DHS

Comparative Reports

Female Genital Cutting in the 

Demographic and Health Surveys: 

A Critical and Comparative Analysis

7
MEASURE DHS+ assists countries worldwide in the collection and use of data to monitor 

and evaluate population, health, and nutrition programs. Funded by the U.S. Agency for 

International Development (USAID), MEASURE DHS+ is implemented by ORC Macro in 

Calverton, Maryland. 

 

The main objectives of the MEASURE DHS+ project are: 

1) to provide decisionmakers in survey countries with information useful for informed policy choices, 

2) to expand the international population and health database, 

3) to advance survey methodology, and 

4) to develop in participating countries the skills and resources necessary to conduct high-quality demographic 

and health surveys. 

 

Information about the MEASURE DHS+ project or the status of MEASURE DHS+ surveys is available on the 

Internet at http://www.measuredhs.com or by contacting: 

ORC Macro 

11785 Beltsville Drive, 

Suite 300 

Calverton, MD 20705 USA 

Telephone: 301-572-0200 

Fax: 301-572-0999 

E-mail: reports@orcmacro.com
DHS Comparative Reports No. 7 

Female Genital Cutting 

in the Demographic 

and Health Surveys: 

A Critical and Comparative Analysis 

P. Stanley Yoder 

Noureddine Abderrahim 

Arlinda Zhuzhuni 

ORC Macro 

Calverton, Maryland, USA 

September 2004 
This publication was made possible through support provided by the U.S. Agency for 

International Development under the terms of Contract No. HRN-C-00-97-00019-

00. The opinions expressed herein are those of the authors and do not necessarily 

reflect the views of the U.S. Agency for International Development. 

Editor: Sidney Moore 

Series design: Katherine Senzee 

Document production: Justine Faulkenburg 

Recommended citation: 

Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhuni. 2004. Female 

Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative 

Analysis. DHS Comparative Reports No 7. Calverton, Maryland: ORC Macro. 
Contents iii 

Contents 

Tables v

Preface vii

Acknowledgments viii

Executive Summary ix 

1 Introduction 1

1.1 Terms and Concepts Regarding FGC 1

1.2 Purpose of This Study 3

1.3 Questions to Consider 3

2 Studies of Female Genital Cutting 7

2.1 Collection and Interpretation of Data on FGC 7

2.2 FGC Prevalence Estimates 7

2.3 Types of Female Genital Cutting 8

2.4 Health Consequences of FGC 10

2.5 Continuation of the Practice of FGC 12

2.6 Research Priorities 14

3 Development of FGC Questions in DHS Surveys 15

3.1 Early DHS Surveys 15

3.2 Later DHS Surveys 16

3.3 FGC Status of Respondents 17

3.4 Respondents’ Accounts of the Circumcision Event 18

3.4.1 Approaches to Asking about the Type of FGC 18

3.4.2 Identity of the Person Performing the FGC 20

3.5 Respondents’ Accounts of Daughter’s Circumcision 21

3.6 Perceptions of FGC 22

4 Discussion of FGC in DHS Survey Reports 25

4.1 National Rates of FGC Prevalence 25

4.2 Disaggregation of Data in Country Reports 26

4.2.1 FGC Prevalence by Age and Residence 27

4.2.2 FGC Prevalence by Region 27

4.2.3 FGC Prevalence by Education 28

4.2.4 FGC Prevalence and Religion 30

4.2.5 FGC Prevalence and Ethnicity 31

4.3 Circumstances Surrounding the Circumcision 33

4.3.1 Age at Circumcision 33

4.3.2 Type of Circumcision 34

4.3.3 Identity of Person Who Performed FGC 36

4.4 Health Consequences from Survey Data 37
iv Contents

4.5 Individual Perceptions of FGC 39

4.5.1 Support for FGC among Women 39

4.5.2 Reasons to Continue FGC 42

4.5.3 Support for FGC among Men 43

5 Changes Over Time 45

5.1 Tracking Changes in the Practice of FGC 45

5.2 Comparison of Age Cohorts 45

5.3 Mother-daughter Comparisons 49

5.4 Comparison of Survey Results at Two Points in Time 49

6 Conclusion: Use of DHS Data on Female Genital Cutting 53 

References 55

Appendix 59

Female Genital Cutting Module for the Women’s Questionnaire 61

Female Genital Cutting Module for the Men’s Questionnaire 65
Tables v 

Tables 

Table 3.1 Coverage of specific FGC topics in DHS surveys 1989-2002 17

Table 3.2 Distribution of DHS surveys that included questions about 

FGC, according to the criteria used to identify the FGC 

experience of respondent’s daughter, DHS surveys 1989-2002 22

Table 4.1 Prevalence of FGC among women in DHS surveys by region, 

1989-2002 26

Table 4.2 Sociodemographic variables used for disaggregation of FGC 

prevalence data in DHS surveys, 1989-2002 27

Table 4.3 Among women with at least one living daughter, the percentage 

of eldest daughters circumcised, by mother’s education, DHS 

surveys 1989-1999 29

Table 4.4 Among women with at least one living daughter, the percentage 

who had at least one daughter circumcised, by mother’s education, 

DHS surveys 1995-2002 29

Table 4.5 FGC prevalence among women by religion (Muslim or Christian), 

DHS surveys 1989-2001 30

Table 4.6 Range of FGC prevalence among ethnic groups in eight DHS 

surveys, 1998-2001 31

Table 4.7 FGC prevalence among women in specific ethnic groups in four 

DHS surveys 1998-2001 32

Table 4.8 Percent distribution of circumcised women by age when cutting 

occurred, DHS surveys 1989-2002 34

Table 4.9 Among circumcised women, the cumulative percent circumcised, 

by age when cutting occurred, DHS surveys, 1989-2002 35

Table 4.10 Percent distribution of circumcised women by type of FGC 

received (prompted), DHS surveys 1995-1999 35

Table 4.11 Percent distribution of circumcised women by person who did the 

cutting (traditional practitioner or medical personnel), DHS 

surveys 1989-2002 37

Table 4.12 Percentage of daughters who experienced specific health 

consequences after their circumcision according to mothers’ 

reports, DHS surveys 1999-2001 38

Table 4.13 Percent distribution of circumcised women by whether they 

support the continuation of FGC or want it to stop, DHS surveys 

1989-2002 40
vi Tables

Table 4.14 Among circumcised women with at least one living daughter, the 

prevalence of FGC among eldest daughters, by whether the 

mother supports or opposes FGC, DHS surveys 1995-1999 41

Table 4.15 Among women who want FGC to continue, percentage who gave 

specific reasons for continuing FGC, DHS surveys 1989-1999 42

Table 4.16 Percentage of women and men who said that FGC should 

continue, DHS surveys 1995-2001 44

Table 5.1 Percentage of women circumcised, by age, DHS surveys 1989-

2002 46

Table 5.2 Percentage of circumcised women who were cut by a medical 

professional, by age, DHS surveys 1989-2002 47

Table 5.3 Percentage of women who support FGC, by age, DHS surveys 

1989-2002 48

Table 5.4 Circumcision status of eldest daughters and their mothers, based 

on information from women who have heard of FGC and have at 

least one living daughter, DHS surveys 1995-1999 49

Table 5.5 FGC prevalence and support for FGC in four countries where two 

DHS surveys were conducted, DHS surveys 1994-2002 50

Table 5.6 Comparison of two surveys in four countries by characteristics of 

the FGC experience, DHS surveys 1994-2002 50
Preface vii 

Preface 

One of the most significant contributions of the MEASURE DHS+ program is the 

creation of an internationally comparable body of data on the demographic and 

health characteristics of populations in developing countries. The DHS Comparative 

Reports series examines these data across countries in a comparative framework. The 

DHS Analytical Studies series focuses on specific topics. The principal objectives of 

both series are to provide information for policy formulation at the international level 

and to examine individual country results in an international context. Whereas Comparative Reports are primarily descriptive, Analytical Studies take a more analytical approach. 

