Women's position and attitudes towards female genital mutilation in Egypt: A secondary analysis of the Egypt demographic and health surveys, 1995-2014

Female genital mutilation (FGM) is still a common practice in many African countries. The World Health Organization (WHO) estimates that worldwide between 100 and 140 million women have been cut [1], of which about 91.5 million in Africa. They also estimate that in Africa about three million girls are circumcised every year.

In Egypt, FGM remains nearly universal: over 95 % of women between 15 and 49 years old are circumcised, and this proportion remains fairly constant across all cohorts [2 and own calculations]. WHO distinguishes four types of FGM [3]. In Egypt types I (clitoridectomy) and II (clitoridectomy + (partial) removal of the labia minora) are the most frequent ones [4]. Type III (infibulations) is fairly rare, as is type IV (other forms). The practice usually takes place before puberty [5]. The median age at circumcision is 10 years of age, and almost all girls are cut before their 13^th birthday [2]. Traditionally, the cutting was done by Dayas, traditional midwives, but the practice is increasingly medicalized [5, 6]. By 2005, more than 70 % of the cuttings were performed by doctors and only 22 % by Dayas [2].

For over half a century Egypt has been developing, to little effect, policies to discourage and ban FGM. An important reason for their failure is that FGM still enjoys the support of a large majority of the population [7, 8]. In 2003, only 23.3 % of ever-married women favoured its discontinuation [2], and 60.8 % believed that FGM is required by their religion. Although some prominent Islamic leaders have recognized that Islam does not require women to be cut [9] and even though the country’s supreme Islamic authorities reiterated it was prohibited [10, 11], many Islamic leaders still accept or even support the practice [4, 12, 13]. In 2007 and 2008 laws were passed that banned the practice [14, 15]. However, it remains unclear how rigidly these laws have been enforced. Although the 2007 law prohibited general practitioners from performing FGM, Rasheed, Abd-Ellah and Yousef [16] found that in Upper Egypt, the incidence of FGM remained very high, and that most cuttings were still performed by general practitioners. The social and political upheaval leading to and following the fall of the Mubarak regime in 2011 may further have undermined the enforcement of the laws as the Muslim Brotherhood is said to support the practice.

Although female genital mutilation or female circumcision is still nearly universal in Egypt, there is some evidence that the social and political climate regarding FGM is changing. According to the 2014 Egypt Demographic and Health Survey (EDHS) 92 % of ever married women between the ages of 15 and 49 were circumcised [17]. However, the prevalence of FGM among 20–24 year old ever married women was only 87 %, compared to about 95 % for 35 to 49 year olds. El-Gibaly et al. [6] also demonstrated that the prevalence of FGM among girls aged 10–19 was about 10 % lower than among their mothers. Other studies confirm these results [5, 18], suggesting a slow decline of the practice. Given the embedment of FGM in tradition and social structure and the widespread support for it, the eradication of this practice – which is the objective of current legislation -- seems impossible without major changes in popular attitudes. Theories of behaviour change stress the importance of attitudinal change as a necessary, although not sufficient, precursor to behavioural change [19‐24]. For people to abandon traditional behaviours, such behaviours must be delegitimized while alternative ones need to gain acceptance.

The starting point of this study is that FGM is associated with the social position of women, i.e., their location in recognized status and role structures, and that the practice is culturally embedded and therefore widely supported. The delegitimization of the practice and an attitudinal change among large parts of society are essential steps in the abolishment of the practice. Countries where FGM is prevalent typically have high gender inequality. International organizations emphasize female empowerment, improving women’s position in society, and reducing gender inequality as a strategy to eradicate FGM [25] This paper examines the hypothesis that anti-FGM attitudes initially emerge among the more ‘modernized’ segments of Egyptian society, where women are believed to be more empowered, and subsequently spread from there to the rest of society.

