Findings from a longitudinal study focussed on FGM/C practices in Ethiopia

1. Exploring the diversity of FGM/C practices in Ethiopia:
Drivers, experiences and opportunities for social norm change
March 2022
Domestic worker in Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020

2. Outline of Presentation
1
• FGM/C—Overview and Ethiopian context
2
•GAGE-Overview and sample and methods
3
•Findings on FGM/C
4
• Programming and policy implications
5
• Questions

3. 3
FGM/C
Overview and Ethiopian context
An adolescent girl, Ethiopia © Nathalie Bertrams / GAGE 2019

4. What is FGM/C and where is it practiced?
• FGM/C is sometimes called ‘female circumcision’—but unlike male circumcision it has no benefits, only risks
• FGM/C is practiced in dozens of countries—but is most common in Africa
• FGM/C is not associated with any particular religious faith—it is practiced among communities
that are Christian, Muslim and animists, and in the Ethiopian context also some adherents of the
Jewish faith (Beta Israel)
Source: National FGM Centre
Female genital mutilation/cutting: all procedures involving injury to or removal of the external female genitalia
for non-medical reasons

5. FGM/C includes a range of practices
• Type 3, removal of the clitoris and inner and outer labia—
known as infibulation
• Type 4, all other procedures including scraping and nicking
WHO and UNICEF delineate four types of FGM/C:
• Type 1, removal of the clitoris and/or clitoral
hood— known as clitorectomy
• Type 2, removal of the clitoris and inner labia

6. FGM/C is common—but declining-- in Ethiopia
At a national level, 65% of women
between the ages of 15 and 49 have
undergone FGM/C—down from 80% in
2000.
Source: 2016 DHS
Cohort analysis captures further
improvement:
Source: 2016 DHS
Cohorts of women
%
cut
%
cut
At a national level, 28% of girls aged 10-14 have undergone FGM/C
• but this does not speak to incidence because many girls are cut in early adolescence.

7. Regional diversity is key to understanding FGM/C
• Have different FGM/C incidence rates
• Practice different types of FGM/C
• Practice FGM/C on girls of different ages
Amhara
 62% of women
 51% of girls 15-19
 carried out soon after birth
 clitorectomy most common
Afar
 92% of women
 92% of girls 15-19
 carried out in early childhood
 infibulation is traditional
Oromia
 76% of women
 46% of girls 15-19
 carried out across childhood and
early adolescence
 mixed- primarily Types 1-2
Ethiopia’s political system is based on ethnic federalism. Its
eleven regions are named after—and governed by—its largest
ethnic groups.
Because of this, regions:

8. Tracking changes in FGM/C type is fraught
• There is debate about whether shifts to Types 1
(or 4) constitute progress in areas where Types 2
and 3 have been common.
• Those advocating for ‘harm reduction’ correctly
observe that Type 3 is most likely to result in
death.
The DHS classifies type
of FGM/C differently
than WHO:
• Cut, no flesh removed
(3%)
• Cut, flesh removed
(73%)
• Sewn closed (7%)
Many girls and women do
not know what type of
FGM/C they have undergone:
• 18% of all women did not
report/ know
• 25% of girls 15-19 did not
report/know
• The international community has come down
predominantly on the side of ‘no’.
• Regardless, this is hard to track in Ethiopia

9. Overview of GAGE
Adolescents in Afar, Ethiopia © Nathalie Bertrams / GAGE 2019

10. Gender and Adolescence: Global Evidence (GAGE):
A longitudinal research programme in the Global South (2015-2024)
By finding out ‘what works,’ for whom,
where and why, we can better support
adolescent girls and boys to maximise
their capabilities now and in the future
We are following 20000 adolescent girls and boys - the largest cohort of
adolescents in the Global South

11. GAGE longitudinal research sample

12. GAGE Ethiopia research sites
3 regions:
• Afar, Amhara, Oromia
• plus Dire Dawa City Administration
Research site selection based on:
• Districts with among highest rates of child
marriage as proxy for conservative gender
norms (MOWCA, UNICEF and ODI, 2015)
• Urban and rural sites
• Food insecure and pastoralist sites as a proxy
for economic poverty
• Woreda-based mapping of all kebeles based
on infrastructure and service availability
(vulnerable/ less vulnerable)
• Programming capacities of NGO
implementing partners