The Comparative Reports series covers a variable number of countries, depending 

on the availability of data sets. Where possible, data from previous DHS surveys are 

used to evaluate trends over time. Each report provides detailed tables and graphs 

organized by region. Survey-related issues such as questionnaire comparability, survey 

procedures, data quality, and methodological approaches are addressed as needed. 

The topics covered in Comparative Reports are selected by MEASURE DHS+ staff 

in conjunction with the MEASURE DHS+ Scientific Advisory Committee and 

USAID. Some reports are updates and expansions of reports published previously. 

It is anticipated that the availability of comparable information for a large number 

of developing countries will enhance the understanding of important issues in the 

fields of international population and health by analysts and policymakers. 

Martin Vaessen 

Project Director 
viii Acknowledgments

Acknowledgments 

The authors would like to warmly thank those who reviewed the document and made 

numerous helpful comments: Sunita Kishor of ORC Macro, Bettina Shell-Duncan 

of the University of Washington, and Ylva Hernlund of the University of Washington. 
Executive Summary ix 

Executive Summary 

Female genital cutting (FGC), also known as female circumcision, or female genital 

mutilation (FGM), is a common practice in many societies in the northern half of 

sub-Saharan Africa as well as in Egypt and Yemen. Nearly universal in a few countries, it is practiced by various groups in at least 25 African countries, in Yemen, and 

in immigrant populations in Europe and North America. The cutting varies from a 

symbolic nicking of the clitoris to excision of tissue and partial closure of the vaginal 

area (infibulation). The ritual aspects vary from the straightforward cutting of an infant in the household context to complex rituals involving the cutting of groups of 

adolescent girls held in seclusion for weeks or months. In a few societies, the procedure is routinely carried out when a girl is a few weeks or a few months old (e.g., Eritrea, Yemen); in most, it occurs later in childhood or in adolescence. 

This comparative report summarizes data on FGC from Demographic and Health 

Surveys (DHS) implemented between 1989 and 2002. It is intended to make more 

accessible the basic information on the distribution and practice of FGC and to encourage country-specific analysis of DHS data on FGC. The report describes the 

types of DHS data available on FGC, outlines some overall patterns in the data, 

identifies important changes over time, and comments on the questionnaires used 

from 1989 to 2002. By the end of 2002, there were a total of 20 DHS surveys that 

included questions on the circumcision status of women. The surveys covered 15 

countries in Africa, plus Yemen. 

FGC prevalence at the national level among women 15-49 years of age in African 

countries varies from 5 percent in Niger (1998) to 99 percent in Guinea (1999). 

Among the 15 African countries for which FGC prevalence data were available by 

the end of 2002, 8 had prevalence levels between 71 and 99 percent, and 7 were between 5 and 45 percent. When the countries are arranged in tables by region, certain 

similarities in prevalence rates appear; for example, FGC prevalence in the countries 

of northeastern Africa (Egypt, Eritrea, Ethiopia, and northern Sudan) ranges from 

80 to 97 percent, while that of eastern Africa (Kenya and Tanzania) ranges from 18 

to 38 percent. 

Except for countries with prevalence rates above 90 percent, FGC prevalence varies widely within countries by ethnicity. Ethnicity provides a better explanation of the 

distribution of FGC within countries than other variables. Prevalence may be 1 percent in one group and 95 percent in another, in the same country. Distribution by 

religion or urban-rural residence is uneven. 

The report discusses how the specific questions on FGC used in DHS surveys 

have changed over time (1989 to 2002). There has been variation in how women are 

asked about their circumcision status and, if circumcised, what type of circumcision 

was performed. There has also been variation in the way daughters are identified for 

purposes of determining circumcision status, and variation in the questions on individual perceptions about FGC. 

Recent studies of FGC in African societies have shown that the practice varies 

widely in how it is conducted, and changes are under way in some societies. The literature on FGC suggests that overall, FGC prevalence is decreasing, that in many 

countries girls are being cut at earlier ages, that the ceremonial aspects of female circumcision have been reduced, and that a larger proportion of girls are being cut by 
x Executive Summary

medical personnel than before. DHS data documents these trends in some countries 

but not others. Changes in FGC practices should be monitored so program specialists can design interventions that are adapted to local practices. 
Introduction 1 

 1

Introduction 

1.1 Terms and Concepts Regarding FGC 

he practice of female genital cutting (FGC) refers to “the cutting and removal of 

tissues of genitalia of young girls to conform to social expectations” (Gruenbaum 

2001:2). The World Health Organization (WHO) speaks of injury to or removal of 

the female genitalia “for cultural or any other non-therapeutic reason” (WHO 1996). 

The practice has often been called female circumcision, for in some societies, the rituals 

surrounding both male and female circumcision form a part of the process of initiation into adulthood (e.g., Droz, 2000; Gessain, 1960; Jackson, 1977). However, 

many authors protest against any mention of circumcision, which, they argue, mistakenly suggests that FGC is analogous to male circumcision (cf. Transgrud, 1994). 

FGC is indeed quite unlike male circumcision in its physical and social consequences. 

In the mid-1990s, WHO and many other groups adopted the term female genital 

mutilation (FGM) to describe the cutting of female genitalia, for it emphasizes the 

permanent physical damage done to the body. This is the term used by the majority 

of English speakers, as well as many activists who direct interventions against the 

practice, but there seems to be a clear shift toward using FGC. Yet another term that 

has been suggested, but not often used, is female genital surgeries (Obermeyer, 1999). 

More recently, researchers and interested parties have expressed concern that the 

term female genital mutilation “stigmatizes the practice to the detriment of the programs trying to change it” (USAID, 2000). A number of specialists from African 

countries have objected to the term mutilation, saying the term is judgmental and 

implies disrespect (Eliah, 1996). According to Shell-Duncan and Hernlund, it was 

Ugandans working on the REACH (Reproductive, Educative and Community 

Health Programme) project who first suggested the term female genital cutting to replace FGM (Shell-Duncan and Hernlund, 2000:6). The more neutral term, female 

genital cutting, preferred by an increasing number of researchers, is the term recommended by the United States Agency for International Development (USAID) and is 

used in this document to refer to the practice. For linguistic convenience, however, 

words such as circumcise and circumcised are still used in the text as synonyms of the 

term cut. French speakers generally use the term excision for actions or practices that 

are known in English as FGM or FGC. 

FGC is a common practice in many societies in the northern half of sub-Saharan 

Africa as well as in Egypt and Yemen. Nearly universal in a few countries, it is practiced by various groups in at least 25 African countries, in Yemen, and in immigrant 

populations in Europe and North America. In a few societies, the procedure is routinely carried out when a girl is a few weeks or a few months old (e.g., Eritrea, 

Yemen), but in most, it occurs later in childhood or adolescence. In the case of the 

T 

FGC is a common practice 

in many societies in the 

northern half of subSaharan Africa as well as 

in Egypt and Yemen. 
2 Introduction

latter, FGC is often part of a ritual initiation into womanhood that includes a period 

of seclusion and education about the rights and duties of a wife. 

FGC includes a range of practices, varying from a simple nick of the clitoris to the 

partial or complete removal of the external female genitalia for nonmedical reasons. 

For a sample of what is most commonly thought about this subject, we refer to the 

opening paragraph of a 1997 article called “Female circumcision: Rite of passage or 

violation of rights?” written by Frances Althaus (1997:130). 

Female circumcision, the partial or total cutting away of the external female genitalia, has been practiced for centuries in parts of Africa, generally as one element of a rite of passage preparing young girls for womanhood and marriage. Often performed without anesthetic under septic 

conditions by lay practitioners with little or no knowledge of human 

anatomy or medicine, female circumcision can cause death or permanent 

health problems as well as severe pain. Despite these grave risks, its practitioners look on it as an integral part of their cultural and ethnic identity, 

and some perceive it as a religious obligation. 

