Epidemiology
DOI: 10.1111/j.1471-0528.2012.03481.x www.bjog.org
The association between female genital mutilation and intimate partner violence HM Salihu,a,b EM August,c JL Salemi,a H Weldeselasse,a YS Sarro,d AP Alioe a Department of Epidemiology & Biostatistics, College of Public Health, University of South Florida, Tampa, FL b Department of Obstetrics & Gynecology, College of Medicine, University of South Florida, Tampa, FL c Department of Community & Family Health, College of Public Health, University of South Florida, Tampa, FL d Center for TB and AIDS Research in Mali (SEREFO), University of Bamako, Bamako, Mali e Department of Community & Preventive Medicine, University of Rochester, Rochester, NY, USA Correspondence: Dr H Salihu, University of South Florida, College of Public Health, Department of Epidemiology & Biostatistics, 13201 Bruce B. Downs Blvd., MDC56, Tampa, FL 33612, USA. Email
[email protected]
Accepted 17 July 2012. Published Online 24 August 2012.
Objective To determine whether female genital mutilation (FGM)
is a risk factor for intimate partner violence (IPV) and its subtypes (physical, sexual and emotional). Design Population-based cross-sectional study. Setting The study used the 2006 Demographic and Health Survey
(DHS) conducted in Mali. Population A total of 7875 women aged 15–49 years who responded to the domestic violence and female circumcision modules in the 2006 administration of the DHS in Mali. Methods Multivariable logistic regression was used to compute
adjusted odds ratios (aOR) and 95% confidence intervals (CI) to measure risk for IPV. Main outcome measures The outcomes of interest were IPV and
Results Women with FGM were at heightened odds of IPV (aOR 2.71, 95% CI 2.17–3.38) and IPV subtypes: physical (aOR 2.85, 95% CI 2.22–3.66), sexual (aOR 3.24, 95% CI 1.80–5.82), and emotional (aOR 2.28, 95% CI 1.68–3.11). The odds of IPV increased with ascending FGM severity (P for trend 85%); four countries have a high prevalence (60–85%); seven countries have a medium prevalence (30–50%); and the remaining ten countries have a low prevalence (ranging from 0.6% to 28.2%).1 Although FGM is recognised as an act of violence against women and a violation of human
rights by many African governments, the issue is clouded in debate, because it is deeply entrenched in culture and tradition, making legislation difficult to approve and enforce.5,9,11 Previous studies highlight the considerable adverse effects of FGM on women’s reproductive health (e.g. haemorrhage, fistulae, urinary tract infections, incontinence, dysmenorrhoea, dyspareunia, more severe perineal tears at the time of delivery) and psychological well-being (e.g. depression, post-traumatic stress disorder, anxiety) that mitigate quality of life.4,10,12–15 Another equally important human rights concern affecting African women is intimate partner violence (IPV). We, and several other investigators, have found that about one of every two women in sub-Saharan Africa is a victim of IPV.16–19 In Mali, 21% of women reported ever being
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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exposed to sexual or physical violence by a partner.19 Violence against women has been found to be a widely accepted sociocultural norm in Mali, as well as in other sub-Saharan African countries.20–22 A theoretical explanation of the association between FGM and IPV may be found in research on child violence and abuse. Previous studies illustrate that women with previous exposure to violence, particularly physical and sexual trauma during childhood, are two to five times as likely to experience violence later in life.23–27 This re-victimisation often takes the form of IPV during adulthood.25–27 As FGM is a form of violence that frequently occurs during early childhood,2,3,14,28 women who have undergone FGM may be vulnerable to IPV. This may be a reflection of the clustering of behaviours. To date, the association between FGM and IPV remains poorly understood. Given the plausibility of a positive association between FGM and IPV, delineating the relationship between FGM and IPV is important for the following reasons. (i) If FGM is a marker for IPV, efforts targeting FGM victims could integrate IPV interventions as a comprehensive package to improve the health of women in countries where FGM has been described by the WHO as a major public health issue.1,12,28,29 (ii) Attempts to encourage legislative regulation of FGM in countries where it is a major concern have, so far, been met with either indifference or lack of public support. Identifying and disseminating information on the public health ramifications of FGM (e.g. promoting social norms in which violent acts against women are unacceptable) may aid in galvanising local support for legislative actions against the practice. In this paper, we sought to determine whether FGM is associated with an increased odds of IPV, as well as its subtypes (i.e. physical, sexual and emotional), using data obtained from a population-based study in Mali, a subSaharan nation located in West Africa and described by the WHO as having one of the highest FGM prevalence rates in the world.1