13. An adolescent herding cattle, Ethiopia © Nathalie Bertrams / GAGE 2019
Findings

14. South Gondar, Amhara
• 35% were cut
• nearly all before their first birthdays
Of younger cohort girls whose female caregivers reported:
• 25% were cut
• 70% of girls did not know when
Of older cohort girls who self reported:
• 61% took more than 3 days to recover
• 12% took more than 7 days
• 79% were cut by a traditional cutter
Of all girls who have been cut:
But some girls undergo Type 2
‘On both sides there is a black part
that is believed to hamper
penetration.’ (father)
Type 1 is most common
‘They cut the tip of the clitoris.’
(woreda level KI)

15. Most respondents see risks—some see advantages
Most girls (74%) and caregivers (66%) report that FGM/C entails risks.
Girls are less likely than caregivers to believe that:
• FGM/C has advantages
• FGM/C is required by religion
• FGM/C should continue
‘It will be difficult for a man to have
sex with her if she is not circumcised’
(kebele level KI)
‘FGM/C helps her vulva to stretch to
make birth easier.’ (youth leader)
‘If a girl is not cut … she would
become a slut.’ (woreda level KI)
74
11 12 12
66
28
26
17
0
10
20
30
40
50
60
70
80
Has risks Has advantages Required by religion FGM/C should continue
%
Older cohort girls Female caregivers of younger cohort girls

16. The dominant narrative is progress
Schools spread the word—with cascading impacts
‘They teach us at school about harmful traditional practices …They are working very hard to teach us about FGM.’
(adolescent girl)
‘When there is an educated person in the family, that person tells [the others] that FGM/C is a harmful traditional practice and
they need to avoid it. That person convinces the family and stops them from doing it.’
(woreda level KI)
Health extension workers target women
‘Health extension workers are active in teaching about
FGM … Starting from when they get pregnant, they
have a follow-up with health extension workers. They
teach them when to go for a check-up.’ (teacher)
Religious leaders tailor messages carefully
‘Jesus was baptised with water, not circumcised.’ (Orthodox priest)
‘It is not possible to follow each rule and law provided
by the book. This we should not follow.’ (Muslim sheik)
Most participants report recent elimination
‘It is totally abolished now.’ (16-year-old girl)
Progress is evident in individual families
‘I circumcised my older children. I have two young girls but they
are not circumcised.’ (mother)

17. But subtexts suggest a need for caution
• ‘There is no girl who is not cut.’ (adolescent girl)
In remote communities, girls are still cut
• ‘The practice of FGM/C is very difficult to sanction since it is practised by mothers/ grandmothers in a very private
and hidden manner.’ (militia member)
Women use ‘hidden practices’
• ‘There is no female genital mutilation … It is prohibited by the government … However, if their families [mother and
father] have the skill, they circumcise their female children in a hidden way. … [His daughter] was circumcised by her
mother … It was me that ordered my wife to circumcise our daughter.’ (father)
Sometimes at men’s order
• ‘These days they will be cut in health centres … the clitoris and the side flesh … If it is cut in the health centre, it
doesn’t take long to heal … In the hospital they give painkillers and they apply ointments on the wound, that is why it
recovers quickly.’ (mother)
There is some evidence of medicalisation
• ‘According to our criminal code of conduct, female genital mutilation is a criminal act … We are not seriously working
on this aspect.’ (teacher)
Kebele level officials are often not engaged

18. East Hararghe, Oromia
Of older girls who self-reported:
• 89% had been cut
• 62% of girls had wanted to be cut at the time
Of younger girls whose caregivers reported:
• 65% of girls had been cut
Of all cut girls:
• Girls were cut at an average age of 9.6 years
• 80% of girls were cut by a traditional cutter
• Over 3/4 of girls took at least 3 days to recover
• Nearly 30% of girls took at least 7 days to recover
‘Some are mutilated at a young age and others
after growing up somewhat.’ (10-year-old girl)
‘They cut just the top part of it [the
clitoris].’ (religious leader)
‘They sew your body and it stays until
you get married.’ (15-year-old girl)
• Girls are cut at different ages
• Girls undergo different types of FGM/C
• Girls also undergo FGM/C in different ways—some
individually and some in a group
‘Everyone in the community do it.’
(15-year-old girl)
• FGM/C is perceived as universal