The image that comes from this description⎯that of a painful traditional rite of 

passage that places the lives of young girls in danger⎯is well known to researchers 

and activists, who often assume that FGC “is an ‘ancient’ and deeply entrenched 

practice, that it is associated with initiation, with Islam, and with patriarchy” (ShellDuncan and Hernlund, 2000:3). The authors point out, however, that FGC is a recent practice in some societies, that it is not always part of an initiation ritual, and 

that most of the Islamic world does not observe the practice. While the practice in 

what is now Egypt and Sudan predates Islam by hundreds of years, in some parts of 

West Africa it began to be practiced in the 19th or early 20th centuries (Ottenberg, 

1994). In countries such as Chad, The Gambia, and Mali, ethnographic research has 

shown that the practice of FGC is changing rapidly (Gosselin, 2000; Hernlund, 

2003; Leonard, 2000). 

If FGC is not just an Islamic practice, if it is not necessarily a rite of passage for 

young girls, if it has not been practiced for hundreds of years in some societies, and if 

the practice is changing over time, then our image of FGC as an ancient tradition 

very difficult to change must be questioned. The best way to clarify and correct our 

stereotyped images of FGC is to collect data on the practice and monitor changes 

over time through population-based surveys and ethnographic studies of current 

practices. There is a wealth of survey data now available, but ethnographic studies are 

few. Some researchers have shied away from conducting research on the practice of 

FGC because they do not want to be seen as condoning the practice. A small number 

of studies of FGC today have been conducted (c.f. Gosselin, 2000; Hernlund, 2003; 

Leonard, 1996; Yoder et al., 1999). 

Since 1984 the Demographic and Health Surveys (DHS) program, which is 

funded by USAID, has assisted developing countries worldwide to conduct nationwide surveys on a wide range of topics related to health and population. The topics 

covered in the core questionnaires for women include demographic characteristics, 

fertility, family planning, maternal and child health and nutrition, and knowledge 

and practice related to HIV/AIDS. In addition to the core questionnaire, modules on 

subjects of particular interest (e.g., malaria, FGC, women’s status, domestic violence, 

HIV/AIDS) are available for use if a country so chooses. By the end of 2002, DHS 

FGC includes a range of 

practices, varying from a 

simple nick of the clitoris 

to the partial or complete 

removal of the external 

female genitalia for 

nonmedical reasons. 
Introduction 3 

had conducted over 150 surveys in 68 countries, with questions about FGC asked in 

16 countries. 

A series of questions (module) on FGC has been used in national surveys in a 

number of African countries since 1989. DHS collected FGC data for the first time 

in a 1989-90 survey in northern Sudan after the USAID Mission and the Ministry of 

Health showed great interest in collecting data on FGC. In that survey, women were 

asked whether they had ever been circumcised, what type of FGC had been done, 

and who performed the operation. A number of questions followed asking their 

opinion about the practice. This pattern of questioning has been followed to a large 

extent in subsequent surveys. 

1.2 Purpose of This Study 

This report summarizes the data on FGC from all DHS surveys implemented between 1989 and 2002 that included questions about FGC prevalence, in order to 

make more accessible the basic information about how and when FGC has been 

practiced, and to encourage country-specific analyses of DHS data on FGC. The 

study describes the kind of DHS data available on FGC, outlines patterns in the 

data, identifies important changes over time, and comments on the questionnaires 

used from 1989 to 2002. By the end of 2002, a total of 20 DHS surveys that included 

questions about whether women had been circumcised had been conducted, including surveys from 15 countries in Africa, plus Yemen. 

By drawing on the data from 20 surveys conducted over a period of 14 years, a 

great deal can be learned by disaggregating variables in different ways and by looking 

at trends over time. It also is important to examine changes in the questionnaires over 

time to see which questions appear to provide the most useful information. This 

study seeks to highlight patterns that exist in the data, illustrates how these data can 

be used to inform programs, examines the development of questions used in the surveys, and reflects on the data collection process. It also raises questions about the 

status of FGC in individual countries that can best be answered by further analysis of 

data from these countries. 

In many ways, this research builds on an earlier study of FGC by Dara Carr called 

Female Genital Cutting: Findings from the Demographic and Health Surveys Program

(1997). Carr summarized the main findings on FGC from DHS surveys from 1990 

to 1996 in six countries in Africa plus Yemen. Carr focused on issues of greatest interest for programs seeking to eradicate FGC. As the first publication that provided 

prevalence and other information on FGC derived from national sample surveys, 

Carr’s report has been extremely useful for understanding the FGC situation in these 

countries. It remains one of the richest and most informative texts available about 

FGC prevalence and related information useful for program purposes. 

1.3 Questions to Consider 

Researchers who have examined evidence of FGC in various countries have been 

most interested in obtaining data on prevalence, on the type of FGC practiced, on 

possible medical consequences, and on indications that the practice is changing. The 

literature on FGC was long dominated by personal accounts of tragic events, smallscale studies of circumcision in a town or a set of villages, and studies of medical 

complications of circumcised women delivering in a hospital. That changed in the 

1990s with population-based surveys and large studies on the types of FGC pracFGC is a recent practice in 

some societies, it is not 

always part of an 

initiation ritual, and most 

of the Islamic world does 

not observe the practice. 
4 Introduction

ticed. Toubia and Sharief (2003) have recently summarized the evolution in perspective within the international development community regarding how and why FGC 

should be combated, underlining the shift from a focus on the medical consequences 

to one on human rights. 

The 16 countries for which we have FGC prevalence data can be divided into 

three categories, according to the national prevalence rate of FGC: 

1. Countries where nearly all girls get circumcised and where prevalence 

is high (70 to 99 percent) 

2. Countries in which only certain ethnic groups practice circumcision 

and where prevalence is relatively moderate (23 to 50 percent) 

3. Countries in which only a few ethnic groups practice FGC and 

where national prevalence is low (5 to 20 percent). 

Data on changes over time can be obtained by comparing information about the 

FGC experience from mothers and their daughters, by comparing FGC among older 

and younger cohorts of women, or by comparing the results of two surveys (possible 

in Côte d’Ivoire, Egypt, Eritrea, and Mali). This analysis will examine evidence for 

changes in the overall rate of FGC at national and regional levels, in the types of operations conducted, in the age at the time of FGC, and in the identity of the person 

carrying out the operation. 

Information about FGC as an event is critical to understanding how female circumcision has been carried out and how the practice is distributed in a population. 

Data on the distribution of FGC and how it is practiced can be useful to guide 

strategies for interventions against the practice. Families live in social environments 

of three kinds with regard to FGC: 1) those in which nearly everyone has their girls 

cut, 2) those in which no one has their girls cut, and 3) those in which some girls get 

cut while others do not. The latter situation occurs in some urban areas and in regions of ethnic diversity. It seems reasonable to assume that interventions would use 

different strategies when all girls are getting cut as opposed to only some. Information about how the event of FGC occurs is also vital in planning interventions. In the 

Egypt 2000 survey data, for example, more than half of the cutting was done by physicians and nurses, while in many countries in West Africa, 80 to 90 percent of the 

operations are carried out by traditional practitioners. In addition, information about 

changes in the practice over time may provide ideas on how to intervene more effectively to abolish the practice. 

Finally, this report discusses how the specific questions asked about FGC in the 

DHS surveys have changed over time from 1989 to 2002. There has been variation in 

how women are asked whether they are circumcised and, if so, the type of circumcision done; there is also variation in the way a daughter is identified to ask about her 

circumcision status, and there has been variation in the questions on individual perceptions about FGC. 

The information provided in this study comes from the FGC data presented in the 

final reports, from additional analyses of country-level data, from contacts with researchers working on these issues, and from a review of recent literature on FGC. 

Data are aggregated in ways that show patterns within or between countries. Particular attention is given to showing how these data can be used for informing program 

priorities. The date given for the surveys is the date of the fieldwork. 

Information about 

changes in the practice of 

FGC over time may 

provide ideas on how to 

intervene more effectively 

to abolish the practice. 
Introduction 5 

The statistical method used by the authors to examine the DHS data was bivariate 

analysis. Additional information could no doubt be gained by using multivariate 

analyses. For example, it might be possible to assess the relative importance of variables such as urban-rural residence, religion, and ethnicity in the distribution of FGC 

prevalence. Such analyses might also explain some of the anomalous results that appear in a few of the tables. 

