife’s circumcision status, even after marriage. —Gomongo adolescent male, aged 20–24 “It is because of the insults. It isn’t your husband Several discussions nonetheless revealed that this who will insult you. It is your co-wives and your traditional view of the dangers of sexuality has shifted. husband’s mother [who will do so]. If you are staying Although some FGD participants believe that female with only your husband, there won’t be any problem.” sexuality is dangerous more participants believed that —Gyanania woman, aged 35–49, polygamous union intercourse with uncircumcised women would be more Discussions thus suggest that for men, the various fac- enjoyable and exciting than intercourse with a circum- tors that explained their support for FGM/C in the past cised woman. have changed in present times. While men appear to “Some men want the two for variety, but the old embrace the notion that a circumcised woman is valued type needed the circumcised ones because they for her fidelity this cultural perspective is increasingly were the traditionally obedient ones. Today, no offset by males’ preference for uncircumcised women. man would go for a circumcised woman, because In the Kassena-Nankana tradition, the relationship they feel they are not as exciting as the uncircum- between FGM/C and girl’s chastity enhances the cir- cised ones.” cumcised woman’s ability to find a husband. However, in present times, the weak significance of FGM/C for hus- —Nayagnia man, aged 35–49 bands has diluted the relationship between FGM/C and Women and adolescent girls also stated men now pre- marriage. As many men admit their indifference towards ferred uncircumcised women: marrying an uncircumcised or circumcised woman; “Most men prefer uncircumcised women especially and, an increasing number of younger men preferring when it comes to sexual intercourse. They claim to marry uncircumcised women, a husband should no uncircumcised women are better in bed as compared longer expect to pay a high bride price for his bride based to circumcised women.” on her circumcision status. As discussed earlier this will in turn affect the economic incentives for the girl’s father —Mayoro adolescent woman, aged 20–24 who no longer can expect a high bride wealth for his cir- The husband’s contribution Some men express the view cumcised daughter. that circumcised brides are more wholesome and more likely to be a virgin, particularly if the girl had no objec- “…formally if you went courting and the lady wasn’t tion to undergoing FGM/C: circumcised she would be told to do it now. When she is finally circumcised she would be made to “If she refuses[to undergo circumcision], the father choose from amongst the contestants (boyfriends), will say that she is not a virgin that is why she has but today the men just go and take the girls away refused to be circumcised.”. without doing the customary rites, so that is why you find men with uncircumcised wives.” —Gomongo adolescent boy, aged 20–24 Most men stated that they did not care if a wife was —Pungu men, aged 26–34 uncircumcised or not. In many cases, men do not know if In summary, the role of men in sustaining FGM/C their bride has been circumcised. is important, but remote and eroding in the causal sys- tem. Chiefs exercise a role in deciding on the legitimacy “When a man is going to marry a woman, who will of village activities. If an excisor visits a village for the know whether the woman is circumcised or not?” purpose of performing circumcisions, he is obligated by —Janania man, aged 50 + custom to visit the chief. A council of chiefs and elders Akweongo et al. Reprod Health (2021) 18:52 Page 8 of 17 cannot ban the practice of FGM/C, but they can dimin- Maintaining mother to daughter traditions. Women ish access to excisors, alerting community members to point out that if the mother had undergone circumcision, the risks associated FGM/C, requiring parental travel and daughters should also expect to undergo the practice. costs that would not otherwise arise. And they can affect Since circumcision has existed for generations respond- the climate of opinion about FGM/C through comments ents did not see any reason why girls today should not at community gatherings. Male leaders are rarely propo- be circumcised if their mothers and grandmothers were nents of FGM/C, however, men in general have a minor able to endure the practice. Elderly women consistently role in sustaining the practice. Economic incentives that support the practice. This is illustrated by the following are implicitly derived from bridewealth are being weak- statement: ened by changes in male values and marriage prefer- ences. As a consequence, most men in this FGD study “In the past, we were circumcised, but today we have were open to the idea of change. been told that we should not circumcise our daugh-ters. To me, I think the practice is good. Our grand- mothers have all been circumcised, so why should it be stopped now?”