Epidemiology, Regional Characteristics, Knowledge, and Attitude Toward Female Genital Mutilation/Cutting in Southern Iran

Epidemiology, Regional Characteristics, Knowledge, and Attitude Toward Female Genital Mutilation/Cutting in Southern Iran

 Maryam Dehghankhalili, MD,* Soghra Fallahi, MD, Forugh Mahmudi, MD,Fariborz Ghaffarpasand, MD, Mohammad Esmaeil Shahrzad, MD, Mohsen Taghavi, MD, and Marjan Fereydooni Asl, MD

*Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Research Center of Molecular Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran; Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran; Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

A B S T R A C T

Introduction. Female genital mutilation/cutting (FGM/C), also known as female circumcision, is an ancient traditional procedure that involves partial or total removal of the female external genitalia for nonmedical reasons. Although it is well described in African and some Arabic countries, data from Iran are scarce.

Aim. To describe the epidemiology, regional characteristics, knowledge, and attitude toward FGM/C in Southern Iran.

Methods. This cross-sectional study was conducted during a 36-month period from 2010 to 2013 in Hormozgan, a southern province of Iran near the Persian Gulf. We included 780 women in six major rural areas of the province who referred to healthcare centers for vaccination, midwifery, or family planning services. All participants underwent complete pelvic examination to determine the type of FGM. The questionnaire consisted of several sections such as demographic and baseline characteristics, and two self-report sections addressing the knowledge and attitude toward FGM/C and its complications. Baseline sociodemographic characteristics including age, educational level, marital status, religion, and nationality were the independent variables.

Results. Among the participants, 535 (68.5%) had undergone FGM/C. FGM/C was associated with higher age (P = 0.002), Afghan nationality (P = 0.003), Sunni Islam as religion (P = 0.019), illiteracy (P < 0.001), and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). Ancient traditions in the area (57.1%) were mentioned as the most important factor leading to FMG/C. Urinary tract infection was the most common reported complication (60.4%).

Conclusion. FGM/C is a common practice in rural areas of Southern Iran. It is associated with increased age, illiteracy, Sunni Islam religion, Afghan nationality, and positive family history. Lack of knowledge toward FGM/C is the main cause of its high prevalence and continuation in the area. Dehghankhalili M, Fallahi S, Mahmudi F, Ghaffarpasand F, Shahrzad ME, Taghavi M, and Fereydooni Asl M. Epidemiology, regional characteristics, knowledge, and attitude toward female genital mutilation/cutting in Southern Iran. J Sex Med 2015;12:1577–1583.

Key Words: Female Genital Mutilation/Cutting; Female Circumcision; Knowledge and Attitude; Determinants; Iran

Introduction

Female genital mutilation/cutting (FGM/C), also known as female circumcision, is an ancient traditional procedure that involves partial or total removal of female external genitalia for nonmedical reasons [1,2]. According to the World Health Organization (WHO), there are four main types of FGM/C: type I (clitoridectomy), type II (excision), type III (infibulation or pharaonic circumcision), and type IV, which are used to describe all other harmful procedures to the female genitalia in the absence of medical necessity [3]. The nomenclature for the practice varies across regions, ideological perspectives, and research frames. We use the expression preferred by United Nation’s International Children’s Emergency Fund and United Nation’s Population Fund, the two central policymakers in the global effort to end the practice, “female genital mutilation/cutting” (FGM/C) [1]. Since the early 1970s, Western efforts to end FGM/C have relied primarily on two frames that have influenced the discourse of FGM/C and, in turn, the ideological contestation over the practice [4,5]. FGM/C has not only been associated with violation of human rights, but has also been shown to be associated with impaired physical and mental health [6,7]. Several physical and mental complications have been associated with FGM/C including pain, bleeding, localized infection and abscess formation, pelvic inflammatory disease (PID), sepsis, tetanus, urinary problems such as urinary tract infection (UTI), hepatitis and human immunode ficiency virus (HIV) infection, and reproductive problems. Psychiatric complications include post- traumatic stress disorder (PTSD), flashbacks to the event, and affective disorders [8–10].

FGM/C is a worldwide practice being mainly reported in African and Middle Eastern countries. It has been estimated that about 100 and 140 women and girls have experienced FGM/C [11]. FGM/C is currently practiced in more than 28 countries among different ethnic and religious groups. It is estimated that about 1.5 million girls undergo FGM/C annually [12]. Although the epidemiology has been evaluated in several countries, the predictive factors and social determinants remain unknown and undetermined. Such data would be helpful for understanding the variation in the frequency of FGM/C as well as trends for its performance despite the legislations. In addition, reports from Iran are scarce, and only few studies have addressed the issue, previously [13,14]. Accordingly, we performed the current study in order to estimate the prevalence of FGM/C and the knowledge and attitude of women toward it in Southern Iran. We also aimed to identify the correlates of these beliefs to identify high-risk subpopulations.

Materials and Methods

Study Population

This cross-sectional study was carried out in a 36-month period from September 2010 to September 2013 in Hormozgan, which is a Southern region near the Persian Gulf in Iran. Hormozgan province has an area of 70,697 km2 (27,296 sq mi), with Bandar Abbas being its capital. The province has 14 islands located in the Persian Gulf and 1,000 km (620 mi) of coastline. The estimated population of the province, according to the latest census in 2011, is 1,578,183 people, and an estimated 789,712 people live in rural areas. Overall, 384,589 women live in the rural areas of the province. The current study included all the women living in six major rural areas of Hormozgan including Minab, Dehbaz, Bandar-e-Lenge, Qeshm, Bandar-e-Khamir, and Bastak. The total population size and the population of women in these six areas are 179,445 and 86,669, respectively.

We included all the women who referred to healthcare centers of these six areas, within the study period. These women referred to the health care centers to receive vaccination, midwifery, or family planning services. The women were selected consecutively and were included in the survey. The study protocol was approved by the Institutional Review Board (IRB) and the Medical Ethics Committee of Hormozgan University of Medical Sciences. All the participants provided their informed written consents before entering the study.

Study Protocol

All the particpats were interviewed by a trained medical student visiting the healthcare centers for the research project as well as providing healthcare services. All the participants underwent complete pelvic examination in the lithotomy position by the female trained medical student and a midwife. The presence and type of FGM was identified according to the WHO classification and was registered into the data collection forms. The data collection form consisted of several parts including demographic information, knowledge, attitude, and beliefs toward FGM/C. The age at which the FGM was performed was recorded according to the patient’s own or parents’ information. First, participants were asked, “Have you ever been circumcised?” (yes/no). Second, participants were asked, “Do you think this practice should be continued?” (yes/no). Participants who had not heard of FGM/C or female circumcision were also recorded. Our independent variables were basic sociodemographic characteristics such as age, education (illitrate, primary, high school, diploma, MS degree, above), marital status (currently married, single), religion (Shia or Sunni Islam), and nationality (Iranian, Afghan, Arab). We also recorded the family history of FGM/C in mother, sister, and grandmother.