This report is organized around the following questions: 

1. What issues have interested researchers studying FGC? 

2. How has the data collection process changed over time? 

3. What do we know about the prevalence of FGC in various countries? 

4. What can be learned from looking at the distribution of FGC within 

countries? 

5. What indications of changes in the way FGC is done can be discerned in the data? 

6. How can data on individual perceptions of FGC be used to better 

understand the situation? 

The concluding chapter discusses the implications of FGC studies and the ongoing collection of FGC data by the Demographic and Health Surveys for programs 

and organizations seeking to abolish the practice of FGC. 

Studies of Female Genital Cutting 7 

Studies of Female Genital Cutting 

2.1 Collection and Interpretation of Data on FGC 

he literature on FGC ranges widely from life histories and anecdotal accounts of 

personal tragedy to medical studies and reports from population-based surveys. 

Advocates for interventions to eradicate FGC as well as researchers who study the 

practice have often argued over terminology as well as priorities. 

We will not be presenting a full account of studies of FGC over the past several 

decades because other researchers have published such summaries. In the introduction to their edited volume entitled Female “Circumcision” in Africa, Shell-Duncan and 

Hernlund present an overview of the discourse around FGC, beginning with the 

Hosken Report in 1979 (Shell-Duncan and Hernlund, 2000). They include an insightful discussion of the issues surrounding FGC as they have become politicized 

both nationally and internationally. They argue that the practice of FGC must be 

understood from the viewpoint of participants as well as outside observers and that 

the practice is undergoing rapid change. Ellen Gruenbaum writes about the evidence 

for FGC prevalence and the debate about what constitutes FGC, with a focus largely 

on Sudan, but her insights can be applied broadly (Gruenbaum, 2001). An article in 

Medical Anthropology Quarterly by Carla Obermeyer summarizes evidence from 435 

published accounts of FGC studies related to prevalence, health consequences, and 

other consequences (Obermeyer, 1999). Obermeyer has pointed out that resources 

for studies on FGC have gone largely to projects designed to eradicate FGC, and 

that solid evidence for the negative health consequences of cutting is sparse at best. 

This brief review comments on key issues related to several common questions. 

Each of these questions structures a brief discussion of the relative evidence available. 

• Where does FGC occur? 

• How does FGC occur? 

• What are the health consequences of FGC? 

• Why does the practice continue? 

2.2 FGC Prevalence Estimates 

Figures on the prevalence of FGC are important for estimating the extent of the phenomenon and the number of women at risk. Once national prevalence figures are 

calculated, it is possible to estimate how many women are at risk for FGC in subSaharan Africa. These overall figures can then be used to publicize the threat that 

FGC poses to women’s health and human rights. 

The first effort to estimate prevalence at the national level was made by Francis 

Hosken. She published The Hosken Report (1982), which included estimates for 

 2

The literature on FGC 

ranges widely from life 

histories and anecdotal 

accounts of personal 

tragedy to medical 

studies and reports from 

population-based surveys. 

T 
8 Studies of Female Genital Cutting

prevalence at the national level for 28 countries. However, much of the information 

in the report was based on anecdotal evidence. In a more systematic approach a decade later, Nahid Toubia summarized data on FGC prevalence in her report entitled 

Female Genital Mutilation: A Call for Global Action (Toubia, 1993). When Toubia’s 

report was published in 1993, no population-based survey covering an entire country 

had been conducted using questions about FGC prevalence. In 1990, ORC Macro 

published a country report on Sudan that covered only the six northern provinces. 

FGC prevalence cited in that report was 89 percent. The next surveys with similar 

questions were carried out in 1994. The first comparative study of DHS data on 

FGC was published by Macro in 1997 (Carr, 1997). 

It is important to get accurate estimates of FGC prevalence for several reasons: for 

judging the relative importance of adverse health consequences, for the allocation of 

resources, and for planning interventions. For example, Nahid Toubia (1993), borrowing from Hosken, provided an estimate of 50 percent prevalence for Nigeria. This 

estimate prompted Ellen Gruenbaum to write the following: “Nearly a third of the 

cases in Africa are in Nigeria, not because of high prevalence but because of its large 

population; the country accounts for 30.6 million of the 114.3 million cases for Africa 

as a whole, according to Toubia” (Gruenbaum, 2001:8). In the DHS survey of 1999 

in Nigeria, however, a prevalence of 25 percent, not 50 percent, was found. 

In a publication from 2000, the authors state that, “based on current estimates, 18 

African countries have prevalence rates of 50 percent or higher” (Rahman and 

Toubia, 2000:7). DHS surveys to date have found eight countries with a prevalence 

rate of more than 50 percent, but no DHS surveys with questions about FGC have 

ever been conducted in Somalia, Djibouti, The Gambia, or Sierra Leone, all countries where prevalence is thought to be high. The total number of countries with 

FGC prevalence greater than 50 percent is thought to be at least 12. 

Early estimates of the prevalence of FGC in African countries were good faith efforts to calculate likely numbers on the basis of the evidence available. These estimates have not often been confirmed by national surveys, having erred on both the 

high and the low side. A number of texts have suggested that more than two million 

girls are at risk for FGC each year, most of them in sub-Saharan Africa. By the end 

of 2003, DHS had collected data on FGC prevalence for 17 of the 28 countries discussed by Toubia, and 3 of the remaining 11 are The Gambia, Guinea-Bissau, and 

Djibouti, with small populations. Figures for the numbers of females at risk of FGC 

in African countries can now be calculated with the annual birth rates and FGC 

prevalence figures from national-level survey data. 

2.3 Types of Female Genital Cutting 

Knowing what was done to a girl or woman at circumcision is important for anticipating possible health consequences in the short and long term⎯consequences that 

may range from psychological distress to death. Both the frequency and severity of 

health complications after FGC are a function of the extent of the cutting and the 

circumstances of the event (Obermeyer, 1999). The extremes are easily described: a 

simple nick of the clitoris to draw a drop of blood versus infibulation, which involves 

removal of the female external genitalia accompanied by closure of the vaginal area. 

The types of cutting (variations of clitoridectomy and excision) range along a continuum between the two extremes, and can be described but not easily identified. 

Early estimates of the 

prevalence of FGC in 

African countries have 

not often been confirmed 

by national surveys, 

having erred on both the 

high and the low side. 
Studies of Female Genital Cutting 9 

On the recommendation of Toubia (1994), the World Health Organization 

adopted a classification of FGC that divides the operation into four types, or categories: 

• Clitoridectomy: total or partial removal of the clitoris 

• Excision: removal of the clitoris and partial or complete removal of 

the labia minora 

• Infibulation: removal of the clitoris, the labia minora and labia majora, with a narrowing or near closure of the vaginal opening 

• Any other variations.

Systematic data on FGC type have been collected through population-based surveys and through clinical examinations. In the earlier surveys, women were usually 

asked about what was done to them, and the answers were classified by the interview 

into precoded categories. In clinical contexts, women may be also asked whether they 

had been cut, but a gynecologist conducts vaginal exams and makes a judgment about 

what was done. Surveys offer the advantage of providing information on large numbers of women, but the information may not always be accurate. Clinical examinations are more accurate, but usually accommodate only a small number of women. 

A few studies of FGC typed through clinical examination have been conducted by 

medical researchers. The 1995 Egypt DHS survey included a clinical component designed to compare the answers of respondents on their FGC status with physical examinations. The study was conducted in five university hospitals, several rural hospitals, and two urban clinics. Women attending the family planning clinics or who 

came for other gynecological examinations were interviewed with the FGC questions 

from the DHS and were then given pelvic examinations by gynecologists specially 

trained to identify the type of FGC. The study included 1,339 women age 15-49. In 

94 percent of cases, the woman’s report regarding whether she had been circumcised 

matched that of the examining physician. In 5 percent of cases, the woman had reported that she was circumcised, but no such evidence was found. The study did not 

report on the types of FGC observed. 