19. Risks are poorly understood and attachment is strong
• Girls are less likely to perceive risks than
caregivers (30% vs 46%)
• Girls are more likely to support
continuation than caregivers (49% vs 37%)
• Girls and caregivers believe:
• FGM/C has advantages (~1/3)
• FGM/C is required by religion (>2/3)
‘It is our culture … It is also a principle of
Sharia [law] too.’ (social court member)
30
32
71
49
46
32
68
37
0
10
20
30
40
50
60
70
80
Has risks Has advantages Required by religion FGM/C should continue
%
Older cohort girls Female caregivers of younger cohort girls

20. Drivers are rooted in girls’ reproductive roles
‘I didn’t find girls who got married without being circumcised. It is shameful here not to be.’ (HEW)
Girls cannot marry without FGM/C
‘During intercourse there is no way to insert the penis if the clitoris is not removed.’ (father)
It is believed that sex is not possible without FGM/C
‘If the girl is not circumcised, she will not get pregnant.’ (younger boy)
It is believed that pregnancy is not possible without FGM/C
‘The sexual desire of women who haven’t had FGM is inflated… We are farmers and engage in tiresome
activities of farming… We cannot handle another responsibility of satisfying our wives because their
sexual desire is heightened if they are not circumcised.’ (father)
It is believed that FGM/C is required to lower girls’ and women’s sex drive

21. Despite pain, most girls want to undergo FGM/C
Girls admit that they choose FGM/C
‘Daughters beg their families in order to
get circumcised.’ (10-year-old girl)
Girls are excused from housework and pampered by their
mothers.
• ‘They gave me milk and egg … They prepared for me rice
and macaroni with sauce.’ (12-year-old girl cut at age 10)
• ‘We prepared food and chicken and then the people come
and give you money.’ (14-year-old girl cut at 12)
Girls want to fit in with their peers
• ‘There is an insult for girls who are not circumcised.’
(married 11-year-old girl)
Girls want to show their peers they are old enough to attend
shegoye dances
• ‘They have to be first circumcised. It is after circumcision
that a girl attends shegoye.’ (17-year-old girl)
Girls acknowledge that FGM/C is
painful
‘They will tie your hand and leg together
and also cover your eyes. They also hold
your mouth hard so that you don’t cry.’
(12-year-old girl)
Why do girls want to be cut?

22. But parents make sure girls ‘choose’ correctly
‘It cannot be stopped … If we are not interested to be
circumcised, our parents beat [us] and force us to be
circumcised … We cannot decide. It is our families who
force us to be circumcised.’ (17-year-old girl)
‘If she married without, they will cut her during aruza
[honeymoon] ... If they cut you during aruza, the pain is
huge. So it is better to have FGM long before getting
married.’ (14-year-old girl)
‘The government has a huge plan to prevent FGM … but her
mother never accepts it because she considers it as a big shame
culturally … They will not be willing to spare their girls from
undergoing FGM.’ (social court member)

23. Backsliding is increasing—and set to increase more
‘If we see it and hear about it, we
will put them in jail.’
Officials proclaim progress
‘In the past, during our mothers’
time, they were prohibited to
practice circumcision … Now, it’s
open.’ (13-year-old girl)
But girls report the reverse
‘You go to a health facility. You can
deliver through an operation, for
instance.’ (17-year-old girl)
Awareness raising is falling flat
‘The kebele administrator takes
money from people who circumcise
their girls. He takes (for instance)
up to 200 birr (~$4)… The
administrator stopped now. People
don’t even give him [the money]
even if he asks now. They don’t
listen to him now. They do the
circumcision freely.’ (young woman)
Fines are ignored
‘Girls do not listen to their families
… They just go with boys … They
go with boys to get married. In the
past, we didn’t go after boys
unless we were asked for marriage
because we were circumcised.’
(grandmother)
There are calls to resume more
invasive types
‘There was a female teacher that
used to register the names of
parents who allowed girls to
undergo FGM/C, but since there is
no school, they cut girls and there
is no one to question them.’(kebele
level KI)
Covid has complicated protection
‘Previously it was forbidden, but
now they allow it.’