. The role of women Maternal care Women view their role in fostering the cir- —Chana-Kayoro woman, aged 50 + cumcision of their daughters as a part of their responsi- bility as good mothers. Therefore, mothers try as much “I think it [FGM/C] should be continued. I have no as possible to ensure that their daughter gets circumcised clitoris so why is it that my daughter should not be so that a mother will retain a respectable status among circumcised? My daughter will be circumcised.” the women in the community. A mother who arranges —Minigu woman, aged 50 + the circumcision of her daughter has fulfilled her respon- The younger women held the contrasting view that, sibilities as a good mother. The practice is associated from their experience, there are health risks associated with womanhood and the readiness for marriage. Tradi- with the procedure. tionally, as aforementioned, young girls learned specific skills during the circumcision ceremony. However, even I have undergone FGM/C, but I will not advice any in modern times, many women subscribe to the norma- girl to undergo it following the rumours we hear tive value of circumcision in the belief that a girl will be these days. Today, it is death, tomorrow, it is loss of considered a woman only after circumcision. Therefore, a blood and so on. woman wants her daughter to be circumcised so that she —Mayoro adolescent female 20–24 years is thought of as a responsible mother who has raised her Moreover, participants noted that parents who compel daughters properly. daughters to undergo FGM/C are liable for arrest if law “To be precise it is the mothers who push their enforcement officers are aware of this action: daughters to circumcise because if your daughter is I think that policemen should be brought here to not circumcised, the mother would be seen in the vil- arrest practitioners and parents who want to force lage as an irresponsible mother. So if a mother does their daughters into FGM/C. all that is necessary for a daughter without circum- cision, she has failed in bringing up her daughter —Natugnia adolescent female 20–24 well… Mothers who witness their daughters being If most girls are educated, they could explain to their circumcised, are made proud and respected for the fathers about the law banning circumcision and this good upbringing of their daughters.” would make them afraid of going to jail. So no girls will be forced to undergo FGM/C. Mayoro adolescent female —Gongnia woman, middle aged 20–24. In polygamous households, tensions can arise if one Maternal funeral rites. Many women feel it is especially woman has not circumcised her daughters while her co- important to circumcise their first-born girls because wives have circumcised her daughters. Therefore, when a first-born girl plays an important role in her mother’s a woman arranges the circumcision of her daughter, she funeral rites. Among the Kassena-Nankana, daughters also eludes ridicule from the co-wives and her children. carry their deceased mother’s personal effects in the “Mothers can force their daughters to be circum- funeral procession. Her personal effects will include the cised just because her rivals [meaning: co-wives] are piligo, which is a pot that a woman keeps as a safe for insulting her and her daughters.” all her valuable and emergency items. Only circumcised girls are allowed to participate in her mother’s burial. —Gomongo adolescent boys, aged 20–25 For this reason, mothers often insist that her first-born A kweongo et al. Reprod Health (2021) 18:52 Page 9 of 17 daughter is circumcised for to be buried without a wives. They will insult you in such a way that even daughter’s participation would bring shame on the fam- if you think you will die when you do it, you will ily. As one woman stated, her mother insisted on having still do it.” her circumcised so that her that her own funeral rites will be proper: —Gyanania woman, aged 35–49, polygamous unionAbout one-third of marriages in the Kassena-Nankana “I got circumcised because my mother wanted me to district are polygamous and many women in monoga- take an active part in her funeral preparation when mous unions anticipate the eventual onset of polygyny. she dies.” Women are particularly sensitive to pressure from co- —Natugnia woman, aged 35–49, polygamous union wives to undergo circumcision, which often takes the But, once the eldest daughter is circumcised a woman form of circumcised co-wives flaunting their status and will not be so concerned about arranging the circumci- openly insulting uncircumcised women in their com- sion of her other daughters. pound. This can create a tension in the household, which an uncircumcised woman feels she can mitigate “The mother also sees it as very necessary for her first by undergoing the procedure. She may seek to undergo daughter to undergo FGM/C. She will not be much FGM/C even if she has married a husband who harbors worried if only her first daughter undergoes FGM/C, no particular interest in her circumcision status: leaving the younger ones.” “Look! My friends, co-wives can force you to circum- —Mayoro adolescent woman, aged 20–24 cise…I have seen co-wives being mishandled because In contrast, male groups discuss the significance of they are not circumcised. So the impact is felt more undergoing circumcision, not in respect to parental bur- from the co-wives.” ial rites but for rather for the girl’s own burial and ulti- mately, her role in the after life: —Natugnia woman, aged 35–49, polygamous unionWithin the husband’s house, an uncircumcised woman “Another tradition is that, when the woman dies