Social Norms Around FGM
Despite more than 25 years of efforts to curtail its practice, female genital cutting (FGC) - defined by WHO and UNICEF as “the partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non-therapeutic reasons” is still a deeply rooted tradition in more than 28 countries in Africa and in some countries in Asia and the Middle East. In the world today there are an estimated 200 million girls and women who have been subjected to the operation. Currently, about 3 million girls, the majority under 15 years of age, undergo the procedure every year (Tag-Eldin et al., 2008; Elkington, 2012; Galvan, 2014).
WHO classifies FGC into four types: Type 1: Partial or total removal of the clitoris (clitoridectomy) and/or the prepuce FGC; Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision); Type 3: Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation); Type 4: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, pulling, piercing, incising, scraping and cauterization. There is a growing awareness that FGC exacts a heavy toll in damage to health. In most countries FGM is performed mainly by traditional practitioners, including traditional midwives and barbers, who may use scissors, razor blades or knives. In recent times FGC is increasingly being performed by health personnel: for example, in Egypt up to 90% of FGC procedures are performed by a health-care provider. The specific impact of FGC on the health of a girl or woman depends, among other factors, on the extent and type of the cutting, the skill of the operator, the cleanliness of the tools and setting used, and the physical condition of the girl or woman. Severe pain and bleeding are the most common immediate consequences of all forms of FGM. Since in most cases the procedure is carried out without anaesthesia, the resulting pain and trauma can produce a state of clinical shock. In some cases, bleeding can be protracted and result in long-term anaemia. Infections are also common, particularly if the procedure is carried out in unhygienic conditions or with unsterilized instruments. Urinary retention is also a frequent complication, especially when skin is stitched over the urethra. Long-term adverse effects include abscesses, painful cysts and thick, raised scars called keloids, which can in turn cause problems during subsequent pregnancy and childbirth. Other long-term complications include infertility and haematocolpos (the accumulation of menstrual fluid in the vagina).
The literature points to many different potential factors for the prevalence of FGC. Some common ones are that it prevents promiscuity by reducing sexual desire and therefore increases marriageability in a lot of these communities (Berg et al., 2010). It is also an integral part of their culture, a significant indicator of family honor and is often seen as the rite of passage for girls to step into womanhood (Vogt et al., 2016). The practice increases the girls’ likelihood of social acceptance, some ethnicities see it as a religious obligation and think its more aesthetic or hygienic for the girl herself (Koski et al., 2019). Some other contributing factors are mother’s education level, views of the paternalistic grandmother, income levels, among others (Yount et al., 2002; Berg et al. 2012; Mahgoub wt al., 2019)
Survey data available for 18 of the 28 countries in Africa where the practice of FGC is prevalent, shows the prevalence of FGM to range from 5% to 97% of the female population. In Mali specifically, almost 91% of the women between 15 to 49 years have been cut at some point in the past (Dibate et al., 2017). The prevalence varies by ethnicity and geography. It is much higher among girls in the Soninke, Malinke, Senufo, and Fulani ethnic groups (over 90%) than among Bobo and Songhai girls (less than 50%). It is also more prevalent in the south west region of Mali. Currently, there is no national legislation that criminalises FGC. However, there have been some information campaigns and activist movements in recent history.
As a part of this research, we design a survey instrument to try and understand whether the practice of female genital cutting if a social norm in the cultures that it is practiced in and if it is then how can the practice be reduced by altering the peripheral beliefs without targetting the core beliefs that the people of the community hold so closely to their value system.
Part 1: Is the practice of FGC a social norm?
In order to design effective interventions to encourage the abandonment of female genital cutting in Mali, we need to first establish whether this practice is, indeed, a social norm. We have thus created a comprehensive 126-question survey, which would act as an interview guide to local partners and trained social workers. Since the Penn Social Norms Group had already designed an intervention in partnership with UNICEF tackling child marriage and nutrition in Mali, we leveraged this previous work by basing our survey on their model. There will be both an English and a French version of this document, for the benefit of the local French speakers, and it will ideally be conducted in different Malian districts.
The interview guide will include several sections, which will be tailored to the different members of the community that we seek to interview (e.g., mothers, fathers, young girls, community leaders, etc.) The first two sets of questions will be rather standardized. They will target 1) demographics, such as information about personal characteristics, household, assets, children, and 2) self-declared behaviors (e.g., Are you planning to have your daughter cut?). The next six sets of questions, however, will be specific to female genital cutting and allow a deep-dive into the beliefs and behaviors surrounding the practice to clearly establish whether or not FGC is a social norm in Mali.