24. Zone 5, Afar
Of older cohort girls who are self reporting:
• 84% have been cut
Of younger cohort girls whose mothers are
reporting:
• 92% have been cut
Of all girls who have been cut:
• Girls were cut at an average age of 1. 5 years
• 78% took at least 3 days to recover
• 17% took at least 7 days to recover
• 67% of girls were cut by a traditional cutter
‘Up to now, there is no girl who is not circumcised ... all
girls are circumcised.’ (19-year-old girl)
FGM/C is effectively universal:
• There is some variation in age—soon after birth to pre-school aged
• Who cuts girls is shifting—primarily to make it more private
‘Previously, there were skilled elder women who made FGM, moving
from home to home. However, now every mother practises FGM of her
own daughter.’ (mother)
‘Though we know that female genital cutting harms our
daughters, we are still practising it.’ (religious leader)

25. In more central communities, type is (probably) shifting
‘In previous times, we used to cut them deep. We even take some part from the side and then we sew it. But now we
have learnt that this will have a problem at the time of giving birth. So we cut only the part called haram [forbidden by
Islamic law].’ (mother)
‘Currently people cut only the tip of the girl’s clitoris, people stopped cutting the entire part of the inner of the girl’s
genital organ from three directions.‘ (clan elder)
Type 1 is replacing infibulation
‘We work with women doing it and give them alternative income opportunities. And we also organised a reward
programme for champions who stopped doing it.’ (Justice KI)
‘I told my relatives if they try to practise it again, they would get imprisoned for 10 years, pay a 10,000 birr fine.’ (HEW)
Because of officials’ efforts
‘Especially, the Sharia persons and religious leaders taught us to change the type of cutting and to use the ‘sunna’ type.’
(clan elder)
‘Muslim leaders tell us it is contrary to the Sharia and only slight cutting is allowed.’ (male community KI)
And most especially because of religious leaders’ efforts

26. In more remote communities, stasis rules
‘What we are practising now is what we
were practising previously.’
(clan elder)
‘Those circumcised girls’ legs will be tethered together using rope, to make the cut organ stick
together and their organ will get narrower. They do not use any medical treatment to heal the
wound, they use cultural treatment, and the wound will cure after a week or after two weeks …
There is no sewing in our locality, the cut organ will be stitched up together with blood.’ (19-year-
old girl)
‘There is no sanction or punishment because all
people in this community accept that female
genital mutilation is normal.’
(clan elder)

27. Advantages are perceived to outweigh risks
• Just under half of girls and
caregivers report that FGM/C has
risks
• Just over half of girls and caregivers
report that FGM/C has advantages
• More than two thirds of girls and
caregivers believe that FGM/C is
required by religion
• Girls are more likely than caregivers
to believe that FGM/C should
continue
‘Girls would misbehave and be disobedient to their
parents unless they were circumcised.’ (mother)
‘It is difficult to have sex with uncircumcised girls
since the clitoris prevents the penis penetrating deep
in the girl’s vagina.’ (14-year-old boy)
44
56
71 72
46
56
65
51
0
10
20
30
40
50
60
70
80
Has risks Has advantages Required by religion FGM/C should continue
%
Older cohort girls Female caregivers of younger cohort girls

28. Social pressure ensures compliance
‘We are also told that a father who didn’t circumcise his
daughter is considered as lazy and we are also ordered
not to get in the house of a man who didn’t circumcise
his daughter because having a daughter who is not
circumcised is considered haram.’ (clan elder)
‘I wouldn’t be happy if I wasn’t circumcised … Not
being circumcised is haram.’ (15-year-old girl)
‘We are happy [to be cut] … They insult us by
singing “their clitoris is longer like hala wolf ”.’
(17-year-old girl)
‘If a girl is not cut, she will be isolated by the
people. So, the girls themselves agree to
circumcision. They prepare themselves and ask
the mother to do it. It is done based on family
interest and the girl’s willingness.’ (mother)
‘It becomes risky to speak about stopping FGM among
rural communities and they are afraid to teach about
FGM as a bad practice because it has been a long-held
traditional practice … For instance, there is a midwife
working at Community B and she told us that the
community laugh when she teaches about avoiding
FGM.’ (woreda level KI)
Girls comply to avoid exclusion Adults comply to avoid exclusion