Statistical Analysis

All data were entered into a computer-based data- base and were further analyzed. Statistical package for social sciences (SPSS Inc., Chicago, IL, USA) version 16.0 was used for all statistical analyses. Data are reported as mean ± SD and proportions as appropriate. Parametric data were compared between those undergoing FGM/C and controls using independent t-test, while proportions were compared using chisquared test. A two-sided P value of less than 0.05 was considered as statistically significant.

Results

Overall, we included 780 women who participated in the survey, from the rural areas of Hormozgan. The mean age of the participants was 30.5 ± 14.6 (ranging from 14 to 38) years, and their mean age at which they first had their FMG/C was 5.6 ± 3.6 (ranging from 2 to 38) years. Among the participants, 535 (68.5%) had undergone FGM/C. Thus, the estimated number of the women being circumcised in the area according to screened the population (86,669 people) would be 59,446. In other words, the prevalence was 68,589 in each 100,000 rural female population. The baseline characteristics of the study population are summarized in Table 1. Most participants were married (68.3%) and Iranian (93.1%). The great proportion of the participants were illiterate (36.6%) and had family history of FGM/C. Clitoral nicking was the most common performed procedure (28.7%) followed by type I (clitoridectomy) FGM/C (27.9%).

Table 2 demonstrates the determinants of the FGM/C in the study population. Those who have had undergone FGM/C were significantly older (P = 0.002) when compared with controls.

FGM/C was more likely to be performed among Afghans compared with Iranians (P = 0.003) and among married women compared with singles (P < 0.001). FGM/C was associated with Sunni Islam as religion (P = 0.019) and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). The frequency of illiteracy was significantly higher among those who have had undergone FGM/C compared with controls (P < 0.001). In the same way, the years of education were significantly lower among FGM/C group when compared with controls (4.6 ± 1.3 vs. 9.6 ± 2.6 years; P = 0.013).

The knowledge and attitude of the participants toward FGM/C and its complications are summarized in Table 3. The most common belief regarding the performance of FGM/C was the ancient traditions of the area (57.1%). Religious instructions were mentioned by 30.3% of the participants, while increasing self-libido (25.8%) and the partners’ sexual arousal (32.1%) were other common causes of performing FGM/C. Mothers had higher intention to continue the practice compared with fathers (40.6% vs. 14.9%; P < 0.001). Overall, 70.6% of those who had undergone FGM/C reported some types of complications (Table 3). UTI was the most common reported complication (60.4%) followed by procedure bleeding (56.7%), itching (51.7%), and burning sensation (46.7%). Also, 8.8% participants reported psychiatric disorders. PTSD was the most common diagnosed mental disorder.

Discussion

FGM/C is a widespread practice being an ancient tradition since antiquity. It persists today primarily in Africa and among small communities in the Middle East and Asia. According to WHO reports, about 100 million women worldwide had undergone FGM/C, while 4 and 5 million procedures are performed annually among female infants and girls [1]. The most severe and invasive subtypes of FGM/C has been reported in Somalian and Sudanese population [15]. Several reports have described the knowledge and attitude as well as epidemiology of the FGM/C in African and Middle East countries. However, data from Iran are scarce. To the best of our knowledge, this is the first study from Southern Iran reporting the prevalence and determinants, as well as knowledge and attitude toward FGM/C. We found that the prevalence of FGM/C was considerably high in Southern Iran despite previous reports [16].

The estimated prevalence of FGM/C varies widely among countries where FGM/C is a routine procedure. This is contrary to the fact that all these countries are geographically neighbors [17]. The differences in epidemiology and characteristics of FGM/C are due to social, historical, traditional, and political variations between countries. More recent studies have demonstrated that nine out of 10 women and girls in Djibouti, Egypt, Guinea, Mali, Northern Sudan, Sierra Leone, and Somalia undergo the procedure annually [12]. It has been also reported that about 87 million girls have undergone the procedure in 27 African countries and Yemen [18]. In the same way, the estimated number of women who have undergone FGM/C was 28,170; 24,710; and 23,240 in Nigeria, Egypt, and Ethiopia, respectively [12,18,19]. We found that 68.5% of all women in Southern rural areas of Iran have undergone some types of FGM/C. Our results are comparable with previous reports from Southern [13] and Northern [14] Iran which showed a prevalence of 70% and 55.7%. This shows that the prevalence of FMG/C is approximately high among rural areas of Iran. The mean age of the participants in the current study was 5.6 ± 3.6 years, which was lower when compared with previous reports from Iran (9.2 ± 14.2 years) [14]. We conclude that the practice is being performed among lower age groups in Southern Iran. The 15- to 19-year age group is considered to be the most common age for FGM/C in most African countries [17,19]. We also found that the prevalence increased by age. Interestingly, we found that some of the girls received FGM after 18 or 21 years of age.

The age at which FGM is performed varies between countries and even from area to area within the same country; sometimes, it is performed soon after birth and sometimes before marriage [5,6]. We found that the procedure is mostly performed by local circumcisers (47.4%) and grandmothers (39.2%). This is consistent with other studies. Pashaei [14] indicated that the majority of mutilations were performed by traditional midwives and old women (96.4%) who did not use anesthesia (100%). Tag-Eldin et al. [20] also showed that FGM/C among Egyptian women are mostly performed by local circumcisers who do not use local anesthesia. The data of the present study demonstrate that lower educational level is significantly associated with increased prevalence of FGM/C, which is consistent with previous reports from Iran and African countries [14,17,21–23]. The interesting finding of this study was that the FGM/C in southern rural areas of Iran was associated with Sunni Islam as religion. In other words, those with Sunni Islam are more willing to perform the procedure and continue it. Previous reports have shown that FGM/C is associated with Islam as religion [2,16]. Taking all the studies together, it could be concluded that being older, having less education, and being currently or formerly married as opposed to never married is associated with increased odds of having been circumcised. In addition, being Muslim also increases the odds for being circumcised. We have also shown that Sunni Islam is associated with higher prevalence FGM/C when compared with Shia Islam. This could be explained due to higher prevalence of Sunni Muslims in the area. The other explanation is that the Sunni Muslims are more conservative and traditional compared with Shia Muslims in these areas of Iran. It has been also shown that being older, having less education, and being Muslim are associated with higher odds of having had a daughter circumcised [17]. We also demonstrated that positive family history of FGM/C in grandmother, mother, and sister is significantly associated with higher prevalence of FGM/C. Consistent with previous reports, we found that type I FGM/C was the most common performed procedure in the region [1,13,14,17,20,24]. However, clitoral nicking was even more common. This shows that the practice is performed minimized in this region which is limited to nicking and scratching the clitoris.

