Introduction
Female genital mutilation (FGM), also referred to as female genital cutting or circumcision (FGC), comprises "all procedures that involve partial or total removal of the external female genitalia, or another injury to the female genital organs for non-medical reasons" [
1]. There are four main types of FGM/C. Type 1 constitutes either a total or partial removal of clitoral glans and/or clitoral hood, while type 2 involves the total or partial removal of the clitoral glans and inner folds of the vulva. The third type—also called infibulation—is characterised by the narrowing of the vaginal opening, while type 4 constitutes any other harmful procedures to females' genitalia for non-medical reasons [
1]. More than 200 million females globally have undergone the procedure [
1]. People at risk include young girls between infancy and adolescence and in some instances, adult women. Globally, more than three million girls are estimated to be at risk annually [
1]. FGM/C has been documented in about 30 countries in Africa, the Middle East and Asia [
1,
2]. Currently, FGM/C abandonment interventions trail behind the incidence rate and its prevalence is anticipated to escalate within the next decade if efforts are not expedited [
3].
Traditional circumcisers usually execute FGM/C; however, due to adverse health concerns, healthcare providers are involved at times in countries like Egypt, Kenya, Indonesia and Malaysia [
2,
4]. The WHO has therefore adopted strategies to deter health workers from the practice [
5]. FGM/C subjects women to cruelty, torture and inhuman treatment, and can lead to the contraction of infections including HIV and AIDS [
6‐
8] and even death [
1]. It is associated with various short- and long-term health implications, depending on the type. Some of the short-term consequences are haemorrhage, repetitive infections of the low urinary tract and acute anaemia [
9‐
11]. The long-term consequences include pregnancy and childbirth complications and infertility [
1,
12,
13]. Multiple psychological implications have also been reported, including low self-esteem, psychiatric diagnoses, anxiety, somatisation and phobia [
14,
15].
In many communities, FGM/C is performed on very young females under the age of 18 with devastating results. A report from Sierra Leone in 2018, for instance, revealed that a 10-year-old girl died after undergoing FGM/C as part of a mass initiation of 68 girls into a secret society [
16]. The ages of the girls who participated in this initiation ranged from nine to 12 [
16].
These and several other appalling implications of FGM/C have led to a strong global call to eliminate FGM/C. A considerable number of UN human rights treaty monitoring bodies such as the Committee on the Elimination of All Forms of Discrimination against Women, the Committee on the Rights of the Child and the Human Rights Committee have condemned the practices and provided recommendations to help states end FGM/C [
17]. Target 5.3 of the SDG emphasises the elimination of all harmful practices, such as child, early and forced marriage and FGM/C by 2030 [
18].
The World Health Organisation (WHO), the United Nations Population Fund (UNFPA), other local and international human rights organisations and several countries have also introduced measures to end FGM/C. These include the Joint Programme on Female Genital Mutilation, implemented in 15 African countries [
19]. The World Health Assembly (WHA) has also passed Resolution WHA61.16 resolution [
20], which adopts a multi-sectoral approach to deal with FGM/C. Prevention and protection measures have also been taken globally to stop healthcare providers from performing FGM/C [
5,
21]. For instance, there is the development of healthcare providers' tools and training to manage FGM/C-related complications and prevent new FGM/C cases [
21].
FGM/C is one of the activities conducted during a rite of passage ceremony to transition girls to adulthood in Sierra Leone [
22]. An influential women's group known as the Bondo society conducts the ceremony. The Bondo society is a secretive custom or tradition of some women in Sierra Leone, which is rooted in mythology and has FGM/C as its mainstay [
23,
24]. Some women believe even talking about the society puts them at the risk of demons or curses [
24]. During the ceremony, a traditional leader, locally called a Sowei, performs the act [
23,
25].
Sierra Leone is a country with one of the highest FGM/C prevalence globally [
26]. It is the only country in south western Africa with very high FGM/C rates [
27]. To date, there is no explicit law that prohibits FGM/C in Sierra Leone [
28]. There is no strong political will to combat against FGM/C in Sierra Leone, as the traditional FGM/C practitioners, locally known as Soweis, influence females’ votes and serve as the link between some communities and the central government [
23,
29]. The practice is considered a social norm. Females who refuse it are sometimes ostracised and labelled as ill-mannered or unready for marriage and forfeit the public recognition earned by those who comply [
30].
The most recent Demographic and Health Survey (DHS) of Sierra Leone reported a national prevalence of 89.6% [
31]. Studies have been conducted on various dimensions of FGM/C in Sierra Leone and other sub-Saharan African countries to understand the possible drivers of the act [
23,
32,
33]. Some evidence from Sierra Leone suggests that women were the main decision-makers of FGM/C and that educational attainment influences decision-making [
34].