29. Progress depends on religious leaders
‘We will never accept what the government law is saying.’
(clan elder)
‘We can change the practice only if we heard it from religious
leaders. We do not stop because of meetings.’ (grandmother)
‘They taught us that it became a big sin if a female child died
without being circumcised.’ (mother)
Some religious leaders are actively promoting FGM/C
The law pales beside religious authority
Adolescents, in Afar Ethiopia © Nathalie Bertrams /GAGE 2018

30. Infibulated girls need support
‘Husbands use energetic efforts to dis-virgin
[have sexual intercourse with] their wives.’
(clan elder)
‘Many girls cry during sexual intercourse.’
(married 17-year-old girl)
‘The organ that was connected during circumcision
doesn’t allow her to give birth freely.’
(married 18-year-old girl)
‘Doctors are insulting girls during childbirth … They say
that because we are circumcised, we are unable to labour
… When we tell them there was nothing we could do about
it, they reply, saying that we know nothing about giving
birth because we are circumcised.’
(married 19-year-old girl)
Sex is painful
Giving birth is difficult and humiliating

31. Urban areas
At a national level, the prevalence of FGM/C in urban areas is 54% (compared to 68% in rural areas)
‘ I know a teacher who forced her daughter to get cut. She
used to teach us about harmful traditional practices and HIV
and AIDS. She even goes to rural villages to raise awareness
on this. I remember how shocked I was to learn this. I did not
expect this from her. ‘ (17-year-old girl, Dire Dawa)
• But GAGE urban areas are not all the same:
• 19% in Debre Tabor (Amhara)
• 29% in Batu (Oromia)
• 46% in Dire Dawa
• Girls growing up in urban areas are most often cut in rural areas over
school holidays.
Adolescents student, Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020

32. Donor and NGO efforts are broad…but challenges are large
What efforts?
• Community
conversations about
FGM/C and gender
• Engagement with
religious and clan
leaders
• Girls’ clubs
• Engagement with
mothers
• Engagement with
men and boys
• Exposure to local
champions
• Education and
alterative income for
cutters
Which actors?
Examples include:
• UNICEF-UNFPA
• CARE
• Pathfinder
• Population Council
• Action Aid
• Save the Children
• Plan
• African Women
Organisation
• Islamic Relief
Worldwide
• KMG
• Norwegian Church
Aid
Participant girls
are ~ 25% more
likely to know
risks of FGM/C

33. Implications
Adolescents, Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020

34. Implications for policy and programming
1
• Address underlying gender norms through context-tailored approaches incl. working with religious leaders, parents,
and adolescents—and addressing risks and perceived advantages.
2
• Raise awareness of the criminalization of FGM/C—considering transparently levied and bottom-up fines on a
community-by-community basis and providing girls with uncut role models to counter peer pressure.
3
• Engage with health care providers to encourage their work with new mothers, prevent medicalization, and ensure
that cut girls are treated sensitively.
4
• Adopt a long-term lens that recognizes that change is non-linear and that continuous pressure is required over time
to prevent hidden practices and resurgence.

35. Questions
An adolescent IDP girls, Ethiopia © Nathalie Bertrams / GAGE 2019

36. Contact Us
WEBSITE
www.gage.odi.org
TWITTER
@GAGE_programme
FACEBOOK
GenderandAdolescence
About GAGE:
 Gender and Adolescence: Global Evidence
(GAGE) is a nine-year (2015-2024) mixed-
methods longitudinal research programme
focused on what works to support
adolescent girls’ and boys’ capabilities in the
second decade of life and beyond.
 We are following the lives of 20,000
adolescents in six focal countries in Africa,
Asia and the Middle East.