FGM/C has been associated with several health consequences including long-term and short-term complications [8,25,26]. As many women undergo FGM  in  infancy,  they  may  not  experience any immediate adverse effects. Accordingly, Obermeyer [26] believes that FGM is associated with few number of complications and health consequences and that the hypothesized complications attributed to the FGM/C are not supported by evidence. According to the WHO [11], the immediate complications include infection, urine retention, severe pain, shock, hemorrhage, and death. Long-term consequences of types I and II include abscess, scar neuroma, and the formation of keloid and dermoid cysts. Long-term complications of the type III procedure include those mentioned for types I and II as well as dysmenorrhea, urinary incontinence, and vaginal stenosis. The HIV, hepatitis B, and other blood borne diseases may be transmitted through all forms of FGM [1,11]. As most of our patients were type I, the complications were minimal and limited. Chronic urinary and reproductive tract infections and PID are also linked with FGM. These problems are of particular importance because they are among the leading causes of infertility [8,25]. We also found that UTI and bleeding were the most common reported complications, while cyst formation and infertility were the least common complications. Pashaei [14] demonstrated that circumcised respondents suffered pain (48.2%) and bleeding (1.5%) after FGM. Several studies have showed that women undergoing FGM/C have decreased libido and higher frequency of sexual dysfunction [7,22]. This is considered among the most important mental complications of the procedure [9]. In this study, dyspareunia and decreased libido were reported by 39.6% and 17.2% of participants, respectively. It has also been shown that clitoral reconstruction is associated with improved libido and sexual function [27]. The important point that should be kept in mind is that although there is a global concern regarding HIV transmission via FGM, the direct causal link is still to be identified via large epidemiological studies [28].

We found that the most common reason for performing FGM/C was tradition (57.1%), cleanliness or making the girl Halal (40.1%), and partner’s sexual arousal (32.1%). Religion was mentioned by 30.3% of the participants, while increasing self sexual pleasure was reported by 25.8% of the participants. Pashaei et al. demonstrated that the reasons for FGM/C were tradition and customs (66.7%), cleanliness (17.2%), religion (2.8%), health (2.6%), and control of the sexual desire (1%). It is clear that tradition, religion, and social pressure were the main motives for performing FGM/C. In a study by Tag-Eldin et al. [20], the reasons for FGM were mainly religious (33.9%), cleanliness of the girls (8.9%), and social and cultural traditions (17.9% and 15.9%). Mohammed et al. [23] also reported that among Egyptian women, tradition, cleanliness, and virginity were the most common motives for FGM/C continuation (100%), followed by men’s desire, esthetic factors, marriage, and religion factors (45.2–100%). Our finding is consistent with a previous survey in Iran which showed that FGM/C is a social practice rather than a religious obligation [14]. Generally, there is no reason for FGM/C in Islam. It clear that Islam forbids damaging the human body, and there is no scriptural evidence in the religion to support of FGM/C [19]. The interesting finding was that 40.6% of the mothers mentioned that they would continue the practice for other children. This shows that lack of knowledge contributes to continuation of the practice in the region. More than 80% of the participants also mentioned that their mothers and grandmothers were the main decision makers for this practice. Regarding the role of the mothers and grandmothers in FGM/C, the results are similar to those reported by Tag-Eldin et al. [20] and Herieka and Dhar [29]. Therefore, according to our findings, interventional programs should put emphasis on women’s education on FGM/C hazards.

There were some limitations in our study. The current study was cross-sectional which included the women in the area in order to determine the characteristics of FGM/C in the area. We used a self-reported questionnaire for determining the knowledge and attitude of the participants toward FGM/C. We performed pelvic examination to determine the type of the procedure. This methodology only enables us to report the prevalence of sexual dysfunction among the participants according to their own opinion. Thus, we cannot comment on the association between sexual dysfunction and FGM/C. The other shortcoming of our study is that we did not include the spouses or the fathers of the participants of the study. The role of male partners in continuing the practice is an important issue which is not addressed in the current study. However, this is the first large study on FGM/C in Southern Iran which provides valuable information on characteristics and knowledge toward FGM/C in Iran. Further population interventional studies based on education and media are required to decrease the incidence of FGM/C in the area.

In conclusion, FGM/C is a common practice in rural areas of Southern Iran and is associated with increased age, illiteracy, Sunni Islam religion, Afghan nationality, and positive family history. Lack of knowledge toward FGM/C is the cause of this high prevalence. Increasing the target population knowledge regarding FGM/C via public media and schools would be necessary to cease the continuation of the practice in the region.

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we will have meetings with scholars on circumcision of girls

we will have meetings with scholars on circumcision of girls

After announcing numerous reports through various associations and publishing materials, finally one of the provincial governors of Hormozgan was well informed:

Director General of the Office of Social and Cultural Affairs of Hormozgan Governorate has stated that we will have meetings with scholars on circumcision of girls.

Director General of the Office of Social and Cultural Affairs of Hormozgan governorate has stated that there is no definite statistics on the circumcision of girls, but the majority of the people of the province adhere to this issue. He has said that since this issue is based on religious principles, it is very difficult to get into this issue and it is opposed to this unless the attitudes of the scholars and religious leaders of these societies change. We have plans in this regard. One of the plans is to send advisers to have meetings with scholars and elders in these areas and say that female circumcision has a very negative psychological impact.

He remarked: At the meetings of the Social Security Staff, we opened the girls’ discussion about the circumcision, and the mindset was getting more prepared. We had meetings with advisers and talked, and now it’s better to have an interventionist approach in this regard.

This despite the fact that the director of public relations at Bandar Abbas University of Medical Sciences (Norouzian ) had said: Female circumcision is not routine and it is not known, and if it is done in the family, it is completely secretly, not in the doctor’s office. This action is a moral, legal, medical, and health mistake, and if we know who is doing these activities, we will surely avoid it, but because it is done in secret, it is unidentifiable. Because this is not common practice, public education cannot be provided, but in the past 20 years when this was done in Kong Bandar, one of the health center personnel at that time was able to educate and inform the inhabitants of the port about the progress of this action.

Also, Pari Sayyadi, Director General of the Office of Women and Family Affairs of Hormozgan Province has stated:

The statistics provided by some sites are far from reality. We have not seen such a case during the periodic trips we have to the provincial towns. I myself have witnessed cases of female genital mutilation in other provinces that I did not name, but about women 40 years ago. Of course, in the same provinces, that is not common.

A new announcement of a meeting with scholars shows that officials and practitioners have finally accepted the practice of circumcision in the province. It is hoped that such news will be heard in other provinces like Kermanshah, Kurdistan and East Azerbaijan.

Statistics show that with different distributions, about 60% of women living in Hormozgan Province tend to circumcise their daughters; this figure in other provinces is about 30%. In 1394 (2015), some news reported that a girl in Buchan was referred to the hospital due to the severity of the injuries caused by hemorrhage and severe hemorrhage. It was hoped that such an accident would alarm the authorities!

Female sexual abortion is prohibited in many countries of the world. In Iran, according to some current laws, Diyah (blood money) is also granted to female genital mutilation.