Methods We used the Demographic and Health Survey (DHS) individual recode data. The DHS is an international project conducted in 90 countries throughout the world, including sub-Saharan Africa. This project is funded by the United States Agency for International Development and implemented by Macro International for the collection and dissemination of accurate, nationally representative data. A primary purpose of the DHS is to identify sociocultural factors that negatively impact reproductive function among women of childbearing age (15–49 years). Given the high prevalence of both FGM and IPV in the sub-Saharan region of Africa, this study focuses on com-
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bined data available from this region. The study scope was further limited to the 11 sub-Saharan African countries identified by the WHO as having almost universal prevalence (seven countries with rates of more than 85%) or high prevalence (four countries with rates of 60–85%) of FGM.1 Our inclusion criteria were that the country-specific DHS data set included the modules for both female circumcision and domestic violence. Only one sub-Saharan African nation met both inclusion criteria: Mali. Therefore, our analysis was limited to data provided in the DHS Mali survey. The DHS survey administered in Mali was modified from basic questionnaires from the DHS programme to consider the context of the country of Mali.30 Numerous peer-reviewed publications have resulted from the DHS data with proven details regarding the validity and reliability of the methodology used.31–34 Other authors have referenced the results of many of these peer-reviewed publications. The DHS Mali survey (2006) provides data on a nationally representative sample drawn from every region of Mali and used a two-stage clustered sampling design based on national census data.30 After stratifying regions by urban or rural status, a total of 13 695 households were selected at random, with a sampling probability that was proportional to the population of the region. Of these households, 13 160 were identified as occupied. The survey was then administered from May through December 2006 to a total of 12 998 households, resulting in a household response rate of 98.8%. Of the 15 102 women aged 15–49 years who were identified from the selected households, 14 583 women participated in the individual survey, yielding a 96.6% response rate. The high response rate may be partially attributable to the rigorous implementation of the DHS survey methodology and the provision of capacity building at the local level.35 Individuals who are knowledgeable about the geographical area and study population were enlisted as staff for the DHS and were supplemented with technical assistance during all critical stages of survey implementation to ensure all avenues for identification and recruitment of participants are exhausted.35 From survey respondents, a subset of women (n = 10 272) was selected for the domestic violence module, and 9849 (95.9%) were interviewed. This final study sample was further limited to women who responded to the main study questions on both the female circumcision and domestic violence modules, generating a total sample size of 7875. A flow diagram depicting the exclusionary process for the study is presented in Figure 1. The survey assessed FGM by asking respondents if they had been circumcised. In addition, the DHS survey also collected information on the type of circumcision, the timing of circumcision, and who performed the
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
FGM and IPV
Household selection
Woman selection
DHS – Mali: N = 13 695 households
Women aged 15-49 years in sampled households: N = 15 102 women
Exclude 535 (3.9%) unoccupied households: N = 13 160 households
Exclude 519 (3.4%) women that did not consent for main questionnaire: N = 14 583 women
Exclude 162 (1.2%) nonparticipating households: N = 12 998 households
Exclude women not selected (4,311), selected but not interviewed (423), failing to respond (937), or with non-positive sampling weights (92) For domestic violence module: N = 8 820 women
Exclude women who did not respond to items on The female circumcision module (945, 10.7%): N = 7 875 women
FINAL SAMPLE: N = 7 875 women
Figure 1. Flow diagram of exclusion criteria for the study using Demographic and Health Survey data in Mali.