In communities that practice FGM, people often accept it as a normal part of growing up as a woman. In traditional societies being cut confers status on a woman because it identifies her as a member-in-good-standing of her community. Parents fear that non-circumcised daughters will do less well on the marriage market than circumcised women. Specifically, parents worry that they will have more difficulty finding a spouse or will have to be satisfied with a lower status one. Whether a woman has been circumcised determines not only the moral standing of a woman, but also her social identity and status within the community [12, 26‐30]. The practice of FGM stresses not only the subservient position of women in society, but also symbolizes girls’ coming of age and confirms them as full members of the community [4, 30]. Noncircumcised women risk being treated as outcasts, as immoral women. Not being cut leads to stigmatization and loss of status, for both the woman and her family [27, 31, 32]. Parents experience considerable social pressure to have their daughters cut [33, 34]. The social costs of not having one’s daughter cut can be quite substantial: loss of status, lower marriage opportunities for their daughters, social exclusion, etc. Several studies have shown that the non-circumcision of a daughter may lead to a loss of status and stigmatization, not just for the daughter herself, but for the entire family [13, 27, 31, 32, 35‐38]. As FGM is linked to the position of women in society [12, 25, 28, 30], substantial social pressures exist to conform to the norm that states that FGM is a normal aspect of every woman’s life. The practice is strongly embedded in the society’s traditions and contributes to the social status of both the women themselves, and their families. The extent to which individuals and families can withstand such pressures and go against tradition depends on the available sources of status as well as on their exposure to other social environments and influences. Therefore, not all groups are equally likely to change their attitudes toward FGM.

The strong cultural embeddedness of the practice makes a shift in societal attitudes essential for a fundamental and long-lasting behaviour change and the final eradication of FGM. Most individual-level theories of behaviour change inspired either by social cognitive or rational choice theories recognize the role played by attitudes [19‐22]. Attitudes reflect the relative values of both old and new behaviours, and might signify the readiness to change, although it does they may not necessarily lead to behaviour change. The problem with cognitive models of behavioural change is that they ignore the context in which decisions are made and assume that when an individual is convinced of the benefits of behavioural change he or she is also empowered to implement this change [39, 40]. Coale’s famous Ready, Willing, Able model [23, 24], already pointed out that one not only needs to be ready to change, but also willing and able to do so. According to this model all three conditions need to be met before an actual behaviour change occurs. As FGM is deeply entrenched in social traditions and cultural frames and is strongly connected with family social status simply being ready to stop the practice (as reflected by anti-FGM attitudes) usually will not be sufficient to trigger behaviour changes, as actors may neither be willing (due to the social costs of not cutting one’s daughters) nor able to do so (because of lack of power in the decision process). Nevertheless, an attitudinal shift remains essential. Although anti-FGM law enforcement can force people to change their behaviours, without attitudinal change, such changes in behaviours tend to be short-lived.

Attitudes are anchored in community structures and reflect one’s position within this community. Attitudes relating to gender, including FGM, therefore are linked with the position of women in the community. The stronger their position, the more likely they will be able to adopt a more ‘modern’ or ‘western’ view on these issues. The empowerment of women is often linked to processes of modernization: urbanization, increased education, industrialization, rationalization, individualization, emotional nuclearization, etc. [33, 38, 41‐43]. Education is the key factor here, spreading modernity across society. Jejeebhoy [44] lists five ways in which education empowers women and thus may affect their reproductive health decisions and behaviours. First, by exposing women to outside influences education expands women’s knowledge beyond the common knowledge of the community and changes their outlook and values. Second, educated women are not only more confident, but also are in a stronger position relative to other family members with less education, which enhances their decision autonomy. Third, educated women tend to be more mobile and are thus better able to interact with actors outside the community. Fourth, education leads to a shift in loyalty away from the extended family and community and towards the nuclear family, which in turn leads to emotional nucleation. Finally and potentially most importantly educated women tend to have more control over material resources, largely because they tend to be more active in the money economy. In combination with employment in modern sectors of the economy, education provides women with alternative routes of status attainment. Marriage no longer is the only way for women to obtain status, and thus the social ‘need’ to have one’s daughters cut is lessened. Women with higher levels of autonomy are typically more likely to oppose FGM. For instance, Allam et al. [9] found that among the most modernized group in Egypt, i.e., university students, support for FGM was substantially lower than in the rest of society. Only 28 % of the students supported it. Those favouring its abolishment also had better knowledge of the dangers of the practice and tended to claim it had no advantages. Other studies found that mother’s education affects the likelihood that their daughter are cut or that they intend to have them cut [6, 45] or to oppose FGM [5, 6, 33, 46]. More emancipated women with greater autonomy tend to be guided less by tradition and less subjected to social control, and to also have better knowledge of the benefits and costs of FGM. For them and their daughters, marriage no longer is the only way to obtain status as they possess alternative routes of status attainment.