Article 664 of the Islamic Penal Code, adopted in 2013, also states that “the removal of either side of the woman’s genitals causes half of the woman’s full diyah (blood money), and the interruption and destruction of some part of the body has Diyah.”In this decree, there is no difference between virgin and non-virgin, young and adult, healthy and defective, such as rebellion and coronation.

In addition to this article, other provisions of the same law have addressed similar issues:

Article 704: Eliminating the power of ejaculation or reproduction of a man or pregnancy of a woman or destroying the pleasures of male or female intercourse leads to Arsh.

Article 708: Eliminating or permanent or temporary damaging other senses such as trickling, sleeping, and menstrual periods, as well as causing diseases such as tremor, thirst, hunger, fear and faint lead to Arsh.

Article 449: “Arsh” is a non-tangled diyah which amount is not specified in the Shari’ah. The court determined the extent of the crime in terms of the type and quality of the crime and its impact on the health of the innocent and the amount of damage incurred by considering the deceased and with the opinion of the expert. The rules of determined Diyah are subject to Arsh, unless otherwise provided in this law.

Talking to circumcisers in Iran: Kind women, violent tradition

Talking to circumcisers in Iran: Kind women, violent tradition

Talking to circumcisers in Iran: Kind women, violent tradition

By Rayehe Mozafarian

More than 7000 communities across Africa are working to abandon FGM. But there are some other countries in the Middle East and Asia where FGM is also common as a tradition. Despite the efforts of some organizations in the Middle East and Asia mutual cooperation between the respective governments and international organizations is difficult in some countries such as Iran, Saudi Arabia, Pakistan and etc.

Daye1 KopieFGM is tradition and culture which is still continued by women themselves. Although FGM is also men’s demand it can only be kept alive if women are complicit. There are no reports that FGM is done by doctors, educated nurses or midwives in Iran. The studies show that girls are mostly mutilated by native women.

Local surgeon women who do this operation and have learned it hereditary are known as Daye. Most of them are old women who learned it from their mothers or grandmothers. In modern times one thing is particularly important to note that the process of becoming and being Daye still continues. “Becoming Daye” can be defined as the process in which a woman with her own desire, social craving, illness and death of a former Daye or etc. accepts responsibility for the mutilation of girls and after a while the others will know her as Daye. There will by Dayes for at least another 40 years as in some villages, young Dayes still accept this responsibility.

Daye with several other women (in most cases the mother) as an assistant or helper circumcise the girls. For reducing injuries, the assistant holds the girl’s hand and feet strongly to prevent additional movements. In some cases, it has been reported that FGM is done by the closest person for instance the mother, grandmother or aunts.Daye2 Kopie

FGM is usually done with a razor and without anesthesia medicine. It is rare that they use other kinds of sharp instrument. These women have different approaches to disinfect the place of cut. They often use Betadine, but in places where accessory to disinfection is difficult they use ashes of fire or cloths, natural soil and the smoke of turpentine.

In my travels to different parts of south, I visited various villages to find Daye and inquire about FGM. It can be estimated that there is at least one Daye in each village and in some can be found more.

I asked a Daye: “Why did you circumcise your granddaughter?” her face was broken and aging, laughed and said: “We have mercy, they cry and I can do the operation”. It was the points of view which should be corrected. In fact, I need to find the root of their passion for doing FGM which was completely different with my experience. Barbarity and cruelty were not a good reason.

Daye3 KopieMost people who have never seen these women think of them as butchers, violent, cruel and heartless but for me that I am in search of “why the continuation of FGM” for many years – and the presence of a Daye is one of the fundamental factors – the image of these women is different. Before I was so involved in the issue of FGM, I was surprised by the cruelty of these women. This image had changed when I traveled and talked to them myself. Their laughter, their hospitality, their warm greeting, shaking hands and kissing on their hands, all of them had no signs of cruelty and violence. They were deprived of the best education and facilities like all other disadvantages areas. But they would like to learn and continue their firm beliefs and circumcise the girls to practice and respect their religious tradition.

While most researchers believe that female genital mutilation is not rooted in Islam, people in areas where circumcision is carried out do so according to the Hadith of the Prophet and the Imams of the Shafi’i School to show thier commitment to religion. Although there is no compelling reason to do circumcision in Islam on girls.

DAye4 KopieWhat’s the solution?

4 steps to prevent the continuation of FGM must be considered. 4 social groups will be involved to improve their awareness.

  1. Stop the process of becoming a Daye

One of the important factors in development of each country is to reduce maternal mortality. This index is a good measure to show the extension of accessibility and availability of facilities, especially for pregnant women. So each country try to develop its potential to show its development such as access to health centers, facilitate transport and routes, especially in rural areas (rural network), emergency medical services, the cost of health care, women’s literacy status, etc.

In the eighties and nineties, the Ministry of Health and Medical Sciences decided to work together to improve the health of pregnant mothers and also promote the development of Iran. Then they start to find and identify local midwives in each villages and stop them assisting deliveries at home. These midwives were forced to sign a strong commitment to withdraw from their responsibilities. The project was very successful. The village can be found below where delivery takes place at home. This story can be repeated in the same situation for eliminating FGM in Iran. If the government wants, they can find the Daye, get them more right information then stop them to continue their jobs. Because more nurses who are active in FGM they worked as maternal health care.

  1. Improving the knowledge of women:

Another important aspect in reducing the prevalence of FGM is informing the women of the communities. Women’s literacy rates are not high in these areas so it is necessary to organize rural educational workshop and inform them of the dangers of FGM. Very good examples of these activities for the prevention of FGM are organized in Iraqi Kurdistan since more than 10 years ago with the participation of government and non-governmental organizations. Women gather together in each village, they watch an educational film, talk about their experiences and their sexual health issues and finally the session ends with the presentation of gifts. This session does not mean that the activists leave areas forever, after informing women the prevention process will be monitored.

  1. Informing religious leaders

Another social group who have an impact on the eradication of FGM are the Mullahs and religious leaders. The importance of this segment of society is due to its dominance on the traditions and religious traditions, Hadith and Quran and more importantly they have close relations with the men of the community. These religious leaders can make men aware of the dangers of FGM and persuade them to discontinue FGM with their religious messages.

  1. Doctors, midwives and nurses:

Experience has shown that residents of deprived areas share their physical health problems with the doctors and trust them to talk about everything. So the doctors explain about the danger of FGM and sexual hygiene. Because the doctors are being sent from different regions and FGM is underground, it is necessary to inform nursing and medical students.

WASTED YOUTH; Children’s Rights in Iran

WASTED YOUTH; Children’s Rights in Iran

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INTRODUCTION

Iran is a young country, with more than 28 million inhabitants under the age of 18 in 2011. However, the vast potential of this young, bright population is largely being squandered as a result of poor education policies, discriminatory legislation and insufficient child protections. Iran’s young people face a myriad of major challenges to their development, and it is essential that government and civil society work more closely together to develop long-term solutions.