living among the circumcised is not even considered a uncircumcised, she would be sent off without house- woman. Any slight provocation will incite many insults hold accessories like, calabashes and pots.” referring to her circumcision status. This limits her abil- + ity to assert her role in the husband’s house and challenge —Paga male, aged 50 her rights as a married woman. “It is believed that when a woman dies uncircum- “Rivals [a term connoting dysfunctional co-wife rela- cised, she would be buried like a man, to prevent tionships] see their uncircumcised colleagues as not that they circumcise, that is what I have also heard.” being women and at the least provocation she insults —Nayagnia male, aged 35–49 her ‘Momte giee’ [translation: protruding clitoris]… Marital life. In the parental home, kin, parents, or peers Rivals would also not give you any rest but would can exert pronounced social pressure on a girl to undergo always be insulting you. In fact, there are times that circumcision. Once a woman is married, however, the a newly married woman cannot go to the backyard FGM/C opinion leaders in her father’s compound cease garden because there is that belief that when she to have any influence whatsoever. Instead, the women of crosses a calabash plant it would die or it would not the husband’s home often have an even greater influence bear fruits just because she is not circumcised.” on the decision to undergo circumcision than her par- —Gongnia woman, 35–49 ents had during her adolescence. As the following state- In general, it should be noted that the pressure is par- ments suggest, the pressure to undergo circumcision can ticularly difficult to fend off when a junior wife is living be unbearable for a young woman who has yet to have with co-wives. A married woman’s decision to undergo children. circumcision is viewed by discussants as not a prac- “Maybe the pressure at her parent’s home to get cir- tice done under duress, but is a decision women take in cumcised was not very great. But in the husband’s response to peer pressure from co-wives or the wife of home, the mother-in-law and co-wives would not the compound head: take it easy, they will insult her thus pushing her to “I feel the impact to circumcise is greater from the get circumcised.” peer group. If you are married, [pressure is from] —Natugnia woman, aged 35–49, polygamous union your fellow wives. If you are a girl, your colleagues. The rest can complain [about FGM/C to you] but “It is always from your mother-in-law and co- they cannot force you.” Akweongo et al. Reprod Health (2021) 18:52 Page 10 of 17 —Natugnia woman, aged 35–49, polygamous union are encouraged to eschew individualism and honor cor- In most households, a married woman can expect to porate familial values and group participation. Being live and spend considerable time with her mother-in- excluded from a peer group is particularly feared, since law. A mother-in-law who values circumcision is likely to adolescent girls have little autonomy and social inter- ostracize an uncircumcised daughter-in-law. A mother action in highly valued. Adult women were consistent who is circumcised usually wants her son to marry a in expressing the view that peer pressure to undergoing woman who is circumcised in the belief that she will be a circumcision was intense, mainly because circumcision good, upstanding wife for her son. is necessary for preventing familial discord: “The mother-in-laws would not leave you alone, they “Living with circumcised women is very unpleas- keep attributing every bad thing in the compound to ant, every where they go your name will be men- you having a clitoris. So by all means to become free tioned as one of the women who have not been cir- of those blames, you simply [get] circumcised.” cumcised. Mockery will be very common and you —Natugnia woman, aged 35–49, polygamous union can never feel free conversing with them because you would be seen as a social outcast. That is why “It is the husband’s mother who brings about the every woman was advised to circumcise, in order whole problem. When she insults you and you can- to be able to join the women fraternity.” not endure it you will have to get circumcised.” —Natugnia woman, aged 35–49, polygamous union —Mirigu woman, aged 50 + Thus, an uncircumcised woman can face daunt- “It is true, when you are an uncircumcised woman ing social pressure from other married women. Older in a group of circumcised women, you will never women, and most particularly wives of compound heads, feel comfortable, because they keep looking down exert a profound influence on FGM/C decision-making upon you. You had to get circumcised to be part of among all women in the compound. During childbirth, the group.” birth attendants are commonly the older women in the —Chana Katiu woman, aged 25–34 house. Older women who assist in delivery often attrib- Expressions of pressure to undergo circumcision ute problems associated with delivery to not undergoing after marriage, however, are sometimes less a matter circumcision and sometimes spread rumors about the of antagonism than a form of sisterly social support. circumcision status of young mothers: “Friendly advice” maybe extended to young women by “Some circumcise after marriage because when she peers, a