Female circumcision—also commonly known as female genital mutilation or female genital cutting—is highly prevalent in Sudan. Findings from the 1989-1990 Sudan Demographic and Health Survey (SDHS) indicate that 89% of ever-married women have undergone some form of genital cutting, varying from 65% in Darfur Region to almost 99% in the Northern Region.¹ Strong social pressure maintains high levels of circumcision, which is believed to promote premarital chastity among women.² In most areas in Sudan, uncircumcised women are generally viewed as impure and thus unmarriageable.³ Given their lack of choice and the powerful influence of tradition, most women accept circumcision as a necessary, and even natural, part of life, and adopt the rationales given for its existence.⁴

Types of female circumcision vary from culture to culture and from region to region. The World Health Organization has defined three main categories.⁵ Type 1, which is often referred to as clitoridectomy, entails removal of the tip of the prepuce, with or without excision of part or all of the clitoris. In Type 2, the clitoris is removed along with part or all of the labia minora. Type 3, infibulation, the most severe form of female circumcision, involves removal of most or all of the external genitalia. The vaginal opening is then stitched closed; only a small opening is left for the flow of urine and menstrual blood. Women's infibulation scars may have to be cut open at childbirth or if problems in sexual intercourse are encountered.

In Sudan, Type 1 is known as Sunna, and generally entails only removal of the tip of the prepuce. The intermediate Type 2 is referred to as Matwasat, and Type 3 is known as Pharaonic.⁶

Female circumcision is not associated with any one religious group. It is practiced by Muslims, Christians, Jews and members of indigenous African religions.⁷ Some Sudanese believe that Islam supports female circumcision, although Muslim theologians state that there is no explicit support for the practice in the Koran.⁸

Female circumcision is often performed by lay practitioners with little or no formal knowledge of human anatomy or medicine. In most cases, the operation takes place under unhygienic conditions and without anesthesia or sterile instruments.⁹ Circumcision can have many immediate and long-term consequences. These consequences vary considerably by the type and severity of cutting, with the most serious complications associated with infibulation. The immediate consequences include difficulty in passing urine, urine retention, hemorrhage, infection, fever, stress and shock and damage to the genital organs.¹⁰

Over time, circumcised women may also develop menstrual complications, vulvar abscesses, obstetric complications, urinary tract infections, chronic pelvic infection and low fertility or sterility.¹¹ In addition, female circumcision, especially infibulation, may make intercourse per- functory or even painful.¹² Despite these grave risks, its practitioners look on it as an integral part of their cultural and ethnic identity. In societies in which few women remain uncircumcised, problems arising from female circumcision are likely to be seen as a normal part of a woman's life and may not even be associated with circumcision.¹³

Methodology

The data for this study come from a baseline survey on reproductive health conducted in three project areas in Sudan by the Central Bureau of Statistics of Sudan with the financial and technical assistance of the United Nations Population Fund. The three project areas are: Haj-Yousif, a semi-urban area in Khartoum state; Juba, the capital of Bahr El Jebel state; and Shendi, a province of Nahr El Nile state that includes both rural and urban areas. In Haj- Yousif and Shendi, more than 90% of the population is Muslim, while in Juba, more than 90% of the people are Christian.

The baseline survey was limited to ever-married women aged 15-49. A random sample of 1,000 women from each project area were targeted for interview. Ultimately, 1,114 ever-married women from Haj-Yousif, 993 from Juba and 1,019 from Shendi were successfully interviewed.

The sample respondents were selected from each area following a two-stage stratified cluster sampling design. The details of the survey may be seen in the baseline survey report.¹⁴ Each project area consists of several councils (districts), which were treated as strata. At the first stage, a random sample of clusters (villages in rural areas and quarter-councils in urban areas) was selected with standard probability proportional to size. At the second stage, households were listed and then selected systematically from each selected cluster.