Over the course of this report, we will engage with three primary clusters of rights taken from the core reporting clusters of the UN Convention on the Rights of the Child. These core reporting clusters include the right of children to be protected from violence, the right to education, and the right to health. Through an exploration of these three clusters, we hope to illustrate a number of the key obstacles to the happiness and full development of Iran’s young people.

This report will provide an overview of the current landscape around children’s rights in Iran and the challenges facing activists, advocates and children’s rights organisations as they work to improve the situation of young people in the country today. It will achieve this through an analysis of the internationally recognised legal frameworks that guarantee the rights of minors, the national legislation that exists to support these objectives, and a brief overview of a number of areas in which Iran is in violation of internationally recognised norms.

The report will also highlight the specific needs of Iranian children’s rights activists and organisations through a series of interviews with leading figures in the field and an analysis of a number of digital initiatives that have been established to raise awareness and mobilise the public around children’s rightsrelated issues. We will then outline a series of recommendations for the Iranian government, the activist community, and the international community which we hope will prove valuable in the development of future policy in the field of children’s rights, and maximise the opportunities available to Iran’s young people in the coming decades

FEMALE GENITAL MUTILATION IN IRAN

At the same time as underaged labour deprives children of bright futures, the scourge of child marriage locks many young girls and boys into a troubled present, vulnerable to violence, sexual abuse, and poor health. Additional threats to young girls’ reproductive health arise from the persistence of the practice of female genital mutilation (FGM) among a number of marginal communities, constituting a terrible violation of young girls’ human rights, and a real danger to their lives.

In the face of all these challenges, however, civil society is mobilising itself. Groups are being set up in urban and rural communities to provide schoolbooks and new facilities for economically deprived children. Other activists are developing campaigns about the negative impacts of child marriage and FGM, and are working with local community leaders to push back against these practices. But far more support is needed, both from Iranian authorities and the international community.

By speaking with activists on the ground and assessing a number of the initiatives they have developed in digital spaces, we aim to help provide some direction for Iranian and international organisations as they develop capacity building initiatives to support the great work being done by civil society organisations in Iran.

‘Stop FGM in Iran’ is a campaign aiming to eradicate the practice of FGM in Iran by educating the public about its disastrous effects upon girls’ and women’s physical and mental health. The website is aimed at providing information to the general public, and showcasing the organisation’s work to potential donors and supporters.

The website contains a variety of information about the practice of FGM, as well as information about the organisation’s events and seminars, stories from victims of FGM, and materials to draw public attention to the issue.

The campaigners argue that more needs to be done in order to completely eradicate the practice of FGM in Iran, through raising public awareness about the negative health impacts and providing government officials with information about its prevalence and practice. Much of the organisation’s own awareness-raising work is achieved through conducting seminars in the four worst affected provinces, and through engaging in face-to-face discussions with local people. The group also carries out documentation work of instances of FGM, which is then integrated into the group’s advocacy and public awareness initiatives.

The site is well-structured, and is well-populated with diverse content ranging from emotive stories to statistical analyses of FGM in Iran. However, a weakness of the site arises in the seemingly low levels of user engagement with most content. Similarly, the group’s Facebook community is only partially engaged with the group’s content. Although many posts manage to inspire a handful of shares, the number of discussions arising from the content appears to be minimal. Additionally, the campaign lacks any clear calls to

action that could serve to mobilise its not inconsiderable following to engage in actions to support the campaign’s objectives.

The campaign shares a Telegram channel with the Stop Early Marriage in Iran campaign. This channel shares website content from each of the two campaigns it features, alongside relevant news articles, images, and documentation.

Sexual Function, Mental Well-being and Quality of Life among Kurdish Circumcised Women in Iran

Sexual Function, Mental Well-being and Quality of Life among Kurdish Circumcised Women in Iran

Farzaneh DANESHKHAH 1, *Hamid ALLAHVERDIPOUR 1, 2, Leila JAHANGIRI 1, Tatiana ANDREEVA 3

  1. of Health Education & Promotion, Tabriz University of Medical Sciences, Tabriz, Iran
    1. Clinical Psychiatry Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
      1. School of Public Health, National University of Kyiv-Mohyla Academy, Kiev, Ukraine

Abstract

Background: Female genital mutilation is an intentional inhumane procedure that threatens girls and women’s health. It is especially widespread in developing countries due to cultural, traditional and religious preferences. The aim of the current study was to investigate how circumcision affects women’s sexual function.

Methods: This cross-sectional study was conducted in the urban and rural area of Piranshahr County, Iran, in 2015 among convenience samples of 200 women, 15-49 yr old, who were applying to health care centers for receiving rou-tine health care services. Data collection was conducted with the use of a self-administered written questionnaire to assess female sexual function, mental well-being, and quality of life.

Results: Significant differences were found between circumcised and non-circumcised women in total score of female sexual function index (FSFI) in domains of desire, arousal, vaginal moisture, orgasm, satisfaction, and pain [(P<0.001), MD(95%CI)=5.64(3.64 to 7.64)] and based on Hotelling’s T-square, significant differences were found in dimensions of quality of life and FSFI.

Conclusion: The revealed sexual dysfunction among mutilated women gives ground to require that public health sys-tems take actions aimed at implementing special sexual education program to improve sexual functions of mutilated women and changing beliefs and social norms in the community level.

Keywords: Female circumcision, Circumcision, Sexual function, Women’s health

Introduction

Many girls born in countries of Africa and Middle East undergo inhuman procedure known as Fe-male Genital Mutilation/Cutting (FGM/C). “FGM/C refers to all the procedures that inten-tionally alter female genitalia including their partial or total removal for non-medical purposes” (1).

About 100–140 million girls and women have undergone FGM and are suffering FGM conse-quences globally. FGM currently occurs in 28 African countries affecting 67.7 million girls and women who are currently 15–49 yr old and more than three million girls have been estimated to be

at risk for FGM annually (1, 2). In addition to African countries, this phenomenon is seen in the East Asian countries such as Indonesia, Malaysia, and India as well as in the Middle East and among migrants from these areas to Europe, the USA, Australia and other countries where mi-grants carry along their own traditions (3-6). The described practices need to be terminated based on principles stated in the Universal Declaration of Human Rights article five saying that “no one shall be subjected to torture or cruel, inhuman or degrading treatment” (7).

History and the rationale why FGM is practiced in certain nations, religions, and cultures are not sufficiently understood except for the fact that female genital mutilation was known since an-cient Egypt (8). Current observations show that FGM is common in some Islamic countries (9). The prerequisites for female genital mutilation are related to a mix of cultural, customary, tradi-tional, religious and social factors within families and communities, perceived as ancestral socio-cultural roots (1). The rationale for performing FGM/C includes preservation of ethnic and gen-der identity, maintenance of ‘cleanliness’ and as-surance of women’s virginity, along with the con-trol of women’s sexuality. FGM/C is also consid-ered as a rite of passage from childhood to adult-hood (3, 10, 11).