mother in law, or co-wives who warn young is in labor, the attendants say they saw a piece of women about the ostracism that an uncircumcised wood and not a child. Some will also say they saw woman will face in the future. The following statements two children. Thus, out of anger, she could undergo express this view: circumcision.” “When you are sick, your husband’s mother is con- —Gomongo adolescent male, aged 20–24 cerned and tries to make you feel well. In the same way when you are uncircumcised, your husband’s “You can not tell from their faces, but when she mother gets you circumcised so that you can move becomes pregnant and is in abor, those who would and speak freely with members of the household.” attend to her would know and through that every- body in the village would get to know.” —Chana-Kayoro woman, aged 50 + —Gongnia woman, 35–49 “Sometimes, too, when other people keep insulting Peer support for FGM/C. Women of all ages expressed you, good co-wives may advise you to get circum- the view that circumcision is prerequisite for peer cised.” social acceptance in extended households. This senti- —Chana Katiu woman, aged 25–34 ment becomes manifest in household discussion of cir- The role of peers and colleagues appears to have the cumcision as a mark of womanhood. An uncircumcised greatest a influence immediately prior to marriage; and woman is alienated among women inside or outside the co-wives have the greatest influence immediately fol- home, and made to feel that it is imperative that she lowing marriage. Peers and colleagues may influence a becomes circumcised to be socially accepted. If she is girl to the extent that a girl will undergo circumcision not circumcised, she can expect to be socially maligned without her parent’s encouragement or active support. by her peer group. Among the Kassena-Nankana, girls Young respondents elaborated on this peer pressure to undergo circumcision. A kweongo et al. Reprod Health (2021) 18:52 Page 11 of 17 “Sometimes the girls themselves might demand to be in general and the decline in FGM/C was perceived to circumcised. This could generate from the fact that be contributing to social malaise. Both female and male their colleagues are circumcised and thus tease them respondents nonetheless suggested positive reasons when they are together.” for this trend, which ranged from health concerns to —Gomongo adolescent boys, aged 20–24 the notion that circumcised women are often sought by men to the general sense that circumcision is “out- “It could also be your colleagues. They can mock at dated”. Some of this change in social perception is based you and that will compel you to go in for FGM/C on misinformation, and some is based on actual factors since you will not like to be a laughing stock and regarding health problems associated with FGM/C. branded as weak…They refer to you as a man and More typically, however, health concerns reflected a call you ‘long clitoris’. This annoys you and gives you blend of information and misinformation. An example the urge to go and get circumcised.” includes the perception that a decline in the nutritional content of food is believed to make it harder for women —Mayoro adolescent girls, aged 20–24 to recover the blood that they lose during circumcision. While it is apparent that FGM/C is not a practice that is undertaken by overt force, it is abundantly clear that “…now that the food we eat is not very nutritious adolescent girls face daunting social pressure from moth- as before, we can not risk wasting blood through ers, other adult women in the extended family and peers. circumcision.” The actors in the FGM/C decision-making system change when a young woman marries, and her autonomy on —Natugnia women, aged 35–49, polygamous union this issue typically diminishes further. A young woman Men who opposed the practice were sometimes cog- “acquired” through family exchanges has little status in nizant of the health implications of practicing FGM/C her new household and must demonstrate devotion not such as the effect of FGM/C on childbearing, but only to her husband, but also to his complex extended expanded this notion to include child health more gen- family. Given the FGM/C-supportive social structures erally. For example: that young women must operate in, it is little wonder that “I prefer the uncircumcised [women] because the practice has remained pervasive. Although circum- whenever she brings forth, you will notice that the stances under which circumcision occurs vary all over child is beautiful and healthier than the circum- African countries, the concept of force merits some clari- cised woman’s child.” fication in this context. Social forces that impinge on a young woman’s FGM/C —Gomongo adolescent male, aged 20–24 motives are complex, robust and pronounced. In general, These views demonstrate the need to provide effec- women have a more active role in sustaining various roles tive health education about the effects of FGM/C in in the practice of FGM/C than men. As mothers, daugh- ways that combat misinformation about FGM/C as ters, peers, and co-wives, women are socially invested in well as provide a better understanding of why FGM/C the continuation of the FGM/C practice. A mother who should be prevented. influences her