UNDPs Gender Inequality Index shows that gender inequality in Egypt declined slightly between 1995 and 2013. However, Egypt continues to have relatively high gender inequality, ranking 25^th (out of 130) in 1995 and 23^rd (out of 152) in 2013, indicating that progress in gender equality has been slower in Egypt than in most other countries [47]. El-Safty [48] reports that there has recently been a conservative backlash which is leading to a de facto curtailment of women’s rights. However, women’s progress has not been equal across all domains. For instance, Egyptian women have made considerable progress in terms of education, but much less in terms of labour force participation and employment. Female literacy among women age 15 and older increased from 22.4 % in 1976 to 65.8 % in 2012. Gross secondary school enrolment of women has increased from 20.4 % in 1970 to 87.8 % in 2013 [49]. However, the percentage of women aged 15 and older who are employed did not increase between 1990 and 2013. Although the employment rate of this age category fluctuates during this period, in 1990 26.7 % of women aged 15 and over were employed, and in 2013 only 22.9 % [49]. For many women modernization is only partial. Their education level might increase but they remain economically dependent on their husbands or families, limiting their autonomy. As this affects their position in society it is likely to influence their view on the role of women in Egyptian society.

In the modernization model the link between the change of one’s social position, one’s attitudes and behavioural change is quite straightforward. In reality the link may be less clear. Not all modernization processes run synchronously and women’s empowerment may be limited. Usually changes in attitudes are insufficient to trigger behaviour change, because decisions are rarely made in isolation from one’s social environment (family, community, etc.). Even for more individualistic decisions, such as whether to stop smoking or drinking, whether to use a condom or to change jobs, one needs to take into account one’s environment, and that may influence the decision. This certainly will be the case for FGM as this may affect a family’s social status. Therefore, the decision process is likely to be much more complex, involving not only the mother but also other family members. Because the family constitutes the primary unit of status, decisions pertaining to this status tend to be family affairs. The extent that women weigh in on these decisions, including decisions concerning FGM, depends on their position within the family and community. Often mothers have little control over the decision whether their daughters will be cut. They may oppose having their daughters cut, but neither be willing nor able to influence this decision.

The spread of new attitudes through a society is fundamentally a social process in which actors influence each other. New attitudes originate in specific subpopulations and then spread to the rest of society. Some of these (groups of) early adopters may serve as examples, role models, opinion leaders or reference groups for other segments of society. Innovation studies have demonstrated that changes are more likely to be initiated by small groups of innovators. Innovators have a “willingness-to-change” that makes them sensitive and receptive to new ideas and practices [50] and that leads them to engage in more cosmopolitan social relationships [51, 52]. Innovators often adopt such practices after exposure to external influences, through mass media etc. Research on the diffusion of practices in developing nations shows that access and exposure to these external resources is dominated by economically advantaged and less culturally traditional groups. Less advantaged and more traditional segments of society are not only less exposed to sources of innovation but are also ill positioned to take advantage of them. A number of studies have found that highly educated and urban women were more likely to favour the discontinuation of FGM [44, 53], and that wealthier women and better educated women were less likely to intend to have their daughters cut [45, 54]. Given the higher status of these groups they may serve as role models for other segments of society. Several theoretical models, including social cognitive theory [20], social convention theory [55], and diffusion of innovation theory [51, 56], note the importance of role models for behaviour changes. Role models can affect knowledge, attitudes, and behaviour through direct contact, but also through their visibility in the community and their status [51]. In most cases, such role models need to be well perceived by their audience. Marginal groups lack the status to fulfil this role. To the extent that the more modernized segments of Egyptian society serve as role models or reference groups for more traditional segments, anti-FGM attitudes are likely to spread from the former to the latter.