In 1999, Snow and colleagues conducted a cross-sectional study of reproductive 

health among women age 15-49 attending antenatal and family planning clinics in 

three hospitals in Edo State, Nigeria. Clients at these clinics were interviewed by 

nurses/midwives about their social and demographic background, reproductive history, and experience with FGC. The interviews were followed by a routine vaginal 

examination by an obstetrician/gynecologist, who reported on the type of FGC performed on those who had been circumcised (Snow et al., 2002). The article reported 

on a sample of 1,709 women in Benin City and Irrua. The study found that 46 percent (N=789) had undergone FGC according to the physical exam: 34 percent had 

undergone clitoridectomy, 12 percent excision, and 1 percent infibulation. A comparison of the self-reported data with the data from the clinical exams showed that 79 

percent of the women provided correct information about their circumcision status, 

14 percent said that they were not certain, and 7 percent reported their status incorrectly. Among the 14 percent who were unsure of their FGC status, 85 percent had 

not been cut. The proportion of women who were uncertain about their circumcision 

status (14 percent) was larger than expected. 

Knowing what was done 

to a girl or woman at 

circumcision is important 

for anticipating possible 

health consequences. 
10 Studies of Female Genital Cutting

Linda Morison and colleagues conducted a community survey among women age 

15-54 in 20 villages in The Gambia “to estimate the prevalence of reproductive morbidity on the basis of women’s reports, a gynecological examination, and laboratory 

analysis of specimens” (Morison et al., 2001:643). A total of 1,346 women were interviewed in 1999, and 1,157 consented to a gynecological exam. Fifty-eight percent 

of the women interviewed (779 out of 1,346) with a structured questionnaire reported 

having been cut, and 3 of these women reported that they had been “sealed” (similar 

to infibulation). A clinical exam showed that 58 percent (671 out of 1,157) of women 

showed signs of having undergone FGC. 

The study by Morison and colleagues found agreement between the respondents’ 

reports and the clinical examination about the FGC status (cut or not cut) in 97 percent of the cases. A total of 21 women reported that they had been circumcised, although the physical examination showed no signs of it. Ten women reported an excision type of FGC, whereas the examination showed that they were sealed shut; seven 

women reported that they had not been cut, while the exam showed evidence of 

FGC. Thus, in a total of 38 cases (3 percent) out of 1,157, there was disagreement 

between the women’s reports and the physical exams conducted to ascertain the 

women’s circumcision status. 

These studies suggest that there is sufficiently strong confirmation of FGC status 

from women’s reports to warrant the use of survey data to calculate the prevalence of 

FGC. Studies that involve clinical examinations as well as individual interviews about 

FGC can provide valuable additional insights into the practice. Both strategies provide essential information about the practice of FGC. 

2.4 Health Consequences of FGC 

As is apparent in the many published accounts of medical problems following FGC, 

writers in both popular and scientific literature have long been concerned about the 

medical consequences of FGC. There are certain health risks associated with nearly 

all types of FGC, but the risks vary substantially. Until the mid-1990s, efforts to 

eradicate the practice cited health repercussions as the main reason to ban the practice. 

While many accounts of the disastrous effects of FGC on individual women have 

been published, relatively few studies have attempted to judge the extent of the problem or to assess the overall impact of FGC on women’s health in large populations. 

In fact, estimating the impact of FGC on women’s health has proved a major challenge. Using standard terms from epidemiology, Carla Obermeyer has pointed out 

that measuring the degree of cutting—evaluated by the type of circumcision done—

has proved difficult to apply in practice. Measuring the outcome of FGC—the medical consequences⎯is subject to several types of bias (Obermeyer, 2002). There is recall bias, since women are asked about events that occurred many years earlier. There 

is observer bias, as researchers are more likely to notice health consequences in the 

persons exposed (cf. Jones, et al. 1999). It has not proved easy to define and measure 

the health complications likely to have been caused by FGC. 

The World Health Organization has compiled a list of possible health consequences of FGC and divided them into three categories: short-term medical; longterm medical; and sexual, mental, and social consequences (WHO 1996). The shortterm effects include pain, hemorrhage, urinary retention, infection, and shock. The 

long-term consequences include keloid scars, pelvic infections, infertility, menstrual 
Studies of Female Genital Cutting 11 

difficulties, and problems in pregnancy and childbirth. Numerous other complications are mentioned in the literature on medical implications of FGC. Researchers 

have amply demonstrated that many of these complications pose a serious threat to 

health. It has proved more difficult to evaluate the “burden of disease,” the impact of 

these complications on women’s health on a larger scale. How might the relative risk 

of health consequences for FGC be estimated? 

Data on the distribution of medical complications following FGC can be obtained 

through case-control studies that compare outcomes among the “exposed” and the 

“unexposed” groups through clinical examinations or through self-report evidence 

from population-based surveys. Very few case-control studies have been carried out 

to date. The study mentioned above conducted in The Gambia by Linda Morison 

and her colleagues is one example. In both the interview (N=1,346) and the exam 

data (N=1,157), 58 percent of the women had been circumcised. Women who had 

undergone FGC had a significantly higher prevalence of bacterial vaginosis (odds 

ratio [OR]=1.66) and higher prevalence of herpes simplex virus 2 (OR=4.71). Other 

commonly cited consequences of FGC (e.g., excessive keloid formation, damage to 

perineum, painful sex, infertility, prolapse, other reproductive tract infections, obstructed labor) were not significantly more common among those who had been circumcised. 

In 1998, Heidi Jones and her colleagues directed a study of medical consequences 

of FGC in Mali and Burkina Faso, but it was not a true case-control study. They 

interviewed individual women attending antenatal, family planning, and gynecological services and then asked that the women agree to a pelvic exam (Jones et al., 1999). 

Observers were trained to note whether the women had been circumcised, the type of 

cutting, and any evidence of medical complications. However, they failed to note 

whether women who had not been circumcised had any medical complications. The 

study found that 5 percent of the sample in Mali and 14 percent in Burkina Faso 

showed complications that could be associated directly or indirectly with FGC. The 

most common type of complication was scarring (more than three-fourths of cases). 

The study also found that the more severe the cut, the more likely the health complication. 

The study from Edo State, Nigeria, reported above also examined the relationship 

between being circumcised and experiencing problems at childbirth, through selfreport questions. The authors found that circumcised women had higher risks of 

tearing and of stillbirths than those who were uncircumcised, but there was no difference in the risks of prolonged labor, episiotomies, or caesarean sections (Larsen and 

Okonofua, 2002). 

In her comprehensive overview of FGC literature, Carla Obermeyer found that 

only 30 studies out of 435 published before 1996 dealt with the health effects of 

FGC and that only 8 out of those 30 were designed in ways to permit generalizations 

to larger populations (Obermeyer, 1999). In these latter studies, the frequency of 

short-term health problems often cited (e.g., shock, hemorrhage, infection, scarring) 

varied from 0 to 15 percent with self-report data. The studies also found that health 

consequences were more common with infibulation than with other types of FGC. 

Obermeyer’s followup review of publications from 1997 to 2002 found an increase in 

high-quality studies of medical complications of FGC (Obermeyer, 2003). 

DHS data on self-reported health consequences are available for a limited number 

of regions or countries. The DHS surveys asked respondents about the health consequences of FGC from their own experience in only three surveys: Eritrea 1995 and 

A 1998 study found that 

the more severe the cut, 

the more likely the health 

complication. 
12 Studies of Female Genital Cutting

2002, and Egypt 1995. In the 2002 Eritrea survey, women were asked whether they 

had problems during sexual relations or delivery linked to FGC. Those who had been 

infibulated were far more likely to report problems during intercourse (15 percent) 

and delivery (22 percent) than those with a milder version of FGC (1 and 3 percent, 

respectively). 

