By: Dr. Najeeba Abdulghani, 
Department of Child and Mother Care,
Ministry of Health.

Female circumcision, widely known as female genital mutilation (FGM), is a term used for a variety of surgical operations carried out on female genitalia. These operations are practiced on healthy female children for traditional reasons backed by great social pressure. The operations may lead to immediate health risks and, sometimes to long term health damage.
The practice of female circumcision is prevalent in parts of Africa and the Near East. In Yemen it is believed to be limited to certain areas. In the 1991-92 YDMCHS, respondents were asked whether they approved or disapproved to female circumcision. The data indicated that 21% of respondents approved female circumcision in some governorates.

No information was collected on the prevalence of female circumcision or reasons for respondents' attitudes toward female circumcision. The questionnaire in the 1997 YDMCHS included a series of questions on female circumcision. All respondents were asked if they had heard of female circumcision. Those who had heard of the practice were then asked if they had been circumcised and if any of their daughters had been circumcised.
If any of their daughters had been circumcised, the respondents were asked the daughter's age at the time of circumcision, the person who performed the procedure, the place where the procedure was performed, and the instrument used in the procedure. Information was also collected about any complications due to circumcision that the daughter suffered. Attitudinal questions on female circumcision were included for respondents who had heard of the practice.

Questions were asked about attitudes towards female circumcision in general, and about reasons for supporting continuation or discontinuation of the practice. Currently married women were also asked about the perceived attitude of their husbands toward female circumcision.

Knowledge and Practice of Female Circumcision
It was shown from the practical study that slightly more than half of respondents (51%) have heard of female circumcision. Knowledge is lowest among women 15-19 (43%) and ranges from 50 to 53% among other age groups. Knowledge of female circumcision is much lower in rural areas (45%) than in urban areas (70%). By region, over 90% of women in the coastal region and around 40% in the other regions know about female circumcision. The proportion knowing of female circumcision increases with level of education, reaching 86% among those who have completed secondary education or above compared with 47% among illiterate women.

Prevalence of Female Circumcision:
The same studies show the percenage of women who had been circumcised. Nearly one-fourth of Younger women (23%) have been circumcised Younger women (age 15-19 years) and rural women are slightly less likely to report being circumcised than women age 20-49years, and women residing in urban areas. The prevalence of practice by region varies substantially; 69% of women living in the coastal region were circumcised, compared with 15% in mountainous region and 5% in the Plateau and Desert region.
The prevalence of female circumcision is almost the same among literate and illiterate women. However, the higher the level of education, the higher the level of prevalence among respondents. Only 21% of illiterate women are circumcised, compared with 35% of women who have completed secondary or higher level of education.

Prevalence of Female Circumcision:
Respondents who had one or more daughters at the time of the survey were asked whether any of their daughters was circumcised. The studies indicate that nearly 1 in 5 respondents who had daughters reported that a daughter has been circumcised. Overall the prevalence of female circumcision among daughters (20%) is slightly lower than the prevalence among mothers (23%). However this does not necessarily indicate a decline in the practice because some daughters may still be circumcised later in life.

The proportion of daughters circumcised shows no difference by urban rural residence (20% each), but differentials by region are substantial: Coastal region (63%), Mountainous region (15%), and Plateau and Desert region (2%). By level of education, the highest proportion of daughters circumcised is among those whose mothers have completed secondary or higher education (13%). The decline among daughters of the most educated group, is noteworthy, dropping from a prevalence of 35% among mothers who have completed at least secondary school to 13% among their daughter.

Age at Circumcision:
Other studies present the distribution of circumcised daughters by age at circumcision, residence, and region. In Yemen, almost all daughters who were circumcised (97%) were reported by their mothers to have been circumcised during the first month of life. One in five were circumcised before they were 7 days old. Half were circumcised when they were 7 to 10 days old, and almost three fourths were circumcised by the ten days after birth. More than half of daughters were circumcised at age 7 to 10 days in rural areas, and slightly less than half in urban areas.
However in urban areas, 16% of daughters were circumcised during the first six days of life and six% after the age of one month, compared with 22 and 2%, respectively, in rural areas. Eighty-eight% of respondents living in the Mountainous region reported that their daughters were circumcised within the first ten days of life, compared with 69% in the Coastal region and 61 in the Plateau and Desert region. The median age at which daughters are circumcised is 7.6 days.

Performing Circumcision:
In Africa and the Near East, female circumcision is usually performed by a traditional birth attendant or an experienced elderly woman. Previous studies show that two-thirds of circumcised daughters had the procedure done by a traditional birth attendants (daya) and one-fifth were performed by grandmothers or relatives. Only 9% of procedures were carried out by medical personnel (6% by nurses/midwives). Barbers performed a small proportion of circumcisions (5%). Current studies show that only 3% of circumcised daughters had the procedure done in a health facility while 97% had it done at home. While explanatory studies indicate that razorblades were used in 3 out of 4 circumcision operations performed on daughters; scissors were used in 1 in 5 operations.

