The Attitudes toward Female Genital Mutilation: A Survey among the Residents of Uramanat Region, Iran

Female genital mutilation (FGM) refers to the practices that manipulate, change or remove the external genital organs of girls and women (1). The World Health Organization (WHO) has classified FGM/C as four major types, which range from the partial or total removal of the clitoris to infibulation, in which case the vaginal opening is narrowed through the creation of a covering seal. A traditional circumciser (mostly an elderly woman) with no medical background and training typically performs FGM (2). The current data regarding FGM show that over two hundred million women are circumcised, while three million women are currently at the risk of circumcision. Population growth, especially in the countries where circumcising women is common, has raised the concerns about the increased risk of FGM (3-7). While the exact number of the girls and women who have undergone FGM/C worldwide remains unknown, the United Nations Children’s Fund (UNICEF) has estimated that at least 200 million girls and women alive have undergone FGM/C in 30 countries with nationally representative prevalence data (2). If the practice continues at the current rates, it has been predicted by the United Nations Population Fund (UNFPA) that 68 million girls will be subject to FGM/C by 2030 (4). In Iran, FGM/C has a long history and is known as Khatne or Sonat (3). In many parts of the world, the decline of the practice is slow, while in Iran, the FGM/C rates are dropping rapidly.

FGM/C is often referred to as Khatne or Sonat in Iran, and the national data in this regard remain unclear (8). Similar to other social issues, data is scarce regarding FGM and its prevalence in Iran, and limited research has been focused on this practice (9-11). FGM is carried out in homes by family members (especially mothers) in Iran, and there are no accurate data available in this regard. FGM is a traditional practice in Iran, and due to the lack of adequate data, researchers are unable to discuss the existence of this practice in the society. According to the few studies on FGM, its practice has been confirmed in four provinces of Iran, including Hormozgan province, and the Sunni regions of the north western and western provinces, especially the cities and villages near the border of Iraqi Kurdistan. The prevalence of FGM in these provinces varies from one region to another and from one village to the neighboring village in some cases (12-15).

According to the WHO (2014), two types of female circumcision are performed in Iran, one of which involves the cutting of the tip of the clitoris, and the other entails the cutting of parts or all of the labia minora, in addition to the tip of the clitoris. Based on the religious beliefs of Iranians, there are two types of girls who would not be circumcised, including those who have a small clitoris tip, which is believed to have been circumcised by angels before they were born, and those whose families or mothers do not want to circumcise their daughters, in which case the girl's skirt is torn with a razor to wipe out guilty conscience (13, 16-18). Based on the Sunni Shafi’ie religion, a woman should be circumcised, and families (especially mothers) want to practice this on their daughters. Khatana is frequently performed by "dayeh" (midwives), mothers or the old women in the family without anesthetizers or the observance of health conditions. A shaving razor is used for cutting the head of the clitoris (Balokah); midwives (dayeh) use Betadine to clean and ash wood to prevent the bleeding of the cut piece. Khatana would last 10-20 minutes.

FGM is deeply rooted in the traditions of the society and is a severe form of violence against women through tradition (14, 18-22). Traditional ideas, religious beliefs, and social pressure seem to be the most important reasons for the practice of FGM in Iran. Due to the religious segregation In Iran, the Shiite religious community does not comply with FGM since they believe it is a Sunni practice, which should not concern or involve these particular followers of Islam. Due to this difference, FGM is not considered an important issue to be discussed by authorities such as the health, social, and welfare organizations and universities in Iran, and no official attempts have been made to eradicate FGM/C due to the lack of trust in the Sunni population (13).

In Iran, there are no laws to ban the practice of FGM, and no previous studies have elaborated on female circumcision in Iran. The present study was conducted in Kermanshah province (Iran), which has residents of diverse ethnic, religious, and social groups, with the aim of assessing the beliefs and understanding of the phenomenon among the Uramanat residents (Javanrood, Ravansar, Salas, and Paveh cities) and comparing the differences in the responses of the male and female residents of these areas.