daughter to undergo circumcision avoids Ideational change Focus group respondents often ridicule of herself and her daughter and insures that her noted ways in which FGM/C norms are changing. own funeral rites will be performed correctly. Similarly, Although this is not the predominant view some peers and co-wives also avoid this derisive behavior by women and many men stated that FGM/C is outmoded encouraging a woman to undergo circumcision. Once a and that women who practice it are illiterate and igno- woman undergoes circumcision, she has the right and rant. This view was expressed by a middle aged Natug- capability to negotiate her role in her community of nia woman: women and an element of dignity in her extended family “Whether married or not, circumcision is not prac- that she would otherwise lack. ticed any longer. Only the illiterates stay indoors and still circumcise. If you assemble all girls here, the majority are not circumcised.” Evidence of preferences that oppose FGM/C Health concerns. Despite considerable evidence of the —Natugnia woman, aged 35–49, polygamous union continuing social value of FGM/C, there is some indi- Women expressing this view also acknowledge cation that support for the practice is eroding and that that the pattern of mockery that was once directed to prevalence of circumcision may be declining. It was a the uncircumcised is now more typically expressed common theme in discussions that FGM/C is declin- as mockery against those who are circumcised. For ing as part of the erosion of wholesome family values example, a respondent claimed that women who are Akweongo et al. Reprod Health (2021) 18:52 Page 12 of 17 circumcised are now lectured about the practice when is a woman’s matter that is sustained and promoted by they encounter health workers. mothers and mothers-in-law as one woman noted: “These days when you are circumcised and you are “The men would never open their mouths that a in labor at the hospital, the nurses insult you so woman should [be] circumcised. It is a woman’s much.” thing. The pressure comes from them.” —Gongnia woman, 35–49 —Natugnia women, aged 35–49, polygamous union Some women cited that they have experienced being ridiculed for having an “empty vagina:” Conclusion “These days if a circumcised woman tries to look Since the practice of FGM/C is grounded in customs per- down on an uncircumcised one, she will be seen as petuating the subjugation of women, it is widely assumed ignorant or even an illiterate, because the practice that male preferences and FGM/C beliefs are the deci- is outdated now. So when you are insulted that you sive influences sustaining the practice of FGM/C in tra- have a protruding clitoris, also return the insult by ditional societies. This investigation lends support to this saying that she has an ‘empty vagina’.” perspective in the sense that the male dominated patri- archal system constrains women’s autonomy and leads to —Natugnia woman, aged 35–49, polygamous union a system of social influence that a young woman is pow- Still, while many circumcised women wanted their erless to engage. But to conclude the analysis with this daughters and other women to undergo circumcision, observation would do little to elucidate what happens in some professed a sense of opposition against the prac- the daily lives of women that sustain FGM/C and what tice. Reasons cited were usually health related, though must be done to accelerate the erosion of this harmful some circumcised women expressed regret that sexual practice. relations were enjoyed more by uncircumcised women. “We those who are circumcised don’t enjoy sex as The FGM/C decision‑making system much as the uncircumcised women. We never knew The relationship of factors in the FGM/C decision- it was harmful to us or we wouldn’t have done it.” making system are illustrated in Figs.  1 and 2. Two fig- ures are necessary in keeping with our observation that —Gyanania women, aged 35–49, polygamous union a young woman seeking to avoid FGM/C must run the “I have been circumcised, but when I have a gauntlet of two complex systems of social pressure, one daughter, I will not allow her to get circumcised, dominated by her mother before marriage, the second we were circumcised because we were ignorant.” dominated by her mother-in-law after marriage. As the diagrams show, most men in study communities where —Mirigu old women, aged 50 + the practice FGM/C is extensive do not play a prominent Thus, mockery among women is the main mechanism role in FGM/C decision-making. However, the impor- through which social pressure is exercised. Whereas tant exogeneous role of the patriarchal system should not ridicule was once directed to fostering FGM/C, it is be dismissed as inconsequential. Both men and women now sometimes directed to deriding the practice. While are players in the institution of FGM/C, but the role of fears of women’s sexuality once provided a rationale for women is proximate and pronounced. As the figures FGM/C practice, there is evidence that sexual percep- show, women are the main perpetrators of the FGM/C tions of uncircumcised women may be contributing to practice. Male leaders play an important role in the legiti- changing social acceptance of uncircumcised women. mization of FGM/C- most excisors