Many medical complications, immediate and long term, arise from female circumcision. Bleeding is unavoidable since damage to the blood vessels is inevitable. Shock from the loss of blood and pain since the operation is performed without anaesthetic invariably occur to some degree and in some cases leads to death. Infection is a common complication due to unhygienic conditions in which the operation is performed. Tetanus and septicemia also occur and can prove fatal." Advance studies present the complications associated with the daughter's circumcision. Respondents could mention multiple complications. The most frequent complications. Were bleeding (8%), pain (4%), and infection or fever (2%). Mothers reported no complications for 89% of daughters who were circumcised.

Attitudes Toward Circumcision
In addition to asking ever-married women who had heard of female circumcision whether the practice should be continued or discontinued, they were asked about the perceived attitude of their husbands. The results presented in higher studies that almost half (48%) of respondents believe that female circumcision should be discontinued, 41% believe it should be continued, and 11% have no opinion (unsure/don't know). Support for the practice is not affected by age, but there is a strong association between a woman's attitude toward female circumcision and residence, region, and level of education. Rural women are equally divided on support for continuation or discontinuation of female circumcision.

However, support for continuation is lower in urban areas (32%) than in rural areas (46%). Women who live in coastal region (66%) are more likely to favor continuing the practice compared with women who live in the Plateau and Desert |Region (13%), or in the mountainous region (42%). By level of education, the highest proportion supporting the practice is among women who have completed the primary level (44%), and women who are illiterate (42%).
In contrast, more than 60% of women with preparatory or secondary or higher education believe the practice should be stopped. Not surprisingly, support for continuing female circumcision is associated with the circumcision status of the mother and daughter. Nearly 8 in 10 of those whose daughters were not circumcised. More importantly, 17% of women who had been circumcised favor discontinuation of female circumcision.
Further studies present the% distribution of currently married women who know about female circumcision by their husband's attitudes toward circumcision, according to husband's age and educational level, and respondent's attitude.

The studies indicate that 32% of women believe that their husband support continuation of circumcision, while 21% think their husband would like to see practice discontinued. Forty-five% of women did not know their husband's attitude toward female circumcision. Regarding husband age and attitude toward female circumcision. Regarding husband age and attitude toward female circumcision, there is no discernable pattern. However the higher the husband's level of education, the lower his support is for continuation of female circumcision. Seventy-one% of women who want the practice of female circumcision to continue believe that their husband's shares their attitude. On the other hand, among women who favor discontinuation of female circumcision, only 39% say their husband has the same attitude while 56% do not know their husband's attitude.

Reasons for Attitude Toward Female Circumcision:
Respondents who have heard of female circumcision and stated that they prefer continuation of the practice, were asked about the reasons for their support. They were allowed to give as many reasons as they desired. Looking at the responses presented in these top studies, the most frequently cited reason for continuation of female circumcision was cleanliness (46%). More than one third of women reported "tradition" as reason for continuing the practice, and 33% said that female circumcision was required by religion.
The other reasons in order of frequency are: a "good tradition" (12%), preservation of virginity (6%) and prospects of a better marriage for daughters (3%). By residence, the most frequently cited reason for the continuation of circumcision is again "cleanliness" , 40% for urban and 48% for rural areas.
The second most frequently mentioned reason among urban women is "required by religion" (37%); among rural women it is "tradition" (38%). The third reason for continuing circumcision among urban women is "tradition" (30%) while rural women mention, 'required by religion" (31%). The other reasons are almost the same for urban and rural women.

Reasons for opposing Female Circumcision
Respondents who have heard of female circumcision and indicated that they would like to see the practice stopped were asked why they opposed it. Respondents were allowed to mention multiple reasons.
Up-to-date, studies indicate that 68% of women are against female circumcision because they consider it a bad tradition, 32% believe it is against religion, and 12% oppose it, because of the possible medical complications a women might sustain because of it. One in 10 women who opposed the practice think female circumcision is against the dignity of women.

Only a small proportion (3%) stated that circumcision is a painful experience. The order of reasons for opposing the continuation of circumcision, is nearly the same for both urban and rural women. Nearly two-thirds of women, irrespective of level of education , state that circumcision is a bad tradition.
The higher that woman's level of education, the more likely she is to say that female circumcision is against the dignity of women and the less likely she is to say the practice is against religion. Women with secondary or higher education, more often than illiterate women, report that circumcision causes medical complications (22% versus 11%).