Survey respondents with at least one circumcised daughter were asked about the 

health consequences of FGC for their daughters in six surveys: Yemen 1997, Egypt 

1995, Benin 2001, Guinea 1999, Mali 2001, and Mauritania 2000-01. In Yemen 

1997 and Egypt 1995, women were asked whether any complications arose after their 

daughter’s circumcision and, if so, what those complications were. Eleven percent of 

women in Yemen and 5 percent in Egypt said that their daughters had experienced 

complications. 

In the four West African countries, the same questions were asked. Respondents 

who had a circumcised daughter were asked if their daughter had experienced any of 

the following after her circumcision: 1) excessive bleeding, 2) difficult urination, 3) 

swelling of the genitals, 4) genital infections, and 5) slow or partial healing of scars. 

Each problem was cited, and the mother responded with “yes” or “no” for each one. 

A substantial number of mothers reported complications following their daughter’s 

circumcision: 21 percent in Benin, 22 percent in Mali, 41 percent in Guinea, and 53 

percent in Mauritania. Excessive bleeding and difficulty in urinating were the two 

complications cited most often. 

Data such as these provide some measure of the proportions of girls who suffered 

health complications after circumcision, although the validity of such questions remains unclear. Do we not consider all bleeding to be excessive? Further analysis of 

such data might show the strength of the relationship between the health consequences and the type of cutting done, the type of person who did the cutting, or even 

the age of the girl. Even though the questioning format may lead to an overestimate 

of the number of complications, that does not reduce the seriousness of these consequences for so many girls. 

2.5 Continuation of the Practice of FGC 

Researchers, activists, and observers often ask themselves and others why FGC continues to be practiced. Outside observers find it difficult to understand why families 

would engage in a practice that causes pain and often harms a child. The question 

needs to be refocused to a particular society: Why do the people in society x practice 

FGC? Some researchers believe that understanding why the practice continues may 

lead to identifying more effective ways to combat it. 

In her book, The Female Circumcision Controversy, Ellen Gruenbaum provides an 

overview of the issues that arise in the study of FGC in individual societies. She 

writes from the perspective of an anthropologist who conducted most of her fieldwork in Sudan. Gruenbaum’s comments (2001:33) about why FGC continues are 

often cited in the literature: 

There is no simple answer to this question. People have different and 

multiple reasons. Female circumcision is practiced by people of many 

ethnicities and various religious backgrounds, including Muslims, Christians, and Jews, as well as followers of traditional African religions. For 

A substantial number of 

mothers reported 

complications following 

their daughter’s 

circumcision: 21 percent 

in Benin, 22 percent in 

Mali, 41 percent in 

Guinea, and 53 percent in 

Mauritania. 
Studies of Female Genital Cutting 13 

some it is a rite of passage. For others it is not. Some consider it aesthetically pleasing. For others, it is mostly related to morality or sexuality. 

As the quote indicates, FGC is practiced for many reasons. In some societies in 

western and eastern Africa, FGC forms part of a coming-of-age ritual that is followed soon after by marriage (e.g., Coniagui, Kuranko, Kono, Mandinga, Kikuyu, 

Okiek). In other groups, the cutting is performed in the first few months of a girl’s 

life with little or no ceremony (e.g., Eritrea, Ethiopia, Yemen). Furthermore, in any 

one society, the reasons articulated by respondents will always be multiple. The head 

of a household may propose one reason, a religious leader another, a local poet, or a 

philosopher, or a social scientist still other reasons. 

In seeking to understand why members of a certain society continue to practice 

FGC, the explanations are shaped by where the observer has chosen to look. Is the 

context being considered at the societal level, the family level, or the individual level? 

Most discussions of why FGC is practiced are based on individual or group interviews that ask people to explain why they practice FGC. The question is answered in 

the abstract, seeking a general explanation for the society. Thus, normative and functionalist explanations are offered: It is “tradition, religion, culture, the way of my 

ancestors.” 

At the family or lineage level, the issue of how and why FGC is done often revolves around the senior females of the household. As Ellen Gruenbaum (2001) and 

Molly Melching (2003) have pointed out, mothers organize the circumcision of their 

daughters because that is considered part of raising a girl properly, of being a responsible mother. In small group discussions among women in central Guinea who were 

talking about the Koran and FGC, those who said the Koran required female circumcision said that their religion required that parents do three things for their 

daughters: “to educate them, to circumcise them, and to find them a husband” 

(Yoder et al. 1999). In ethnic groups where nearly everyone circumcises girls, the 

issue is not one for debate, in terms of “do I do it, or not?” Rather, family members 

decide how and when it will be done. 

Ylva Hernlund, who completed a dissertation in 2003 on FGC in The Gambia, 

entitled one of her chapters “Contingency and context: the dynamics and dilemma of 

decision making.” The title was chosen to focus on the contingent and contextual 

nature of deciding to have a girl circumcised. She writes, “I believe there is a broad 

range of realities inhabited by those who participate in FGC, from strong support to 

strong opposition, but with occasional movement over time by an individual or even 

community from one category to another” (Hernlund, 2003:209). She provides accounts of women who wanted their daughters circumcised, some who did not want 

the procedure performed but who failed to prevent it, and some who succeeded in 

shielding their daughters from being circumcised. She also noted that the campaigns 

against FGC were opening the issue of FGC to debate for the first time in contexts 

where the practice was routine. 

Accounts of an individual mother reflecting on whether she should take her 

daughter for circumcision or not, or a single girl or woman deciding to be circumcised herself, are rare indeed, but a few such cases have been described (e.g. Leonard, 

2000). The reason given in these contexts is linked to social status acquired by being 

circumcised. Hernlund (2003) reports that girls in the Bakau area of The Gambia 

were most concerned about being mocked and ridiculed by their peers if they were 

not circumcised. Evidence from several countries has shown that in social contexts 

The issue of how and why 

FGC is done often 

revolves around the 

senior females of the 

household. 
14 Studies of Female Genital Cutting

where a group with political power routinely circumcises its daughters and a subservient group does not, some members of the subservient group will begin to practice 

FGC. 

In countries where some ethnic groups practice FGC and others do not⎯which is 

typical of East and West African countries⎯the social context of life in urban, as 

opposed to rural contexts, presents a somewhat different picture. The ethnic diversity 

of urban populations means that families that practice FGC interact with families 

that do not. Sometimes there is intermarriage between practicing and nonpracticing 

groups (Hernlund, 2003). One would expect that families would have more choices 

to circumcise or not in urban areas, though this phenomenon has not been documented at the family level. At the regional and national level, DHS survey data do 

show contrasts between urban and rural areas. As will be shown later, in most countries prevalence rates are lower in urban areas than in rural areas. 

2.6 Research Priorities 

Documentation of the practice of FGC has increased substantially in the past few 

years, resulting in the publication of many books and articles. The dissemination of 

DHS country reports and other FGC data has provided information on FGC prevalence and its distribution. Many reports on specific anti-FGC projects implemented 

by government institutions and nongovernmental organizations (NGOs) have been 

published. WHO has embarked on a multisite study of the medical consequences of 

FGC. 

It is important that researchers provide information on how female circumcision is 

being conducted so that program specialists can design effective interventions. We 

need to understand who leads the discussions about how and when to circumcise, and 

what sort of persons take responsibility to see that FGC is carried out. In their discussion of recent strategies against FGC, Toubia and Sharief (2003:255) have noted 

the following: 

Because of the lack of understanding of the motives of those who protect 

and promote the practice and their potential benefits from change, the 

outcome of the investment has not always been that intended by the project designers or the funding agency. 

Most girls are subjected to FGC in one of two social contexts: 

1. Within families that are part of clans or ethnic groups that practice it routinely 

2. In urban (and a few rural) contexts where some families or 

groups practice FGC and others do not. 

In contexts where FGC is routine, the research strategy should focus on the process of deciding when and how FGC should be carried out, and who participates in 

the action, so that the most effective ways to create discussions on the subject can be 

identified. In contexts where individuals and families interact with both those who 

practice FGC and those who do not, the research should focus on the interactions 

through which the decision to circumcise or not is negotiated within families or lineages, so that ways to support the decision not to practice FGC can be identified. A 

better understanding of how circumcision occurs in both of these contexts can provide valuable information for programs seeking to abolish FGC. 