A researcher-made questionnaire was distributed among the first 250 male and female residents of four cities of Kermanshah province during 15 days in February 2018. The questions and guidance were provided in Persian. Demographic data included age, gender, religion, education level, and marital status, which were collected and analyzed. In addition, the awareness of the residents regarding FGM and its complications was evaluated.

Data analysis was performed in SPSS using the two-tailed t-test, and the P-value of less than 0.05 was considered significant.

The respondents were from various cities, including Javanrood (50.2%), Ravansar (15.1%), Salas (33.6%), and Paveh (12.2%). In addition, 99.8% of the respondents were Muslims, 110 (53%) were male, and 97 were female (47%) were women. The mean age of the men and women was 32.6 ± 5.1 and 30.4 ± 5.8 years, respectively (Table 1).

According to the findings, 25.21% of the male respondents were in favor of FGM, as well as 10.3% of the women (P < 0.01). The positive attitudes toward this practice were religious (men: 7.8%, women: 50%), social and cultural (men: 10%, women: 10%), sexual (men: 7.1%, women: 10%), and a combination of these factors (men: 10.5%, women: 30.1%) (Table 1).

According to the obtained results, 81% of the men and 84.2% of the women were against FGM. A small proportion (men: 31.5%, women: 25%) were aware of the sexual, menstrual, and labor issues and other FGM complications, and 54.9% of the men and 64.5% the women considered FGM to be legal. In terms of religious recommendations for FGM, 81.08% of the men and 88.5% of the women favored the practice, while 6.3% of the men and 4.2% of the women were against the practice. Although 66.8% of the women had undergone FGM, most of the men and women (75%) were unaware of its complications.

The findings of the current research indicated that 57.8% of the men preferred the women who experienced FGM as their future spouses, and only 11.7% indicated a preference for a spouse with healthy female genitalia, while 16.5% did not assume circumcision would influence their marital life. In addition, 78.7% of the married men had circumcised spouses, and 11.8% were not aware if the spouse was circumcised or had uncircumcised spouses (Table 1).

In total, 64% of the circumcised women stated that their mothers were the decision-makers of the practice, while the grandmothers and fathers were the decision-makers in 12.5% and 22% of the cases, respectively. When the residents were asked whether the practice of FGM should continue, 78.8% of the men and 88.5% of the women stated that the practice should be abolished (P = 0.13), while only a small proportion (15.3% of men and 4.9% of women) believed that the practice should continue (P < 0.01) (Table 1).

To date, few studies have investigated the prevalence of FGM in the women of Uramanat area in Kermanshah province (Iran). For instance, Ahmadi (2015) has reported that 95% of the women in Uramanat have been circumcised, while the prevalence of FGM was lower in the present study in this region (68%).

Our research indicated that a minority of the residents were aware of FGM complications (men: 31.5%, women: 25%), which contributed to the belief of these individuals in the continuation of this practice. Only 21% of the men and 11.5% of the women either favored FGM or were uncertain in this regard. Therefore, it could be inferred that cultural and religious beliefs and the community continue to support this tradition without attention to the associated risks with FGM. In the current research, the residents who favored the practice stated that it is a religious dictate (78% of men and 50% of women), mentioning that it has been advised by Prophet Muhammad "This is a Sonat."

The Iranian law is rather vague about FGM, and as a result, there have been no reported cases of successful prosecutions against those who commit this practice. In the present study, this issue was reflected in the responses of the residents to the question of the association between FGM, the laws against FGM, and religion. Reducing the prevalence of FGM may not be a true reflection of the practice, and it is hoped that public knowledge increase regarding the complications of FGM to eradicate the practice. According to our findings, mothers (64%) and grandmothers (12.5%) were mainly responsible for the decision to circumcise girls, which highlighted the role of women in this inhuman action.