circumcision. Respondents were also asked questions about their experiences with IPV, including physical, emotional and sexual forms of violence. Due to the sensitive nature of the questions on violence, the interview for the domestic violence module of the DHS was undertaken only when privacy could be achieved and maintained throughout the process. A complete description of the DHS sampling, questionnaire validation, data collection methodology and validation of data has been published elsewhere.30
Variables We measured the main exposure category, FGM, from the survey item ‘Respondent Circumcised,’ which was a dichotomous (Yes/No) variable. We delineated the type of circumcision experienced by women based on the WHO’s four-category classification of FGM.1–3,5,6,10 Type I, traditionally referred to as sunna, involves the excision of the prepuce and the partial or total removal of the clitoris. Type II involves the complete removal of the prepuce and the clitoris and the partial or total excision of the labia minora. Type III, also known as infibulation, is the most extensive form, involving the excision of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Type IV includes modifications that do not fall into the other three types, such as pricking, piercing, scraping, cauterisation, or other procedures performed on the clitoris and labia. As in previous studies, the proportion of women who had undergone the various types of FGM was based on
self-reports, which might result in some inaccuracies.36 Therefore, to reduce the possibility of misclassification, we categorised women into three broad dosage categories based on the level of severity reported: none (no FGM); mild/moderate FGM (WHO Types I, II or IV); and severe FGM (WHO Type III). The determination of these groupings was based on responses to three items regarding circumcision, including ‘flesh removed from genital area’, ‘genital area just nicked without removing any flesh’ and ‘genital area sewn closed’. In our study, IPV among African couples was the outcome of interest. The domestic violence module of the Mali DHS Survey includes 13 items that capture violence committed by a male partner or spouse. From these questions, IPV was categorised into three main subtypes: physical, sexual and emotional. Physical IPV includes actions such as pushing, shaking, throwing, slapping, punching, kicking, dragging, burning, strangulation, threatening or attacking with a weapon, and other such acts of physical aggression. Physical IPV was determined as a woman’s report of ever experiencing a physically violent act committed by a partner. Sexual IPV was assessed with the item, ‘ever experienced any sexual violence’, which included forced sexual intercourse or other sexual acts by a partner when not wanted. Emotional IPV was assessed with multiple items, such as ‘ever humiliation’, ‘ever threatened harm’, and ‘ever emotional abuse’, or ‘ever emotional violence’, and was defined as a woman’s report of ever experiencing an act of emotional violence by a partner. Women were further categorised as those who experienced one type of IPV and those who experienced two or more types of IPV. We compared women who had undergone FGM with those who reportedly did not based on a range of variables found to be of importance in the literature. They include: woman’s age (£19, 20–24 and ‡25 years); woman’s age at first marriage (£14, 15–19, 20–24 and ‡25 years); woman’s age at first intercourse (£14, 15–19, 20–24 and ‡25 years); partner’s age (1 type of IPV
1.00 (–) 2.55* (2.04–3.20) 4.77* (3.67–6.19)
1.00 (–) 2.68* (2.08–3.44) 5.39* (4.05–7.19)
1.00 (–) 3.20* (1.77–5.77) 3.34* (1.70–6.56)
1.00 (–) 1.98* (1.45–2.70) 5.45* (3.86–7.68)
1.00 (–) 2.50* (1.92–3.27) 2.99* (2.16–4.13)
1.00 (–) 2.68* (1.84–3.91) 8.81* (5.87–13.24)
*Significant values.
that it represents a comprehensive and methodologically sound analysis of the association between FGM and IPV in an African setting. Our study findings suggest that there may be shared sociocultural factors and established social norms that treat violence against women as acceptable and, therefore, influence the occurrence of both FGM and IPV. Women with a reported history of FGM were more likely to be younger at first intercourse. Furthermore, women with lower educational levels had a higher probability of experiencing IPV. Previous research shows that both early coitus and educational attainment have some relationship with both FGM1,2,29 and IPV,18,20,38 indicating that these public health issues may be linked through common sociocultural factors. We determined that younger female age was associated with a heightened risk of sexual IPV. Additionally, we observed that women who reported FGM generally had older partners. Together, these findings reinforce previous research that underscores the role of male–female age disparities in sexual relationships and adverse health outcomes in sub-Saharan Africa. Numerous studies have found that younger female age is associated with increased risk of sexual violence among African women.39–43 Furthermore, research conducted within Africa has determined that younger women may be more vulnerable to sexual coercion and violence when in relationships with older men, as a large age gap may affect women’s autonomy because of power and economic imbalances.40,41,43,44 An interesting finding in our study was the reduced odds of sexual IPV among women who were categorised within the poorest wealth category. Poverty has been well-documented as a risk factor for violence perpetrated by intimate partners,21,45,46 so this finding is somewhat counterintuitive. A possible explanation of this finding is that this estimate may reflect an under-reporting of sexual assault and violence within this vulnerable population. As sexual coercion has been noted as a sociocultural norm within Africa,21,22 such practices may not have been recognised and reported among study participants as acts of sexual violence. This is one of the first studies to yield information that shows an increased risk for IPV with increasing severity of
FGM (P for trend