It is important that 

researchers provide 

information on how 

female circumcision is 

being conducted so that 

program specialists can 

design effective 

interventions. 
Development of FGC Questions in DHS Surveys 15 

 3

Development of FGC Questions in DHS Surveys 

his chapter describes the development of FGC questions in the DHS questionnaire from the earliest survey in northern Sudan to the current FGC module (see 

Appendix). Questions related to the type of circumcision performed and individual 

opinions and perceptions of FGC are the ones that have changed the most over time. 

After a presentation of the early surveys, this chapter focuses on what has been 

learned about the advantages of the different ways of asking questions about the type 

of circumcision, about which daughter(s) to ask about, and about individual perceptions of FGC. An understanding of the sequence of questions used in each country 

can inform the comparison of data collected in the various surveys. 

DHS included questions about FGC in selected countries from 1989 onward. 

The actual questions asked have varied over the years in response to concerns and 

data needs of Ministry of Health officials from individual countries, of USAID Mission personnel, and of interested parties within USAID and other donors and 

NGOs. Discussions with these and other groups, as well as field experience, have 

resulted in the development by DHS of a standard FGC module with suggested 

questions to be used in any country where FGC is practiced. 

3.1 Early DHS Surveys 

The first DHS survey that asked questions about FGC was the 1989-90 survey in 

northern Sudan. The section on FGC began with three questions about the event of 

circumcision: 

• Have you ever been circumcised? 

• What type of circumcision did you have? 

• Who performed the circumcision? 

Respondents were then asked whether all their daughters had been circumcised, 

and if the response was negative, they were asked whether they planned “to have all 

their daughters circumcised.” Then nine questions were asked about women’s perspectives on the practice. 

The next DHS surveys that included questions on FGC prevalence were conducted in Côte d’Ivoire and the Central African Republic (CAR) in 1994. The Côte 

d’Ivoire survey asked only three questions: Were you circumcised, how old were you, 

and who performed the operation? The CAR survey asked seven questions and included four questions about the event: 

• Are you circumcised? 

• How old were you then? 

• Did you have any problems after the circumcision? 

T 

DHS surveys have 

included questions about 

FGC in selected countries 

since 1989. 
16 Development of FGC Questions in DHS Surveys

• What were those problems? 

In the 1991-92 DHS survey in Yemen, three questions about FGC were asked, 

but women were not asked whether they had been circumcised. Therefore this first 

Yemeni survey is not included in the overall data presentation. The questions asked 

were the following: 

• Do you approve or disapprove of female circumcision? 

• Why is that? 

• What is the main reason for that? 

The DHS questions on FGC increased in number and were standardized after the 

surveys of 1994. The questions asked can be grouped into three categories: 

• FGC status of the respondent and of one daughter 

• Circumstances of the event for the respondent and for the daughter 

(e.g., age, type of FGC, person who did the cutting) 

• Perceptions of FGC (e.g., support, benefits, drawbacks, health consequences, rationale for doing FGC). 

In the majority of surveys after 1996, women were first asked whether they had 

ever heard of FGC before being asked whether they were circumcised. This question 

acts as a filter, and those who say that they have never heard of FGC are not asked 

any more questions on the subject. This approach was used in a little over half of the 

surveys (11 of 20). In two other surveys (Kenya 1998 and Tanzania 1996), respondents were asked whether women are circumcised “in this area” or “in this community,” but the question was not used as a filter. In the seven other surveys, the sequence of FGC questions begins with some form of the question on the circumcision 

status of the respondent. 

3.2 Later DHS Surveys 

Almost all DHS surveys conducted between 1994 and 2002 that included questions 

about FGC asked about the respondent’s and one daughter’s circumcision as well as 

questions about individual perceptions of FGC. While the questions about the FGC 

status of respondents can be considered as roughly equivalent from one survey to the 

next, major variations can be seen in the questions asked about the type of circumcision performed, the way daughters were identified for questions about their FGC 

status, and the opinions of respondents about FGC. 

This chapter examines the ways questions were formulated in each section of the 

FGC module as well as the ways responses can be used. Respondents were usually 

asked three questions about their own experience: How old were you at the time? 

What was done (type of FGC)? Who (type of person) did the circumcision? For 

those with at least one living daughter, the same series of questions was asked about 

the daughter. Questions about individual perceptions of FGC varied widely and will 

be discussed below. 

Almost all DHS surveys 

conducted between 1994 

and 2002 that included 

questions about FGC 

asked about the 

respondent’s and one 

daughter’s circumcision. 
Development of FGC Questions in DHS Surveys 17 

3.3 FGC Status of Respondents 

Table 3.1 shows the main topics respondents were asked about in the 20 surveys that 

reported on FGC from 1990 to 2002. The table does not include a column for the 

circumcision status of the respondent, since all surveys asked respondents whether 

they were circumcised, with slight variation in the way the question was asked. This 

was the only question asked in all 20 surveys, although it took several forms, as seen 

below. 

• Are you circumcised? 

• Have you been circumcised? 

• Have you ever been circumcised? 

• Have you yourself ever had your genitals cut? 

• Did you have your external genitals cut? 

We assume that these forms of the basic question (“Are you circumcised?”) are 

equivalent because they are linguistically similar, and the questions can all be answered by “yes” or “no.” There is no code provided for those who do not know their 

circumcision status. Prevalence rates for FGC in survey populations are calculated 

from the answers to this question. 

It may be useful to add a “don’t know” code as a possible response to the question 

about being circumcised, because a few women may not know if they have been cut. 

Evidence from Nigeria and Ghana suggests that women are not always sure of their 

circumcision status. Two studies using individual interviews at hospitals in Nigeria 

have found that between 20 and 35 percent of women responded to this question 

with “I don’t know” (Adinma, 1997; Snow et al., 2002). Many of these women, however, may never have heard of FGC. The Navrongo research team in northern Ghana 

conducted large sample surveys among women in the Kassena-Nankana district in 

1995 and again in 2000 using the same sample that included questions about FGC. 

It may be useful to add a 

“don’t know” code as a 

possible response to the 

question about being 

circumcised, because a 

few women may not 

know if they have been 

cut. 

Table 3.1 

Coverage of specific FGC topics in DHS surveys 1989-2002 

 Ever Occurrence Occurrence Why Benefits Required 

 heard of FGC for of FGC for Support continue of by Medical 

Survey of FGC respondent daughter for FGC FGC FGC religion problems 

Sudan (northern) 1989-90 X X 

Côte d’Ivoire 1994 X 

CAR 1994-95 X X X 

Egypt 1995 X X X X X X X 

Eritrea 1995 X X X X X 

Mali 1995-96 X X X X 

Tanzania 1996 X X 

Yemen 1997 X X X X X X 

Niger 1998 X X X X X 

Kenya 1998 X X X X 

Côte d’Ivoire 1998-99 X X X X X 

Burkina Faso 1998-99 X X X X X 

Nigeria 1999 X X X X 

Guinea 1999 X X X X X X X 

Egypt 2000 X X X X X 

Ethiopia 2000 X X X X 

Benin 2001 X X X X X X X 

Mali 2001 X X X X X X X 

Mauritania 2000-01 X X X X X X X 

Eritrea 2002 X X X X X X X 
18 Development of FGC Questions in DHS Surveys

The team found 2,391 women (some dropped out) who participated in both surveys 

and who were asked the same question in each survey, “Are you circumcised?” Fifteen 

percent of the women gave different answers to the question in the two surveys (Jackson et al., 2003). Although these results suggest that in some cases, women may not 

be certain of their circumcision status, we would expect to find only a small proportion in this category. 