FGM harms girls and women in many ways (1, 10, 12). In others words, FGM is a risk factor for several adverse health conditions among women, and all types of FGM procedures have immediate and long-term health consequences (13). Imme-diate complication of FGM includes severe pain, shock, hemorrhage, and infection that can lead to septicemia and acute urine retention, psychologi-cal consequences, as well as open sores in the genital region (3, 9, 11). In a long run, a range of traumatic consequences can arise including geni-tal ulcers, keloid scars, fibrosis, and chronic vul-var pain; inflammatory consequences include re-current bladder infections; menstrual difficulties which might manifest as painful and prolonged periods; and psychosexual consequences includ-ing dyspareunia and sexual dysfunction (3, 14). With three types of FGM being distinguished (1), most severe complications arise with types II and

  • procedures and especially type III that include repeated urinary tract and pelvic infections, urethra damage, infertility, an increased risk of childbirth complications, and natal deaths (15, 16). Additionally, various sexual dysfunctions as a component of FGM consequences affect wom-en’s emotional and sexual well-being (16-19).

The above-mentioned evidence of FGM devas-tating impact became the ground for the UN dec-laration on the elimination of FGM and the

WHO commitment to provide a “Global strategy to stop health care providers from performing female genital mutilation” (1), which calls all health professionals to act to prevent this harm-ful and violent practice which is inhuman and threatening to women’s human rights.

FGM is known as a traumatic procedure that can demolish and impair sexual functions of mutilat-ed women including altered desire/libido, pain/discomfort, and diminished arousal result-ing in inhibited orgasm(3, 14) while the British Medical Association concluded that little is doc-umented with regard to the psychosexual and psychological consequences of FGM (20). Addi-tionally, not much has yet been documented with regard to psychosexual outcomes of FGM specif-ic for different nations and regions. In Iran, with a great variety of national, racial, and religious groups, FGM predominantly occurs in the west and south of Iran where most of the people are Sunni (the largest branch of Islam) or belong to Kurdish nation.

Based on the above mentioned background, the aims of the current study were to obtain infor-mation about the consequences of female cir-cumcision on sexual function of circumcised women. We also aimed to acquire explorative information regarding the status of FGM, its prevalence, predominant method/type of female circumcision, and attitude to this practice among the Kurdish women in Iran.

Materials and Methods

Participants and Procedures

This cross-sectional study was performed in Pi-ranshahr County, Iran, near the border of Iraq where a part of Kurdish people is living there. Participants (n=200) were sexually active married women of child-bearing age 15-49. Convenience sampling was conducted through two urban and five rural health centers; all the women who ap-plied to health care centers for routine health care services during the data collection period and agreed to participate were recruited. Data were collected during Feb and Mar 2015 by means of in-person home-based interviews guided with a structured written questionnaire and clinical examination by a midwife. In case of needing to clinical examination, participants were examined by a midwife in the clinic. All participants were covered with governmental health care services. The age of women ranged between 15 and 49 yr; 9.5% of women were younger than 20 yr, 42% were 21-30 yr old, 37% were 31-40 yr old, and 11.5% were older than 41 yr.

Tabriz University of Medical Sciences’ Ethics Committee approved the study, and informed consent was obtained from all study participants before the interview and clinical examination.

Measures

Socio-demographic variables

Socio-demographic variables included age, dura-tion of marriage, employment status (employed, housewife), education (illiterate, primary, second-ary education, high school and higher), number of deliveries, place of living (rural or urban area) and parents’ education level.

History of FGM

This was defined as any partial or total removal of the external female genitalia during the child-hood age. In addition, for determining the type of FGM, participating women were asked about which parts of their genital organs were removed, cutting tool, circumcised, and age they have un-dergone FGM. In case of needing to diagnose the type of FGM, participants were under examina-tion by a midwife. Additionally, viewpoints of circumcised women about why they had been under FGM were obtained by a brief semi-structured interview.

Female sexual function index (FSFI)

The FSFI is a brief, multidimensional, validated tool for assessment of sexual function and con-sists of nineteen items for six domains of libido, arousal, lubrication, orgasm, satisfaction, and pain (e.g. ‘‘Over the past 4 wk, how often did you feel sexual desire or interest? Almost always or al-ways; Most of the time (more than half of the time); Sometimes (about half the time); On a few occasions (less than half of the time); Almost never or never”). Each item has six possible answers that describe the status of sexual function during the last four weeks (14, 21). Responses to each question related to the previous month were recorded and scored either from 0 (no sexual ac-tivity) or 1 (suggestive of dysfunction) to 5 (sug-gestive of normal sexual activity). The reliability coefficient for the scale was 0.95. Higher scores on the scale indicated normal sexual activity.

Quality of Life (QoL)

  • 26-item rating scale was used to gauge wom-en’s perception of their quality of life (QoL) in four domains of Physical health, Psychological,

Social relationship, and Environment (e.g. ‘‘How would you rate your quality of life? Very poor; Poor; Neither poor nor good; Good; Very Good’’). A 5-point Likert-type scaling (1=strongly disagree, 5=strongly agree and 1=never, 5=completely) was used (22). The relia-bility coefficient for the scale was 0.94. Higher scores on the scale indicated better QoL.

Mental wellbeing

The validated 28-item Farsi version of the Gen-eral Health Questionnaire (GHQ-28)(23)was used to measure the wellbeing of women. The GHQ refers to subjective symptoms of psycho-logical distress, somatic manifestations often as-sociated with anxiety and depression, relationship difficulties, and perception of social, family, and professional roles (24). The GHQ-28 is com-posed of four subscales used to measure somati-zation, anxiety, social dysfunction, and depres-sion. Both subscales and summated total scores were used (24, 25). All items had ordinal four-point Likert-type scales (0-1-2-3). A higher score on the GHQ-28 represents poorer mental health status. The reliability of coefficients of reliability of the subscales varies around 0.87 and the inter-nal consistency of the total scale is 0.90.

Statistical analysis

Information obtained from the two groups was analyzed using SPSS version 16 for Microsoft Windows (Chicago, IL, USA). The statistics used to describe the groups included mean, standard deviation, frequencies (number of cases) and percentages where appropriate. Comparison of quantitative variables between circumcised and non-circumcised women was conducted using Student’s t-test for independent samples. To compare categorical data, Chi-square test of in-dependence was performed. Exact Fisher’s test was used instead when the expected frequencies in some subgroups were less than 5. The Ho-telling’s T-square method was applied for simul-taneous comparisons of dimensions between FGM and non-FGM women and finally, bivariate analysis was performed to ascertain the associa-tion between the quality of life and general health with sexual function trait. The correlations be-tween low quality of life as well as low level of general health and low sexual function trait were assessed using Pearson correlation. In all anal-yses, P<0.05 was considered statistically signifi-cant.