First, we will seek to extract from respondents elements that they believe to be true, regardless of whether they are correct or not. Examples of statements to elicit factual beliefs would be as follows: “an uncut girl will easily find a suitable person to marry” or “cutting a girl will not have any lifelong health consequences”. The answer options to these questions would all be the same: True, False, I don’t know, and I refuse to answer. Second, the survey will attempt to elicit personal normative beliefs, which are beliefs about what one ought to do. Respondents will be asked whether they agree or not with statements such as: “In my opinion, all girls should be cut”, or “In my opinion, a cut girl is honorable”. Third, to learn about people’s expectations about what others do, the interviewer will start by depicting general observations about behaviors in different communities and will proceed to ask a more specific question about the prevalence of a given behavior that can be observed in the respondent’s community. An example of a question to elicit empirical expectations is:
Q. “In some communities, many parents try to cut their daughters in the years before they get their first period; in other communities very few do. Out of 10 families in your community, how many will try to have their daughter cut in the years before she gets her first period.
 Everyone 
 Most [6-9]
 Half 
 Few [1-4]
 Nobody 
 I Don’t know”
Once the interviewer has covered asking the respondent about his/her expectations about what others do, the next set of questions would be asked with the aim of eliciting the ‘normative expectations’, i.e., what the respondent believes about what others think one should do. Here the interviewer would start by asking about the general beliefs the participant thinks others in the community have regarding female genital cutting. These questions would be targeted to explore what the respondent thinks is the general belief system of others in the community regarding “shoulds and should not” about FGC. Some examples of questions asked to elicit normative expectation are:
Q. “In some communities, people believe a girl should be cut to be a good wife. In other communities, people believe that a girl does not need to be cut to be a good wife Out of 10 families in your community, how many believe that a girl should be cut to be a good wife?
 Everyone 
 Most [6-9]
 Half 
 Few [1-4]
 Nobody 
 I Don’t know”
Q. “How many families in your community believe that girls should be cut for honor and to respect the tradition?”
With that, some questions would also be asked to infer what the community believes regarding the sanctioning of any outlier behavior (uncommon behavior). An example of such a question is:
Q. “Some people believe that families who don’t cut their daughters shouldn’t be respected and some people don’t believe so. Out of 10 families in your community, how many believe that families who don’t cut their daughters shouldn’t be respected? “
 Everyone 
 Most [6-9]
 Half 
 Few [1-4]
 Nobody 
 I Don’t know”
The section following the exploration of social expectation will be focused on gaining insight into the reference network, which is the group of people that matters the most to the respondents and influences their behavior with regard to FGC. Here the questions would focus on gathering information about whom the respondent seeks advice about FGC from, and who the key decision-maker is. These questions will allow the researchers to identify the key players in the influential network who encourage or discourage the practice of FGC.
The last section would focus on exploring deep values and beliefs about FGC by engaging the respondent into vignettes or short stories that are built around imaginary yet relatable characters where questions are asked about what these characters should do in a given situation. This section would elicit the same beliefs and expectations about FGC as mentioned above, but the questions would be asked in an indirect manner such that along with the deep-rooted beliefs, one can also infer the conditionality of these beliefs. An example of a vignette that was used in the survey is:
Q. “I would now like you to imagine a community similar to your own. A man named Ahmadou, who you don’t know, moved from your area to this community one year ago. In this community, the parents arrange for their daughters to get cut. Also, in this community, the parents believe that a good father should not organize his daughter to get cut. What do you think Ahmadou will do?
 Arrange his daughter to get cut  Don’t know/equally likely  Not arrange for his daughter to get cut  Other (Specify)  Did not understand the question
As discussed the purpose of conducting this survey is to explore a) the potential reasons behind the practice of FGC in Mali, and b) to identify whether the practice of FGC is a norm in Mali or not. This would be done first by analyzing the personal normative beliefs of the respondents to check if they have a conditional preference for the practice and to understand their beliefs, schemas and the scripts associated with the practice. Next, the empirical expectations would be analyzed to see whether it’s an independent practice pursued to meet a personal need or whether it’s dependent on the expectations that their reference network is also practicing it. Lastly, the normative expectations would be studied to explore if FGC is contingent upon the expectations of the reference network and the sanctions involved pertaining to non-adherence to these expectations.
If the analysis displays that there is an empirical expectation (people believe that others in their community practice it), a normative expectation (people believe that others in their community expect others to practice FGC), and a conditional preference (people themselves believe that they should practice it) towards it then one can confirm that FGC is a social norm in Mali.
Along with this, network analysis would be conducted to explore the key reference network of the people. The survey would be explored to determine the centrality, the degree, betweenness, and the closeness of the network. Through this, the key decision-makers and the potential trendsetters would be identified such that impactful interventions can be led through them.
Part 2: Change Peripheral Beliefs
Tostan: A successful strategy combating FGC, is a rural village empowerment program that originated in Senegal in 1991. The word Tostan means “breakthrough” in Wolof (Easton & Molyneaux, 2006). The Tostan program imparts education on health, hygiene and human rights via an integrative approach (Diop & Askew, 2009). When information around FGC is presented, participants slowly begin to confront their own misbeliefs about the practice. The Tostan program systematically targets the peripheral belief and social expectations to enable the norm change. According to Diop et al. (2004) and Diop and Askew (2009), the social-change model begins with a community management committee, influencing a group of village participants via courses. The program encourages each participant to adopt a friend or relative, sharing what they learn. Then, public discussions are held within the community, exposing the whole village to the intervention and seeking support for denouncing the harmful practice. With the community’s support, leaders then begin to educate the neighboring villages that are connected via intermarriage. Intervillage meetings host discussions to obtain support from other villages. Lastly, a public declaration is made by a group of villages to indicate their intention to abandon the practice of FGC. Based on this structure, the impact of Tostan can be amplified from a classroom to several villages. Given the effectiveness of Tostan in changing attitude toward FGC and reducing the practice, WHO and UNICEF have recognized Tostan as the model program for other countries battling to end FGC (Wakabi, 2007). We therefore believe that Tostan is a valuable model of social change, several aspects of which can be replicated for our intervention in Mali.
