Trends in attitudes towards female genital mutilation among ever-married Egyptian women, evidence from the Demographic and Health Surveys, 1995–2014: paths of change

For several decades the Egyptian authorities have tried, to no avail, to curb and regulate FGM. In 2007 and 2008 laws were passed that banned the practice [1, 2]. However, it remains unclear how rigidly these laws are enforced, especially given the political upheavals since 2011. Although the 2007 law prohibited general practitioners from performing FGM, in a study of FGM in Upper Egypt Rasheed, Abd-Ellah and Yousef [3] found that the incidence of FGM remained very high, and that most cuttings were still performed by general practitioners.

Although female genital mutilation (FGM) 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 are circumcised [4]. However, the prevalence of FGM among 20–24 year old ever married women is only 87 %, compared to about 95 % for 35 to 49 year olds. El-Gibaly et al. [5] also demonstrated that the prevalence of FGM among girls aged 10–19 is about 10 % lower than among their mothers. Other studies confirm these results [6‐8], suggesting a slow decline of the practice. Given that FGM is embedded in tradition and social structure and that there is 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 behavior change stress the importance of attitudinal change as a necessary precursor to behavior change [9‐14]. For people to abandon traditional behaviors, such behaviors must be delegitimized while alternative ones need to gain acceptance. The EDHS data indicate that opposition to FGM increased between 1995 and 2014 (see Fig. 1). In 1995 only 13 % of ever married women believed the practice of FGM should be stopped, but by 2014 this had increased to 31 %. Moreover, the data suggest that opposition to FGM spread rapidly during the first decade of this century, but somewhat less rapidly in recent years [4, 15‐19].

FGM is not a harmless tradition, it brings with it serious health risks. In addition to health risks at the time of the event, such as pain, bleeding, infections, psychological trauma and even death, FGM is associated with health problems later in life, including chronic pain, infections, genital infections, sexually transmitted diseases, decreased sexual pleasure, birth complications, depression, post-traumatic stress disorder, infertility, etc. As FGM has no medical usefulness, is harmful to a woman’s health, and is imposed upon her, international organizations consider it a violation of women’s rights and a manifestation of gender discrimination [20]. Although the communities where FGM is practiced may consider it a traditional custom that assures the social status of daughters, it creates inequities in health based on sex and social status.

FGM is linked to the position of women in society [20‐24] and there is substantial social pressure to conform to the norm that states that FGM is a normal aspect of every woman’s life. Theories that focus on the more sociological and social psychological aspects of behavior change, such as social convention theory [25, 26], emphasize that attitudes and decisions are embedded in community structures. Attitudes toward FGM are influenced by individuals’ social environment, which tends to pressure and socialize people toward conformity. The extent to which individuals and families can withstand such pressures 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.

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 [27] and that leads them to engage in more cosmopolitan social relationships [28, 29]. These cosmopolitan-type social relationships are detached from local social circles. Although this detachment may undermine their credibility and status in the local community, it also allows for the introduction of new practices into a population. Innovators often adopt such practices after exposure to external communication channels. 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 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. In this light, the diffusion of attitudes and practices has an inherent role in the reproduction of status inequalities.

In such context the two groups most likely to introduce new (and possibly deviant) attitudes are the modernizing elites and marginalized groups. Modernization in this context refers to both structural factors that alter the social positions of the groups affected by it and to the emergence of new cultural patterns. Among the structural factors education and employment in occupations that require education stand out. The modern cultural pattern is characterized by rationalization, individualization, and detraditionalization. Modernizing elites not only possess alternative sources of status, but they are also exposed to new ideas and attitudes through education and through access to local, national, and international media. A number of other studies have found that highly educated and urban women are more likely believe that FGM should be discontinued [30], and that wealthier women and better educated women are less likely to intend to have their daughters cut [8, 31, 32]. 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 [10], social convention theory [26], and diffusion of innovation theory [33], note the importance of role models for behavior change. Role models not only affect behavior through direct contact, but also through their visibility and status in the community. Marginal groups lack the status to fulfill this role.

This paper examines whether the observed increase in opposition to FGM can be attributed completely to the fact that recent cohorts of young married women are more modernized, i.e., urban, better educated and employed in modern occupations, and therefore more likely to oppose FGM, or whether the opposition to FGM is also spreading from these modernized segments of society to the more traditional ones, which would imply that opposition to FGM is spreading to women of all walks of life.

FGM is deeply embedded in Egyptian society and tradition. At present, the overwhelming majority of girls are still being cut. All evidence, including this study, shows that support for the practice has remained strong in almost all segments of Egyptian society. But there are some indications that support for FGM may be waning. For instance, the EDHS data (see Fig. 1) show that the percentage of ever-married women who believe FGM should be discontinued increased from 12.7 % in 1995 to 31.3 % in 2014. Other studies also show a decline in support for or in the prevalence of FGM in Egypt [3, 5‐7, 37].