Factors associated with FGM/C discontinuation include the level of education, religion, ethnicity, urban residence, age at marriage [
35], geographical factors [
36] and male involvement [
37]. Notably, there is a plethora of evidence that education can be an antidote to FGM/C by enlightening women about the practice’s shortcomings [
38‐
41]. Overall, daughters of highly educated mothers are less likely to experience FGM/C, relative to daughters of mothers with little or no education [
42]. However, it is worth noting that female education has generally been low in Sierra Leone compared to male education [
43,
44]. There is a lack of evidence about the intersection between educational levels and FGM/C in Sierra Leone. A recent study explored the relationship between education and women’s intention to circumcise their daughters and reported an inverse relationship between education and FGM/C intention [
45].
Since FGM/C is socio-culturally entrenched without any political commitment to abandon it [
23,
29,
30], it is worth researching whether double standards exist regarding the abandonment of FGM/C. In Egypt, for instance, although educated women supported the discontinuation of FGM/C, those who had positive cultural conceptions of FGM/C were less likely to discontinue, regardless of educational attainment [
46]. This study appears to be the first research that explores the educational attainment of women and women’s viewpoints on whether FGM/C should be continued in Sierra Leone. The study could benefit Sierra Leone’s public health position by highlighting the need for anti-FGM/C socio-educational Information, Education, and Communication/Behaviour Change Communication (IEC/BCC) interventions. It will be challenging to end FGM/C without identifying and appreciating women’s perceptions of the procedure, and how their education levels impact their views.
Discussion
Using a nationally representative sample drawn from the 2013 DHS, this study investigated how educational levels of women of reproductive age in Sierra Leone influence their thoughts about continuity or discontinuity of FGM/C in their country. We found that women with a higher level of education were more likely to support the discontinuation of FGM/C than those without formal education. The impact of formal education efforts to end FGM/C have been significant [
49]. A previous study from Sierra Leone also reported that as a woman’s educational attainment increases, her intention to subject her daughter to FGM/C reduces [
45]. These findings potentially indicate that educated women in Sierra Leone do not support FGM/C continuation. This suggests that women’s education should be prioritised in Sierra Leone to end FGM/C and thereby enhance the country’s chances of achieving SDG target 5.3 [
56]. Robertson (2013) explains that educated women are knowledgeable about the health implications of FGM/C and understand the short- and long-term implications of the practice [
48]. It is vital to situate FGM/C in the context of intercultural education at basic and secondary levels of education to facilitate efforts to stop the practice, as education alone is not sufficient to end FGM/C [
42,
59]. Similarly, Rawat [
39], investigating FGM/C across six African countries including Sierra Leone found that education is significant in reducing FGM/C [
39]. The current study's findings suggest that education is an important aspect in the fight against FGM/C and educated women may serve as anti-FGM/C advocates [
50,
60].
Our findings highlight the ways in which wealth supports the discontinuation of FGM/C. Wealthier women and women who live in the western part of Sierra Leone are more likely to support the discontinuation of FGM/C. Concerning the association between wealth and support for the discontinuation of FGM/C, the findings corroborate previous studies that found a high socio-economic position helps protect against the practice of FGM/C [
46,
61,
62]. Women with a higher level of education are more likely to be wealthy than those with no formal education [
63]. Additionally, wealthy females with higher education tend to have less likelihood of FGM/C [
56], which is why our finding was anticipated. The observed variation between the rich and poor may imply that women’s economic empowerment may reduce FGM/C [
64].
Our study also found a geographical pattern regarding support for FGM/C discontinuation. Those residing in the country's western region were more likely to believe that FGM/C should be discontinued, while respondents from the northern region support its continuation. Several studies in Sierra Leone have found the western region residents have a high level of schooling, especially those in Freetown [
65,
66]. Therefore, it is expected that women in the western region were more likely to support FGM/C's discontinuation. With high access to education in the region, women will gain more knowledge about the harmful effects of FGM/C, which may influence their perception of continuation. These findings give the impression that perception about the practice’s continuation or discontinuation varies significantly in Sierra Leone and possibly other countries [
55]. The observed variations call for further research in the most FGM/C dominant region (northern) to improve understanding of the factors that promote the continuation of FGM/C and allow for appropriate interventions within communities [
67].
The WHO stresses that education must be the centrepiece of multi-sectoral efforts aimed at stopping FGM/C [
68]. Such measures must involve stakeholders at all levels (local, national and global) and varied sectors (health, economic, justice and education) [
68]. These findings must be translated into action, as stating that FGM/C should be discontinued in itself is not sufficient to reduce its occurrence. Initial steps could involve strengthening the legal framework and motivating and awarding women who do not cut their daughters. Our study also revealed that despite the positive association between education and support for FGM/C discontinuation, more than half of the women sampled had no formal education. Almost 80% of them said that FGM/C should continue. This shows that the effectiveness of policies and strategies aimed at eliminating FGM/C will depend on non-formal education, which could target women with no formal education. This can be conducted through community sensitisation of parents, as they are the primary decision-makers regarding FGM/C practices.
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