are men and religious But foremost, FGM/C no longer seems to be an issue rites prior to the FGM/C practice are performed by men. that is encouraged by men and their preferences or dic- The important, but exogenous role of men appears in the tated by their preferences. Moreover, many women are diagrams as male influences on the left hand side of the cognizant of the fact that men have become ambiva- diagrams. lent about circumcision. Results of this investigation Figure  1 demonstrates the complex and systemic thus, challenge the view that women seek FGM/C in nature of social support of FGM/C. First, there is a strong response to the dictates of men. Instead, women sub- component of gender stratification in the social forces scribe to the notion that circumcision is the concern of that sustain female circumcision. Gender differentia- women only. Men have a role in the FGM/C decision tion of the influences reflects the investment and bene- making system; but all FGD age and gender groups fits expected of both men and women. Fathers stand to lend emphatic support to the proposition that FGM/C gain monetarily from a daughter’s circumcision because of the bride wealth custom. However, the role of the A kweongo et al. Reprod Health (2021) 18:52 Page 13 of 17 Female social opinion Female peers Male social opinion leaders leaders (teachers, (inside (teachers, health workers, health workers, compound) poli cians) poli cians) Wife of Mother Compound head compound head Chief Father Co-wives Elders Uncircumcised adolescent or young Female peers adult woman (outside compound) Excisor Legend: Lines of decision influence Male peers (outside Male directed: StrongMale peers (inside compound) Female directed: Weakcompound) Fig. 1 Lines of relative social influence on FGM/C decision making among adolescents Female social opinion Male social opinion leaders leaders (teachers, (teachers, health workers, health workers, poli cians) poli cians) Mother of Wife of husband Compound head compound head Chief Husband Father of husband Co-wives Elders Uncircumcised bride Male peers (inside compound) Excisor Legend: Lines of decision influence Male peers (outside Male directed: Strong compound) Female directed: Weak Fig. 2 Lines of relative social influence on FGM/C decision making among newly married Akweongo et al. Reprod Health (2021) 18:52 Page 14 of 17 bride wealth in marriage is diminishing and the value of Discussion FGM/C in determining bridewealth is eroding. These This study aimed at clarifying the gender dynamics that changes may be occurring at an even faster rate than underlie social support for female circumcision in the change in FGM/C practice [43, 44]. Nonetheless, moth- Kassena-Nankana District of northern Ghana Results ers and other women in the extended family are socially suggest that the FGM/C decision-making process is com- invested in their daughter’s circumcision because of plex, involving multiple family members. However, in the the social stigma of not being circumcised. For women, course of family dynamics, the girl’s mother takes the pri- the relationship between social benefits and circumci- mary initial responsibility for encouraging a daughter to sion status has not changed, while the reasons for man be circumcised. The father’s role is also critical because to marry a circumcised woman or force his daughter to he is responsible for permitting the circumcision proce- circumcise has diminished. Thus, the lines of influence dure. But, the initiative for undergoing FGM/C is mainly diagrammed in the figures are weak for men but strong the mother’s prerogative. This finding is consistent with for women. conclusions reached by studies of the FGM/C decision- The role of peers further complicates the system of making process elsewhere in Africa. Qualitative research influences diagrammed in Fig.  1. Girls are inculcated on FGM/C determinants in Sudan and Sierra Leone par- with the belief that group membership and corporate val- allel our findings [48, 49]. Moreover, a quantitative study ues are crucial to self-esteem. Ultimately, the decision to conducted in Iran reported that mothers and grand- undergo circumcision thus, depends on whether or not mothers were the main decision makers in the circum- the social climate favors being circumcised or not being cision of 85.1% of the study participants [50]. Patriarchy circumcised. Women at all ages are immersed in a social is nonetheless important. A possible explanation of the environment that constrains social agency and perpetu- role of mothers or females in perpetuating FGM/C is ates circumcision practice. likely to be influenced by their desire to maintain tradi- Figure 2 illustrates ways in which influences on FGM/C tion and despite the dominant role of women in sustain- behavior shift with marriage. As in the Fig.  1 system, ing FGM/C, the practice cannot be disassociated from young married women have little autonomy in FGM/C the more general context that patriarchy conveys. Social decision-making, despite the common assertion that institutions in general are grounded in patriarchal con- FGM/C is not compulsory. The role of extra-familial text of Kassen-Nankana society [48], peer pressure virtually disappears with marriage and the Various studies have shown that a wide