This study confirms that opposition to FGM originated among the more modernized segments of Egyptian society, i.e., urban, better-off and highly educated women, as well as among the small minority of non-circumcised women. These findings are consistent with the literature that shows opposition to FGM is most common among better educated urban residents [8, 30, 32, 38]. Although these groups continue to oppose FGM, opposition is spreading to other segments of society, including more disadvantaged and traditional groups. While the growth of the more modern segments of society (e.g., increases in the percentage of educated women) contributed to the changes in attitudes toward FGM, it is only one part of the story. Women’s desire to abolish FGM has also been diffusing to groups of women who used to cling to more traditional values. The findings here are consistent with theories about innovation diffusion and influence [28, 29, 33]. Some groups in society do function as opinion leaders and reference groups for others.

FGM is entrenched in community traditions and structures, and often there are strong social pressures to conform to tradition. In many cases it would be considered poor parenting not to have one’s daughters cut, as this would diminish the social status not only of these daughters but of the entire family [22, 23, 30, 37]. Often these community structures and processes not only limit exposure to new information, including messages that oppose FGM, but also limit their ability to act on them. Groups that have weak traditional community social controls are more likely to be responsive to messages that discourage FGM, and more likely to change their attitudes toward FGM and to stop practicing it. The two segments of society that are known to be least susceptible to traditional pressures are the modern elites and marginal groups (such as the very poor, and religious and ethnic minorities). Because of the social barriers that marginal groups tend to face, they are less likely to function as role models. The modern elites, on the other hand, are much better situated to act as role models. Members of modern elites are often urban, better educated, employed in the more modern sectors of the economy, and exposed to foreign media and ideas. Moreover, because these groups rely less on traditional sources of status, they are better equipped to abandon traditional practices. These elites can increase or maintain their status and ensure their daughters’ future by means other than FGM. Therefore, it is less important for them to have their daughters cut.

A main limitation of the results presented here is that the EDHS samples do not include never-married women. Therefore, the younger cohorts (15–19 and 20–24) in the samples may not be representative of all women in those age categories. As early marriage is more common among more traditional segments of society the EDHS may underestimate the opposition to FGM in these age groups [5]. The current analysis does not provide any information about opposition to FGM among men. However, although the EDHS surveys are limited to ever married women, the findings may be indicative of trends in the larger population.

A second limitation of this study is that it focuses exclusively on attitudes towards FGM. Although attitudes feature prominently in many models of behavior change [9, 11, 12], changing attitudes toward FGM is not sufficient to eliminate the practice of FGM. Even if women are ready and willing to stop cutting their daughters, they also need to be able to do so [13, 14]. Whether or not to have one’s daughter undergo FGM is rarely an individual decision by the mother. In most cases such decisions involve other household and family members. Hence, it remains unclear to what extent the observed changes in attitudes towards FGM among ever-married women will result in an actual decline in the prevalence of daughters who experience FGM.

The results from this study confirm that opposition to FGM is spreading among Egyptian women. To the extent that the spread of these sentiments is due to the improvement of the position and status of women in Egyptian society and mainly driven by improvements in education there may not be a need for additional campaigns that specifically discourage FGM. Instead, it may be better to focus on improving Egyptian women’s position in general, for example by expanding educational opportunities for women. Although we observe that women’s opposition to FGM has been spreading beyond these modernized and, to some extent. Westernized groups, substantial differences remain among the various segments of society, with some groups of women still lagging considerably. For these groups additional intervention campaigns may remain necessary to discourage FGM.

Our analyses do not allow us to evaluate the effect of the legal ban of FGM on societal attitudes towards FGM. Although one can hope that the legal ban on FGM will speed up its delegitimation, as has been the case with bans on other harmful practices, it remains unclear whether this has actually been the case. We observe that FGM opposition kept spreading after the ban went into effect, although at a slower pace. This finding is consistent with the arguments of Hassanin and Shaaban [37] who also concluded that the impact of the legal ban on the prevalence of and attitudes towards FGM was limited at best. Of course, much depends on how rigorous the new laws will be enforced. In the past the Egyptian authorities hardly ever enforced measures against FGM, as influential parts of society opposed these measures. To be successful such a ban needs the support of influential groups in society, including the leading clergy. In this regard the political events of the past few years in Egypt certainly do not bode well for the fight against FGM. There is little doubt that the fight against FGM has not been a priority in recent years, and currently FGM does not feature prominently on the government’s agenda. Thus, it appears that efforts to eradicate FGM in Egypt may be stalling, only a small number of cases have been brought to justice since the new law went into effect in 2008 [39]. The resurgence of more traditional forms of Islam may mean that attitudes toward FGM may become less determined by structural factors, such as the socio-demographic characteristics included in this study. Nevertheless, comparison of the 2008 and 2014 data shows that sentiments opposing FGM have increased among almost all segments of Egyptian society, although the increase in opposition to FGM has slowed down compared to earlier this century. Whether this is due to the events of the last few years, and whether the increase in opposition to FGM will continue remains to be seen. However, the current political, cultural and economic situation in Egypt does not appear favorable for the social advancement of women, and therefore for the battle against FGM.