Results

In our sample, the total rate of FGM was 70% (n=140). With 53.6% (n=75) among women of older than 31 yr age and 8.6% (n=12) in the less than 20 yr old group. Among the rural women, 93 (66.4%) were circumcised versus 13 (22.7%) among the women in the urban area. Among the uncircumcised women, 17 (28.5%) were em-ployed while it was true about 19 (13.3%) of cir-cumcised women (Table 1).

Table 1: Demographic characteristics of noncircumcised and circumcised women

Variables Non FGM (n=60) FGM (N=140) P-Value
n(%) n(%)
Age (yr) Less than 20 7(11.7) 12(8.6) 0.048
20-30 31(51.7) 53(37.9)
31-49 22(36.7) 75(53.6)
Occupation Housewife 43 (71.7) 121(86.4) 0.013
Employed (28.3)17 19(13.6)
Education Illiterate 1(1.7) 34(24.3) <0.000
Primary 7(11.7) 48(34.3)
secondary 13(21.6) 23(16.4)
high school 21(35.0) 21(15.0)
More 18(30.0) 14(10.0)
Mother’s education illiterate 37(61.7) 125(89.3) <0.001
primary 6(10.0) 10(7.1)
secondary 4(6.7) 5(3.6)
high school 9(15.0) 0(0.0)
more 4(6.7) 0(0.0)
Father’s education illiterate 45.0(27) 100(71.5) <0.000
primary 8(13.3) 29(20.7)
secondary 5(8.4) 2(1.4)
high school 12(20.0) 8(5.7)
more 8(13.3) 1(0.7)
Housing Owned 45(75.0) 123(87.9) 0.023
Rented 15(25.0) 17(12.1)
Residence Urban 47(78.3) 47(33.6) <0.000
Rural 13(21.7) 93(66.4)
Income Low 19(31.7) 28(20.0) 0.115
Middle 39(65.0) 100(71.4)
High 2(3.3) 12(8.6)
Mean)SD) Mean)SD)
Duration of marriage 6.66(0.85) 10.52(0.62(
Number of children 1.18(0.14) 1.88 (0.09)

In addition, 125 (89.3%) of participants with history of FGM reported that their mothers were illiterate versus 37 (61.7%) among uncircumcised women and participants who had literate mother were not circumcised. Table 2 shows the average scores for the participating women’s sexual func-tion: a significant difference was found (P<0.001) between circumcised (mean=18.25, SD=6.32) and non-circumcised (mean=23.90, SD=7.12) women. Additionally, significant differences were found between two groups in all the domains of sexual function scale including desire, arousal, vaginal moisture, orgasm, satisfaction and pain with circumcised women having lower sexual function scores. However, no significant differ-ences between the two groups were found in the quality of life score: (mean=52.73, SD=12.59) among circumcised women and (mean=53.39, SD=12.13) among those non-circumcised. Addi-tionally, average scores for all the domains of quality of life are brought in Table 2. The calculated scores for general health status did not re-veal significant differences between the two groups of participants (P-value: 0.935).

Table 2: Comparison of female sexual function index, quality of life, and mental wellbeing between two groups of circumcised and non-circumcised women

Variable Mean (SD) MD** (95%CI) P-Value
FGM* Non FGM
(n=140) (n=60)
FSFI Desire 2.67(1.07) 3.67(1.43) 0.99(0.63 to 1.35) <0.001
Arousal 2.85(1.30) 3.95(1.46) 1.09(0.67 to 1.50) <0.001
Vaginal moisture 3.02(1.18) 4.01(1.37) 0.98(0.61 to 1.36) <0.001
Orgasm 2.32(1.19) 3.64(1.32) 1.32(0.94 to 1.69) <0.001
Satisfaction 3.60(1.54) 4.34(1.45) 0.74(0.28 to 1.20) 0.002
Pain 3.78(1.56) 4.28(1.14) 0.50(0.06 to 0.94) 0.025
Total 18.25(6.32) 23.90(7.12) 5.64(3.64 to 7.64) <0.001
WHOQOL-BREF General Health 63.12(20.57) 64.16(17.14) 1.04(-4.92 to 7.01) 0.731
Physical Health 62.88(15.96) 61.48(15.22) -1.39(-6.18 to 3.39) 0.567
Psychological 56.96(16.52) 59.86(14.39) 2.89(-1.94 to 7.74) 0.240
Social Relationship 21.45(5.65) 22.60(6.44) 1.15(-0.64 to 2.94) 0.207
Environment 59.24(14.50) 58.85(15.06) -0.38(-4.85 to 4.07) 0.864
Total 52.73(12.59) 53.39(12.13) 0.66(-3.12 to 4.45) 0.731
GHQ-28 Somatic symptoms 5.99(3.71) 6.58(3.78) 0.59(-0.54 to 1.72) 0.307
Anxiety and insom- 5.98(4.17) 6.20(4.29) 0.21(-1.06 to 1.49) 0.742
nia
Social dysfunction 7.30(1.62) 7.21(1.15) -0.09(-0.54 to 0.36) 0.696
Severe depression 4.87(4.70) 4.30(4.27) -0.57(-1.97 to 0.81) 0.414
Total 24.16(10.90) 24.30(10.43) 0.13(-3.14 to3.41) 0.935
  • FGM – Female Genital Mutilation
  • MD – mean difference

CI : Confidence interval

P-Value based on independent samples t-test Assessment of sexual behavior in two groups (Table 3) showed that 68 (48.8%) of circumcised women had low desire for having a sexual rela-tionship while only 16 (26.7%) were similarly characterized among the non-circumcised. Re-garding women’s demand or offer for sexual contact, 15 (25%) of non-circumcised had history of offering sexual contact vs. four (2.9%) among circumcised women which constitute a statistical-ly significant difference. Additionally, 14 (10%) of circumcised women reported history of violence against them by their husband while only 2 (3.3%) reported so among the non-circumcised.

Table 3: Comparison of sexual function between two groups of circumcised and non-circumcised women

Variables Non FGM (n=60) FGM (n=140) P-Value
n (%) n (%)
Sexual status Low desire 16(26.7) 68(48.6) <0.001
High desire 23(38.3) 12(8.6)
Normal 21(35.0) 60(42.8)
Demand for sexual contact by Men 44(73.3) 130(92.9) <0.001
Woman 15(25.0) 4(2.9)
Both 1(1.7) 6(4.3)
Frequency of intercourse per month 4 ≤ 17(28.3) 20(14.3) 0.051
4-20 40(66.7) 117(83.6)
20 ≥ 3(5.0) 3(2.1)
History of Sexual violence by husband No 58(96.7) 126(90.0) 0.111
Yes 2(3.3) 14(10.0)

* FGM – Female Genital Mutilation

P-Value based on Chi-square/Fisher’s exact test

There were significant correlation between low quality of life (r=0.42, P-value<0.000) and low level of general health(r= -0.65, P-value<0.000) with low sexual function trait.