range of fac- young woman’s familial climate of FGM/C values indi- tors have been instrumental in reducing the prevalence cated by in her husband’s extended family. of FGM/C [10, 31, 32, 50]. In this study, respondents have The continuing and robust influence that women play attributed the decline in the prevalence of FGM/C to in sustaining the practice could be related to the need general concerns about the health risks associated with for women to create status for themselves in a women’s the practice, particularly pertaining to loss of blood, and hierarchal society where power and influence is other- the effects of FGM/C on childbearing and child health. wise, vested in the male dominated, patriarchal system. Other factors accounting for the change in the receptive- Instead of representing an “exercise in male supremacy ness of FGM/C are linked to women being ridiculed for and the oppression of women” [45] or reasoning that being circumcised, the general notion that sexual rela- women are “colluding with patriarchy to maintain subor- tions are enjoyed more by uncircumcised women and dination of women in society” [46], programs should seek men’s increased preference for uncircumcised women. to create “social space” for women that enhance the sta- The concerns on the health risks associated with FGM/C tus of women that is associated with female circumcision might be due to the extensive focus on the health risk of without the actual performance of circumcision. As one FGM/C in numerous FGM/C abandonment interven- writer has observed, tions [48, 51]. The horrific experiences of circumcised “to reduce adolescent girls’ belief that excision would women might have also played a role in strengthening the transform them into adult women to patriarchal advocacy against FGM/C. conspiracy would be to ignore how the institution of female initiation regulated relations among women Conclusion as well as between men and women” [47]. Since the practice of FGM/C is grounded in customs perpetuating the subjugation of women, it is widely Women could be portrayed less as victims or mis- assumed that male preferences and FGM/C beliefs guided perpetrators and more as women who can learn are the decisive influences sustaining the practice of and create these same ideals to more positive social FGM/C in traditional societies. This investigation lends mechanisms and customs for themselves. support to this perspective in the sense that the male A kweongo et al. Reprod Health (2021) 18:52 Page 15 of 17 dominated patriarchal system constrains women’s Fifth, the needs of unmarried and married adoles- autonomy and leads to a system of social influence that cents for FGM/C prevention programs cannot be sep- a young woman is powerless to confront. But to con- arated from adolescent health needs more generally. clude the analysis with this observation would do little Activities that build self-esteem and autonomy through to elucidate what actually happens in the course of the livelihood training, peer leadership, or other adoles- FGM/C decision-making process. Women promote, cent outreach program, such as sport promotions, sustain, and initiate discussion of FGM/C in the house- can include FGM/C educational components. Girls hold. For programs to effectively accelerate the ero- organized into peer groups for the Navrongo FGM/C sion of this harmful practice, women’s advocacy of the experiment had no prior experience with extra-famil- practice must be in focus. What then can we conclude ial decision-making or discussion of matters involving about the appropriate design of an FGM/C prevention individual preferences and personal autonomy. Build- program? ing peer leadership for reproductive health is a crucial First, since the social forces that sustain FGM/C are element of the Navrongo FGM/C eradication strategy. complex and systemic, no one strategy or simple initia- Finally, adolescent outreach activities can be designed tive will work. Just as FGM/C is sustained by a complex to have a “right of passage” component whereby young social system, prevention must be guided by a sophisti- men and women receive traditional family life educa- cated sense of respect for the institutions that govern tion and their completion of this process is acknowl- life, prevent social disorder, and sustain family values. It edged by a community celebration. In this manner, is particularly important to focus on the FGM/C motives elements of social values that are so often cited as of adults; program oriented to adolescents alone will fail. rationale for sustaining the practice of FGM/C can be Second, instituting change is possible. Social change in re-associated with a program that is designed to fos- FGM/C values is already evident. Program action is not a ter prevention of this practice. Participants in this hopeless endeavor. Lines of influence that were strong in study were generous with advice on how this could the past, such as fathers, husbands and compound heads, be achieved through appropriate outreach to parents, appear to be eroding. women’s groups and community leaders. While the Third, there is a need to build on the receptive audi- specifics of these recommendations may not transfer ence that men represent. Chiefs, elders and other male to other social