Reliability of self reported form of female genital mutilation and WHO classification: Cross sectional study

Department of Obstetrics and Gynaecology, University of Khartoum, Al Kharţūm, Khartoum, Sudan
BMJ (online) (Impact Factor: 17.45). 08/2006; 333(7559):124. DOI: 10.1136/bmj.38873.649074.55
Source: PubMed


To assess the reliability of self reported form of female genital mutilation (FGM) and to compare the extent of cutting verified by clinical examination with the corresponding World Health Organization classification.
Cross sectional study.
One paediatric hospital and one gynaecological outpatient clinic in Khartoum, Sudan, 2003-4.
255 girls aged 4-9 and 282 women aged 17-35.
The women's reports of FGMthe actual anatomical extent of the mutilation, and the corresponding types according to the WHO classification.
All girls and women reported to have undergone FGM had this verified by genital inspection. None of those who said they had not undergone FGM were found to have it. Many said to have undergone "sunna circumcision" (excision of prepuce and part or all of clitoris, equivalent to WHO type I) had a form of FGM extending beyond the clitoris (10/23 (43%) girls and 20/35 (57%) women). Of those who said they had undergone this form, nine girls (39%) and 19 women (54%) actually had WHO type III (infibulation and excision of part or all of external genitalia). The anatomical extent of forms classified as WHO type III varies widely. In 12/32 girls (38%) and 27/245 women (11%) classified as having WHO type III, the labia majora were not involved. Thus there is a substantial overlap, in an anatomical sense, between WHO types II and III.
The reliability of reported form of FGM is low. There is considerable under-reporting of the extent. The WHO classification fails to relate the defined forms to the severity of the operation. It is important to be aware of these aspects in the conduct and interpretation of epidemiological and clinical studies. WHO should revise its classification.

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    • "There are relatively few studies which provide information about self-reports and clinical information on FGM status thus making it possible to assess the level of agreement between reported and observed forms of FGM [19, 23, 30, 32, 35–37]. In these studies, the accuracy between self-reported and observed FGM status ranged from 94% in Egypt [35] to 57% in Nigeria [36], suggesting that results based only on self-reporting might be unreliable. "
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    ABSTRACT: Objective. To determine forms of female genital mutilation (FGM), assess consistency between self-reported and observed FGM status, and assess the accuracy of Demographic and Health Surveys (DHS) FGM questions in Sierra Leone. Methods. This cross-sectional study, conducted between October 2010 and April 2012, enrolled 558 females aged 12-47 from eleven antenatal clinics in northeast Sierra Leone. Data on demography, FGM status, and self-reported anatomical descriptions were collected. Genital inspection confirmed the occurrence and extent of cutting. Results. All participants reported FGM status; 4 refused genital inspection. Using the WHO classification of FGM, 31.7% had type Ib; 64.1% type IIb; and 4.2% type IIc. There was a high level of agreement between reported and observed FGM prevalence (81.2% and 81.4%, resp.). There was no correlation between DHS FGM responses and anatomic extent of cutting, as 2.7% reported pricking; 87.1% flesh removal; and 1.1% that genitalia was sewn closed. Conclusion. Types I and II are the main forms of FGM, with labia majora alterations in almost 5% of cases. Self-reports on FGM status could serve as a proxy measurement for FGM prevalence but not for FGM type. The DHS FGM questions are inaccurate for determining cutting extent.
    Full-text · Article · Sep 2013 · Obstetrics and Gynecology International
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    • "In Egypt, type I and II are the most commonly reported types of FGM while in Africa type II accounts for up to 80% of all cases [23]. Studies that are based on clinical examination have documented large variations in the level of agreement between self-reported descriptions and clinically observed types of FGM [16,27-30]. Both under-reporting and less commonly over-reporting have been documented. "
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    ABSTRACT: Iraqi Kurdistan region is one of the areas where female genital mutilation is reportedly widely practiced but inadequately studied. The aim of this study was to determine (i) the prevalence of female genital mutilation among Muslim Kurdish women in Erbil city, (ii) the patterns and types of female genital mutilation, (iii) the factors associated with this practice and (iv) women's knowledge and attitudes towards this practice. A cross-sectional study was conducted in the primary health care centers and the Maternity Teaching Hospital in Erbil city, involving 1987 women aged 15--49 years. Data were obtained about female genital mutilation status and knowledge and perception towards this practice. The participants were clinically examined to verify the self-reported female genital mutilation status. The self-reported prevalence of female genital mutilation was 70.3%, while it was 58.6% according to clinical examination of the women's genitalia. The most common type of female genital mutilation was type I (99.6%) and the most common age at which mutilation was performed was 4--7 years (60.2%). This practice was mostly performed by traditional birth attendants (72.5%). Only 6.4% of mutilated women reported having complications after mutilation, most commonly bleeding (3.6%). The practice was more reported among housewives (OR = 3.3), those women whose mothers were mutilated (OR = 15.1) or with unknown mutilation status (OR = 7.3) and those women whose fathers were illiterate (OR = 1.4) or could only read and write (OR = 1.6). The common reasons for practicing female genital mutilation were cultural tradition (46.7%) and dictate of religion (38.9%). Only 30% of the participants were aware about the health consequences of female genital mutilation. More than one third (36.6%) of the women support the practice and 34.5% have intention to mutilate their daughters. Prevalence of female genital mutilation among Muslim Kurdish women in Erbil city is very high; although, most cases are of type I. There is clear lack of knowledge about the health consequences of female genital mutilation and a relatively important segment of women support this practice. Custom or tradition and dictate of religion are the main reasons for this practice that need further in-depth exploration.
    Full-text · Article · Sep 2013 · BMC Public Health
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    • "Nevertheless, none of the participants clearly indicated to have his/her daughter subjected to this mild type. Prior studies on FC among both Somalis in exile and other similar communities argued that circumcisers may claim that they performed Sunna when they really performed a more extensive form [32, 45]. At this stage, we do not know whether or not the circumcisers decide what to cut and what not to cut, or whether it is the parents who should regulate the extent of the cut to be performed by the practitioner. "
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    ABSTRACT: Somalia has the highest global prevalence (98%) of female circumcision (FC), and, despite a long history of abandonment efforts, it is not clear as to whether or not these programmes have changed people's positive attitudes toward the practice. Against this background, this paper explores the attitudes of Somalis living in Hargeisa and Galkayo districts to the practice of FC. Methods. A purposive sampling of 24 Somalis, including activists and practitioners, men and women, was conducted in Somalia. Unstructured interviews were employed to explore the participants' knowledge of FC, their attitudes toward the continuation/discontinuation of the practice, and the type they want to continue or not to continue. Result. The findings of this qualitative study indicate that there is a strong resistance towards the abandonment of the practice in Somalia. The support for the continuation of Sunna circumcision is widespread, while there is a quite large rejection of Pharaonic circumcision. Conclusion. Therefore, since the “zero tolerance policy” has failed to change people's support for the continuation of the practice in Somalia, programmes that promote the pinch of the clitoral skin and verbal alteration of status, with the goal of leading to total abandonment of FC, should be considered for the Somali context.
    Full-text · Article · Apr 2013 · Obstetrics and Gynecology International
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