The common type of mutilation in Iran was type I or clitoridectomy and all the FGM participants were circumcised by removing a part or the whole of clitoris. Regarding viewpoints of cir-cumcised women about why they had been under FGM, 64 (45.7%) reported that religious beliefs, traditional rituals, and customs were the main factors of FGM while 58 (41.4%) of participants did not share any understanding of why they have been circumcised. Additionally, 80 (57.1%) of circumcised women reported that religious beliefs and traditional rituals were the main rea-son for their families and mothers to opt for the FGM procedure for their daughters while 45 (32.9%) reported that cultural beliefs about controlling sexual desire among women were main reasons for mothers to select FGM. Ac-cording to the women participating in the study, men including fathers had no role on FGM in the studied area. All women were circumcised with a razor; 118 (84.3%) of participants responded that gypsy women were responsible for cutting the girls’ genital organs; 15 (10.7%) responded that relatives did so, and 7 (5%) said that this was done by local women. As regards the age when study participants had been circumcised, 72 (51.4%) of women reported that they were circumcised before age 3 and did not remember this, 65 (46.5%) had been 4-12 yr old, and 3 (2.1%) were older than 12 yr and they could recall this unpleasant event. Additionally, partici-pants reported that they had been subjected to FGM based on their mothers and grandmothers’ request. As for the next generation (the daughters of study participants), none of the respondents reported having subjected their daughters to FGM.

Table 4: Simultaneous comparison of dimensions of FSFI,WHOQOL-BREF and GHQ-28 between FGM and non-GGM women

Wilks’ Lambda Value F df1 df2 P-Value
GHQ-28 0.980 0.983b 4.000 195.000 0.418
WHOQOL-BREF 0.934 2.720b 5.000 194.000 0.021
FSFI 0.732 11.795b 6.000 193.000 <.001

Results based on Multivariate Tests of Hotelling’s T-square

The results of Hotelling’s T-square use for simul-taneous comparisons of dimensions between FGM and non-FGM women showed that there were significant differences in QoL and FSFI scores while there was no significant difference in mental well-being score between the two groups (Table 4).

Discussion

The findings of the current study show that women with the history of genital mutilation happen in some parts of Iran similarly to other countries in the Middle East. In particular, it had been common previously between the Arab and Kurds because of cultural and religious beliefs of Sunni Muslims living in the west and south of Iran. However, these practices have dramatically decreased within recent years.

In this study, the proportion of women with FGM was as high as 70% among studied partici-pants in the previous years but it has seen a de-creasing trend of FGM among young women in compare of old women and none of the study participants reported FGM on their daughters. Although our study was not conducted on a community level, our findings are comparable with the results of the studies conducted in high prevalence communities such as 27 African coun-tries, Yemen and Iraqi Kurdistan (26-28). The prevalence that we estimated is in line with stud-ies from some ethnic and religious groups located in the west and south of Iran, where most people are Sunni (29).

One of the prominent facets and facts about cir-cumcising of young girls is the exclusive role of women and mothers in conducting circumcision of girls. In other words, men have no determin-ing role with regard to this practice. Similarly, to other nations and countries (3, 5), findings of the current study indicate that women are responsi-ble for FGM in the west of Iran. Fortunately, in the recent years, mothers in Iran are not request-ing that their daughters be subjected to circumci-sion. The rate of FGM is reduced considerably because when it was asked all participants, none of them reported history of circumcision on their daughters but it is needed to systematic research to measure the current rate of FGM among young girls.

Besides ethnic and religious factors, the likeli-hood of women undergoing FGM might be re-lated to low literacy level among the rural popula-tion. In this study, FGM was significantly associ-ated with some variables, including unemploy-ment and lower literacy of parents. Therefore, the practice of FGM is pertinent to certain social and ethnic groups, which is in line with findings in Ethiopia (30) and Egypt. More than 80% of the circumcised women were illiterate and unem-ployed and that the probability of FGM declined with educational level while being higher among women in lower social strata (31). Low education level and consequent lower level of health knowledge, unemployment and its related pov-erty in line with living in the deprived rural area might have posed these women at risk of becom-ing victims of FGM in the studied sample of Kurdish population in Iran.

Clitoris, which is a sexually sensitive tissue, is re-moved partially or totally in any type of FGM. There is increasing evidence that FGM damages sexual function (3, 14), and findings of the cur-rent study demonstrate that FGM was signifi-cantly associated with diminished female sexual function. In addition, all domains of female sexu-al function namely desire, arousal, lubrication, orgasm, satisfaction, and pain could be affected because of FGM; this is consistent with findings of a recent case-control study in Egypt (32). In contrast, in Saudi Arabia was reported no differ-ence in mean desire score or pain score between FGM and non-mutilated females; however, statis-tically significant differences were reported be-tween the two groups in arousal, lubrication, or-gasm, and satisfaction, as well as the overall sexu-al function score(14). Additionally, as a systemat-ic review and a meta-analysis have concluded, women subjected to FGM significantly more like-ly reported dyspareunia, the absence of sexual desire, and reduced sexual satisfaction (33).

Additionally, numerous studies have identified depression, anxiety and post-traumatic stress disorder (PTSD) as potential consequences of FGM (34-36). FGM has psychological and mental ef-fects, our study did not reveal discrepancies in mental wellbeing between circumcised and non-circumcised women, and thus, this hypothesis can be further tested in larger scale studies paying more attention to mental health of these women. Despite progressive improvement about health indices and quality of health care services, human society is facing phenomenon of female circum-cision, which threatens the health of girls where they become victims of inhumane practices based on certain cultural beliefs. Nowadays, two types of health promotive approaches are needed to overcome FGM phenomenon. First, preventing female circumcision among child girls and sec-ondly, supporting circumcised girls and women who are suffering consequences of FGM.

This study had a number of limitations. First, the cross-sectional study was conducted on a con-venience sample of women in Piranshahr County; as a result, our findings cannot be generalized to all Sunni and Kurdish women and other popula-tions of Iran. In addition, the study used self-reported measures that could lead to inaccurate recall and/or reporting. Furthermore, some measurements were conducted with the use of a researcher-designed questionnaire for collecting socio-demographic and health data, rather than using previously standardized instruments, which may have resulted in lack of comparability with other studies, inaccuracies, and misclassification. Nevertheless, this was the first study of this kind among the under-studied population of Kurdish women.

Conclusion

Many of the Kurdish girls in the county of Pi-ranshahr were circumcised in the past decades, and clitoridectomy was the most common type of mutilation impairing sexual function of muti-lated women. Nevertheless, no differences were found between circumcised and non-circumcised women in quality of life and mental wellbeing, which probably confirms that clitoridectomy, is a less harmful procedure in comparison to other types of FGM. Additionally, none of the mutilat-ed women allowed that their daughters be sub-jected to FGM which indicate a progressive re-duction in the rate of female genital mutilation in recent years.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or fal-sification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

Acknowledgements

The authors would like to thank Tabriz Universi-ty of Medical Sciences for financial support. The authors would like to acknowledge all partici-pants of the study.

Conflict of Interests

The authors declare that there is no conflict of interest.

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