groups that practice FGM/C, the gen- players in the patriarchal system can be active promot- eral principle of consulting communities, seeking their ers of FGM/C prevention. The Navrongo experiment, for advice, and implementing a socially informed program example, utilizes traditional village gatherings, known as should apply to other settings. It is possible that other durbars as mechanisms for communicating FGM/C les- investigations may challenge conventional wisdom sons and correcting misinformation. It is more appro- on what must be done to prevent FGM/C. At least in priate to utilize the lineage and chieftaincy system for this setting, men are logical allies in instituting change; disseminating health education about FGM/C than pro- and women must be the focus of social intervention if fessional health workers who are engaged in ambulatory efforts to institute change are to succeed. care. Rather than dismissing the patriarchal system as the social force that sustains FGM/C, the system of male social leadership and communication should be mar- AbbreviationsCKI: Community key informants; FGD: Focus group discussion; FGM/C: Female shaled to foster abandonment of the practice. genital mutilation; NDSS: Navrongo demographic surveillance system; NHRC: Fourth, social interaction among women is dominated Navrongo Health Research Centre; IRB: Institutional Review Board; UNICEF: by exchanges in the extended family. There is a need to United Nations Children’s Fund; WHO: World Health Organization. build extra-familial women group identity and social Acknowledgements cohesion around activities that challenge traditional The authors gratefully acknowledge advisory support of staff of the Navrongo FGM/C views. Women who are opposed to FGM/C need Health Research Centre who provided support for the field organization and implementation of this study. social support for their perspective. Singing and danc- ing groups exist in all of the FGM/C experimental areas. Authors’ contributions Convening such groups for the purpose of fostering The FGM/C Abandonment initiative was designed by JFP in collaboration with PA and its protocol was developed by JFP in collaboration with the Ghana FGM/C prevention, would build a program around the Health Service. The manuscript was initiated by PA, EJ, SA. Field work for this strong value that women consign to group participation initiative was organized by PA and ES. Initial data analysis was conducted by and collective decision-making. An effective program of PA, EJ, SA, ES and JFP. All authors read and approved the final manuscript. mobilizing women’s extra-familial networks would off- Funding set the isolation and traditionalism that constrains the The FGM/C Abandonment Study was supported by grants of USAID to the autonomy of young women. Population Council. Writing activities of Columbia University coauthors was funded by the Doris Duke Charitable Foundation African Health Initiative Akweongo et al. Reprod Health (2021) 18:52 Page 16 of 17 grant to the Mailman School of Public Health of Columbia University [Grant Upper East Region, Ghana. Reprod Health Matters. 2009;17(34):47–54. 2009058B]. https ://doi.org/10.1016/S0968‑ 8080(09)34474 ‑2. 15. Meroka‑Mutua A, Mwanga D, Olungah C. Assessing the role of law in Availability of data and materials reducing the practise of FGM/C in Kenya. Reprod Health. 2020. https :// Data for study is available upon request. knowl edgec ommon s.popcou ncil .org/depart ment s_sbsr‑rh/1152 16. Shell‑Duncan B, Wander K, Hernlund Y, Moreau A. Legislating change? Ethics approval and consent to participate Responses to criminalizing female genital cutting in Senegal. Law Soc Ethical approval for the Navrongo FGM/C Abandonment project and its Rev. 2013;47(4):803–35. data collection processes, described in this case study, were approved by 17. Diop N, Congo Z, Ouedraogo A, Sawadogo A, Saloucou L, Tamini I. Analy‑ the Navrongo Health Research Centre Institutional Review Board (NHR‑ sis of the evolution of the practice of female genital mutilation/cutting in CIRB‑31‑03‑2003). Both written and oral consent was sought from the partici‑ Burkina Faso. Reprod Health. 2008. https ://knowle dgec ommons .popco pants before data was obtained. uncil .org/depar tment s_sbsr‑rh/139. 18. Abusharef RM. Revisiting feminist discourses on infibulation: Consent for publication Responses from Sudanese feminists. In: Shell‑Duncan B, Hernlund Not applicable. Y, editors. Female “Circumcision” in Africa: culture, controversy and change. Boulder, Colorado: Lynne Rienner Publishers, Inc; 2000. p. Competing interests 151–66. https ://books .googl e.com/books? hl=en&lr=&id=rhhRX iJIGE The authors declare that they have no competing interests. cC&oi=fnd&pg=PP9&dq=Female +“Circu mcisi on”+in+Afric a:+Cultu re,+Contro versy +and+Chang e&ots=IG7nj9 8p4W &sig=MOZ2U KAGJg Author details i_1sVh3C twn9G RkJs #v=onepag e&q=Femal e “Circumcision”inAfrica%3A 1 School of Public Health, University of Ghana, Legon, Ghana. 2 Heilbrunn Culture%2CControversy. Department of Population and Family Health, Mailman School of Public 19. Adongo P, Akweongo P, Binka FN, Mbacke C. Female genital mutilation: Health, Columbia University, New York, NY, USA. 3 Benmore, P. O. 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