In Shendi province, which consists of four rural councils and one urban council, 20 clusters of villages or quarter-councils were selected; 50 households were then chosen from each selected cluster. Similarly, a random sample of 20 clusters (quarter-councils) was selected from Juba City's three councils, and 50 households were selected systematically from each selected cluster. Five of Haj-Yousif's nine administrative quarter-councils were randomly selected; 200 households were then selected from each quarter-council.

Fieldwork for the baseline surveys was carried out by several trained interviewing teams, each consisting of one male supervisor and several female interviewers. Data were collected in Haj-Yousif and Juba City in September and October 1998, and in Shendi in March 1999.

The survey included a series of questions on female circumcision. Women were asked whether they had been circumcised, and if so, which type they had undergone and who had performed the procedure. Women were also asked whether they thought the practice should continue and, if yes, which type they preferred and why. Those who opposed continuation of the practice were asked why they opposed it, why they thought the practice persists and what they thought were the best ways to eradicate it. The interviewers also collected data on women's perceptions about their husband's attitude toward female circumcision. However, they did not ask the respondents about their age at circumcision or the consequences for their health.

The study was based on respondents' self-reporting. The investigators assumed that respondents knew the definition of different types of circumcision, so they made no attempt to verify the types reported. Thus, certain types of circumcision may have been underreported or overreported. One study in Sudan found some discrepancies between the type of circumcision women had undergone and the type they reported.¹⁵ In the baseline survey described here, however, the interviewers attempted to avoid this problem by asking the respondents to describe the extent of excision and infibulation.

Findings

Prevalence of Female Circumcision

Table 1 presents the prevalence of female circumcision among ever-married women of reproductive age by selected background characteristics. The practice is almost universal in Shendi and affects almost nine in 10 women in Haj-Yousif. In Juba, however, only 7% have been circumcised.

Similar patterns of variation with age are evident in the three regions: Women younger than 25 are slightly less likely than older women to have been circumcised, but none of the differences are statistically significant. In Juba and Haj-Yousif, educated women are significantly more likely than uneducated women to be circumcised, while the prevalence of circumcision varies little by educational level in Shendi. These differentials should not be attributed to education, however, as most girls are circumcised between the ages of four and nine.

The household possessions score,* a proxy measure of economic status, also shows a positive relationship with the prevalence of circumcision; again, the differences are significant for Haj-Yousif and Juba, but not for Shendi. Overall, the prevalence of circumcision is lower among Christian women than among Muslim women, and the differences are statistically significant in all the regions under study.

When all variables are entered into a logistic regression analysis, none have significant effects on the prevalence of circumcision in Shendi (not shown). In Haj-Yousif, however, the odds of being circumcised rise significantly with each year of education and with each increase in the household possessions score. In Juba, significant increases in circumcision also occur as the household possessions score rises. In both areas, Muslim women are significantly more likely than Christian women to be circumcised.

Type of Circumcision

Pharaonic circumcision is the most prevalent type in Shendi (96%) and Haj-Yousif (69%), followed by Sunna circumcision (3% and 28%, respectively). Women in Juba, however, were most likely to report Sunna circumcision (53%), with 31% reporting the Pharaonic type (Table 1).

The data in Table 1 suggest that a slight shift from the Pharaonic type to the Sunna type of circumcision may be occurring in Sudan. For example, among women aged 30 or older in Haj-Yousif, 73% reported the Pharaonic type and 24% the Sunna type, compared with 64% and 35%, respectively, of those aged 15-24. Similar patterns appear in Shendi and Juba, but the differences are statistically significant only in Haj-Yousif.

Level of education is negatively associated with the prevalence of Sunna circumcision in Haj-Yousif. However, education does not show any consistent relationship with type of circumcision in Shendi or Juba. Household possessions scores are associated with type of circumcision in Haj-Yousif and Shendi, but not in Juba.

Attitudes Toward Circumcision

In response to the question "Do you think female circumcision should continue?" 67% of the ever-married women in Haj-Yousif and 56% of those in Shendi supported continuation of the practice, compared with only 4% of respondents in Juba (Table 2).