Saleema: In an effort to replace the Sudanese word “Ghalfa”, a derogatory term used by society to demean an uncut girl, the National Council of Child Welfare and UNICEF Sudan devised the behavioral change intervention “Saleema”, an Arabic term symbolizing a healthy body and mind, untouched by harm (Evans et al., 2019). The Saleema Initiative became a national campaign in 2008 to promote sustainable norm change to abandon the widespread practice of FGC by reinforcing the idea that being uncut is an intrinsically desirable state (UNICEF, 2009). The intervention was carried out primarily through four important activities across 18 states in Sudan. These activities are: 1) Sufara Saleema campaign - essence of Saleema is thoughtfully infused into songs, poetry and TV animations and placed tastefully within the context of local culture, 2) Sufara colors - citizens are encouraged to wear clothes in orange, red, yellow and green to publicly demonstrate support, 3) community dialogue - campaign workers stimulate a conversation on human rights among families, neighbors and communities in non-formal classrooms, and 4) born Saleema project - mothers of newly born baby girls are educated by trained health workers who reinforce the Saleema philosophy “Every girl is born Saleema, let her grow up Saleema” (UNFPA, 2012). Multiple evaluation studies point to a powerful change in attitudes towards FGC in Sudan post the Saleema intervention. This can mainly be attributed to two crucial aspects. First, the campaign does not dismiss the deep rooted values associated with FGC as a long-held custom, instead it introduces new meaning to the concept, thereby enabling a new social norm to emerge (UNFPA, 2012). Second, it elevates the value in remaining uncut to an extent that is greater than the importance associated with cutting a girl (Mahgoub et al., 2018). This subtle yet powerful displacement in value proposition significantly adds to the appeal of the Saleema intervention, making it a desirable model to replicate.
Proposed Intervention: While some central beliefs (such as the desire to uphold family honor or ensuring that a daughter becomes a good wife) are considerably more complex and multi-layered, some peripheral beliefs are more fluid and dynamic in nature and therefore present a greater likelihood for change (Bicchieri & Mercier, 2014). Based on existing literature on FGC, we expect to gather from the survey some important peripheral beliefs associated with the practice that are more malleable to such change. For instance, the belief that cutting a girl is a good investment to help secure a good groom is simply a rationalization communities make because cutting a girl has no real bearing on the outcome or quality of marriage (Kudo, 2018). Similarly, the reasoning that Islam advocates FGC may be prevalent among communities although we know that Islamic scriptures do not endorse the practice (Bicchieri & Mercier, 2014). The view that having daughters cut is a guarantee of fidelity also constitutes a peripheral belief because a cut girl may not necessarily feel the need to abstain or be unable to engage in premarital sex.
According to Bicchieri and Mercier (2014), implicit argumentation is an effective method to address and potentially change peripheral beliefs. The demonstration of a conflict between central values that are important to the community and common beliefs that they may have about FGC is a powerful way to subtly indicate to the community the need to put an end to the practice. The Tostan program is a successful example of an intervention that implements this conceptual framework. While the design of the intervention focused on empowering rural villages by imparting life skills, the core methodology of the intervention is centred on deductive reasoning where participants, through the course of the educational experience, draw their own conclusions about FGC (Diop et al., 2004; Bicchieri & Mercier, 2014). For our intervention, contingent upon the results of the survey, we propose to potentially replicate the Tostan model of social change in Mali by introducing an educational program that targets peripheral beliefs that are unique to communities in Mali.
The first step we wish to implement is to better understand the nature of the practice of FGC in Mali. We have designed a survey to test whether it is a social norm or not. We do this by measuring self-declared behaviors, factual beliefs, personal normative beliefs, normative expectations, empirical expectations and reference network mapping. This also provides insights about the factors related to the prevalence of the practice. In a cultural environment such as Mali’s that is fraught with harmful misbeliefs about FGC, it is the degree of participatory education and positive reinforcement of the new norm that will ultimately tilt the dynamics of social change in a favorable manner. More specifically, the formation of long term, tight-knit learning communities that foster critical thinking as well as reward community members for remaining uncut will have tremendous value in bringing about sustainable behavior change in this ecosystem. We believe effectively rolling out our carefully designed survey in Mali will serve as a powerful first step in identifying, measuring and analyzing social expectations in local communities, the structures of which we aspire to transform using hands-on pedagogical approaches and repeated positive reinforcement of the new norm.