When women's attitudes toward circumcision are examined by selected background characteristics, support for continuation rises with age in Haj-Yousif and decreases with rising age in Shendi. However, no consistent relationship between age and support for circumcision is evident in Juba.

Support for continuation of the practice decreases as level of education and household possessions score rise in Haj-Yousif and Shendi. For example, 34% of women in Shendi with a secondary or higher education favor the continuation of female circumcision, compared with 56% of those with a primary or junior level of education and 70% of those with no education. In Juba, however, the proportion of women supporting circumcision increases with education and household possessions score.

Muslim women are more likely to support circumcision than are non-Muslim women. For example, 73% of Muslim women in Haj-Yousif favor continuing the practice, compared with 8% of Christian women. The same pattern appears in Shendi (57% vs. 18%) and Juba (31% vs. 1%).

Multivariate logistic regression analysis identified women's education, religion and household possessions score as significant predictors of attitudes toward female circumcision in both Haj-Yousif and Shendi (Table 3). For instance, each year of education decreases the odds that women would favor continuation of female circumcision in both areas. In addition, Muslim women are significantly more likely to support circumcision than are Christian women in Haj-Yousif and Shendi, and support decreased with rising household possessions scores in both areas. (A multivariate analysis was not carried out for Juba because of the small number of circumcised women.)

Attitudes About Daughter's Circumcision

In addition to looking at women's attitudes toward circumcision in general, we examine respondents' plans to circumcise their own daughters. Overall, 71% of ever-married women in Haj-Yousif who have uncircumcised daughters plan to circumcise them. The corresponding figures for Shendi and Juba are 64% and 2%, respectively (Table 4).

Except among uncircumcised respondents, women are more likely to plan to circumcise their daughters than to support circumcision in general. For example, among respondents in Haj-Yousif who had undergone Pharaonic circumcision, 85% plan to circumcise their own daughters, while 73% say they favor the continuation of female circumcision. The corresponding figures for Shendi are 65% and 57%. However, the opposite scenario prevails in Juba (29% and 45%). About 11% of uncircumcised women in Haj-Yousif intend to circumcise their daughters. Of the four uncircumcised respondents in Shendi, none plan to circumcise their daughters.

Among women in Haj-Yousif who have uncircumcised daughters old enough to undergo the ritual, 16% plan to have their daughters circumcised, while 18% approve of female circumcision in general. The corresponding figures in Shendi are 11% and 11%, compared with 1% and 2%, respectively, in Juba.

Type of Circumcision Preferred

Among women in Haj-Yousif and Shendi who approve of the practice of female circumcision, the majority prefer Sunna circumcision. (Only women in these areas are included, because the number of circumcised women in Juba is too small.) As Table 5 shows, 69% of the women in Haj-Yousif who favor circumcision prefer the Sunna type, 24% Pharaonic and only 8% Matwasat. A similar pattern is evident in Shendi (54%, 35% and 11%, respectively).

Education and household possessions score are significant predictors of the type of circumcision preferred. In Shendi, for example, a rising household possessions score and increasing levels of education are associated with a decreasing preference for Pharaonic circumcision and an increasing preference for Sunna circumcision. In Haj-Yousif, education has a similar effect, while increases in the household possessions score are associated with a shift in preferences from Sunna to Matwasat and Pharaonic circumcision.

Reasons for Attitudes

In Haj-Yousif and Shendi, the overwhelming majority of women who support circumcision state that they want the practice to be continued because it is a custom of the society (69% and 75%, respectively). The second most common reason given in both areas is cleanliness (26% each). In addition, 10-20% of women say female circumcision is a religious demand or that it is a good tradition (Table 6). In Juba, among the few women favoring the practice (N=35), the majority cite better marriage prospects and cleanliness as their reasons for supporting circumcision.

Among women in Haj-Yousif and Shendi who think the practice of female circumcision should not be continued, the majority (63% and 88%, respectively) cite medical complications. Substantial proportions also mention religious prohibition (28% and 32%) and a painful personal experience (29% and 28%). Religious prohibition is the major reason given in Juba (65%), with 31% citing medical complications and 23% saying the practice is against women's dignity.

Husband's Attitude

Some 43% of the wives in Haj-Yousif, 46% of those in Shendi and 35% of those in Juba either do not know their husband's opinion about female circumcision or say that he has no opinion (not shown). Overall, 31% of husbands in Haj-Yousif, 23% of those in Shendi and 3% of those in Juba are perceived to favor continuation of the practice, while 26%, 30% and 62%, respectively, are thought to oppose it. Comparison of these data with those in Table 6 suggest that men are less likely than their wives to support continuation of female circumcision.

Discussion and Conclusions

The prevalence of female circumcision is very high in the northern regions of Sudan, with the Pharaonic type—the most severe—the most common. Although the rate of circumcision is higher among women with at least some years of schooling than among women having no education, multivariate analysis indicates that higher levels of education are significantly associated with the practice only in Haj-Yousif. Women living in wealthier households, however, are more likely to be circumcised.

A shift from the most severe to the least severe type of circumcision may be occurring. An examination of age-specific patterns indicates that women younger than 30 are less likely than older women to have undergone Pharaonic circumcision and more likely to have undergone Sunna circumcision.

In the two northern states, the majority of ever-married women support the continuation of female circumcision. In Juba, on the other hand, the majority are against the practice. A variety of justifications are given by women who favor continuation of the practice, including preservation of virginity, cleanliness, religious requirements and greater pleasure of husbands, but social custom and tradition are the most prominent reasons given. Young and educated women are less likely to support continuation. One-fourth to one-third of women believe their husband is against continuation in the northern states, compared with more than six in 10 in Juba. If the women's perceptions are correct, men are more likely than women to favor discontinuation of female circumcision.

Our data indicate no decline in the practice of female circumcision in the northern states, where the majority of the country's people live. As female circumcision is a deeply rooted tradition in Sudan, it cannot be eradicated unless the deeply felt beliefs of those who practice it are well understood and a culturally acceptable policy is adopted. A purely legal approach will bring little or no success. As Nahid Toubia has stated, "Clear policy declarations by government and professional bodies are essential to send a strong message of disapproval, but if the majority of the society is still convinced that female genital mutilation serves the common good, legal sanctions that incriminate practitioners and families may be counterproductive."¹⁶ In such countries, she suggests, public information campaigns and counseling of families about the effects of the practice on children may be more useful.

A look at history may be instructive. In 1946, during the era of British colonial rule in Sudan, the news that a law banning infibulation was about to be proclaimed sent many parents rushing to midwives to have their daughters infibulated in case it should become impossible later on. When some midwives were arrested for performing circumcision, anticolonial protests broke out. The British colonial government, fearing a massive nationalist revolt such as those that had occurred in Egypt and Kenya, eventually let the law go unenforced. More recently, calls to action by Western feminists and human rights activists have provoked similar negative reactions.¹⁷ Even today, the government of Sudan is not taking a strong stand against female circumcision, probably because of a fear of antagonizing the population. In most cases, activities aimed at eliminating the practice are conducted through nongovernmental organizations.

Since the prevailing socioeconomic dependence of women on men in most of the African society, including Sudan, limits their ability to oppose female circumcision,¹⁸ substantial change in women's attitudes is likely to occur only through improvement of women's status in society. Our data show that women's support of the practice declines as their education and economic status rise.

There is a pressing need to disseminate information, generate internal discussion and present the basic health and religious facts in an accessible manner. The reasons women give for favoring discontinuation of female circumcision—such as medical complications and painful personal experiences—and the fact that female circumcision is not obligatory under Islamic law can be used in mass media campaigns and educational curricula. The greater health risks associated with the Pharaonic type of circumcision should be publicized through the media.

In addition, it is important to educate fathers, mothers, grandparents and the boys who will be the future partners of circumcised girls. Above all, there should be a concerted effort by the government, religious leaders, community leaders, nongovernmental organizations and international agencies against the practice in Sudan.