In column 4 of Table 3.1, “support for FGC” refers to responses to the question, 

“Do you think FGC should continue or be stopped?” Before 1999, those who said it 

should continue were then asked why FGC should be continued, while those who 

said it should be stopped were asked why it should be stopped. Column 6, “benefits 

of FGC,” refers to two questions asked about the advantages of being circumcised 

and of not being circumcised. Column 7, “required by religion,” refers to a question 

asking whether FGC is required by their religion. The last column, “medical problems,” refers to any question about health or medical complications or consequences 

after the circumcision of the respondent or her daughter. 

3.4 Respondents’ Accounts of the Circumcision Event 

In most DHS surveys, respondents who have been circumcised are asked about three 

aspects of the event: their age at the time, what was done to them, and what type of 

person performed the operation. The Egypt 2000 survey did not ask about the experience of respondents, but it did ask detailed questions about the FGC experience 

of one of the respondent’s daughters. Information about these aspects is critical in 

judging the scope and nature of a circumcision event. The two columns in Table 3.1 

on occurrence of FGC refer to any of the questions regarding age at the time of circumcision, the type of circumcision, and the person who performed the cutting. In 

Côte d’Ivoire 1994, respondents were asked only about their age at circumcision, but 

in most other surveys, they were also asked about what was done to them and who 

performed the circumcision. 

Knowing the age at which most girls are cut provides some indication about the 

nature of the circumcision event. Compare the circumcision of a two-week-old girl at 

home in Eritrea with the experience of a 15-year-old girl in northern Guinea, who is 

circumcised with a group of girls, in a ritual that functions as a precursor to marriage. 

The two events differ substantially in terms of individual participation, social significance, and the relationships of the people involved. 

3.4.1 Approaches to Asking about the Type of FGC 

Knowing what was done to a girl or woman at circumcision is useful for anticipating 

possible health consequences in the short and long term⎯consequences that may 

range from psychological distress to death. It is logical to assume that both the frequency and severity of health complications after FGC are a function of the extent of 

the cutting and the circumstances of the event, but reliable data on this are not available. There is evidence that the more severe types of cutting are associated with 

higher risk of complications (Obermeyer, 1999). 

Survey research is confronted with two major challenges to determining what was 

done during circumcision: one of recall and one of type equivalence. First, in asking 

women age 15-49 about an event that may have occurred 20 years ago, it is not clear 

to what extent they are able to recall the nature of the operation. Some women may 

have never known what was done to them (c.f. Snow et al., 2002), and others may 

Knowing the age at 

which most girls are cut 

provides some indication 

about the nature of the 

circumcision event. 
Development of FGC Questions in DHS Surveys 19 

well have forgotten. Second, each society has its own language and ways of classifying 

types of cutting that are known to members, types that do not necessarily correspond 

to the WHO designations. Establishing equivalence between such locally defined 

types and those proposed as guidelines by WHO is not a simple matter. Most DHS 

surveys followed the question about circumcision status with questions about the respondent’s own FGC experience, including age at the time, the type of FGC, and 

who performed the operation. The DHS questionnaire used the WHO types as a 

guideline and sought to determine which of three types of cutting a woman had undergone: clitoridectomy, excision, or infibulation. 

DHS has used several approaches to asking about the type of circumcision to 

which the respondent was subjected. 

Approach #1 (Set list of precoded responses): Ask respondents what was 

done to them and have them choose one of three types of FGC: 

clitoridectomy, excision, or infibulation. 

[Six surveys: Eritrea 1995, Tanzania 1996, Mali 1995-96, Niger 1998, 

Nigeria 1999, and Burkina Faso 1998-99] 

This approach (asking respondents to choose one of three types of FGC) has produced a useful distribution in the six surveys that have used it. For example, the proportion of respondents in the three categories varies by ethnic group, suggesting that 

the categories are meaningful. The validity of this question, however, depends on two 

factors: 1) the extent to which equivalent terms or descriptive phrases are found in 

the local language and 2) the extent to which women know and can accurately recall 

what was done to them years before. In this approach, the respondent interprets the 

question and responds based on a list of precoded responses. 

Approach #2 (Classification into types): Ask respondents to name or describe what was done to them and later try to classify the labels into the 

three WHO types: clitoridectomy, excision, or infibulation. 

 [Two surveys: Côte d’Ivoire 1998-99 and Niger 1998] 

In these two surveys in West Africa, respondents were asked to describe what had 

been done to them, and interviewers wrote down their responses. An attempt was 

then made to classify the terms and descriptions into the WHO types. In Niger that 

strategy produced satisfactory results, but in Côte d’Ivoire the analysts did not sort 

the responses into the three main types. Instead, they identified only the proportion 

of circumcisions that included infibulation. In this approach the analysts are responsible for interpreting and classifying information. 

Approach #3 (Monitoring infibulation): Ask directly if any flesh was cut 

away and then, separately, if the vaginal opening was sewn shut. 

 [Four surveys: Mali 2001, Benin 2001, Mauritania 2000-01, and Eritrea 

2000-02] 

In 2000, this approach was adopted and became part of the standard FGC module 

designed to be used in any country that asks FGC questions. It was decided that efforts to classify FGC into three or more types was not producing valid results and 

In 2000, an approach was 

adopted that seeks to 

identify only cases of the 

extreme, from symbolic 

cuts to infibulation. 
20 Development of FGC Questions in DHS Surveys

that surveys should seek to identify only the extreme cases: symbolic cuts and infibulation. This strategy requires three questions: 

• Was any flesh removed from the genital area? 

• Was the genital area just nicked without removing any flesh? 

• Was your genital area sewn shut? 

Answers to the second and third questions indicate the percentage of women who 

experienced only a symbolic cut (just nicked) and the percentage who were infibulated (sewn shut). The two categories other than infibulation (clitoridectomy and excision) in the list of precoded responses do not correspond well to the two phrases 

now used to describe cutting (“having flesh removed” versus being “merely nicked”), 

because both clitoridectomy and excision involve the removal of flesh. Therefore, 

asking about the removal of flesh provides an estimate of infibulation but does not 

provide any information about clitoridectomy or excision. 

Approach #1 (list of precoded responses) and Approach #3 (monitoring infibulation) can be compared in two countries (Eritrea and Mali). The first strategy was 

used in the first survey in each country: respondents were asked to choose the response that described their experience with FGC. The third strategy (were you “sewn 

shut?”) was used in the second survey five to six years later. The first strategy indicated that the proportion of women who were infibulated in Eritrea was 34 percent 

in 1995; the third strategy gave a percentage of 39 percent for infibulation in 2002. In 

Mali the proportion infibulated was 0.5 percent in 1995 (strategy 1) and 2 percent in 

2001 (strategy 3). In the two countries, the rates of infibulation were similar for the 

two strategies, but the infibulation rates were slightly higher in both countries when 

respondents were asked whether they had been “sewn shut.” The fact that the two 

methods of asking about infibulation produced similar results in countries with a high 

(Eritrea) and a low (Mali) proportion of women infibulated suggests that both measures are valid. 

One other approach deserves mention, even though it was applied only in the 

1999 survey in Guinea (Direction Nationale de la Statistique and Macro International Inc., 2000). Just prior to implementation of the Guinea survey, Macro directed 

a formative study on the experience of women with FGC in the four main regions 

and languages of the country. The stories women told of their own experiences and 

the terms used to describe what had been done were used in the precoded responses 

to the general question, “What was done to you?” The study found that there were 

four types of FGC practiced in Guinea (besides infibulation, which is rare in 

Guinea), including a token nicking that draws a little blood. The DHS data showed 

that these four types varied systematically by ethnic group and by age group, allowing 

for a more detailed analysis of the occurrence of FGC in Guinea than in other countries. 

3.4.2 Identity of the Person Performing the FGC 

Identifying the person who does the cutting during FGC helps in understanding the 

context of the practice. When medical personnel do the cutting the operation is more 

likely to be hygienic, with less risk of infection than when traditional practitioners do 

the cutting. Medical personnel typically do the cutting at a health center or in a 

home, often with an anesthetic, while traditional practitioners most often operate in 
Development of FGC Questions in DHS Surveys 21 

the bush or in their home. The instruments used by and traditional practitioners also 

differ. Thus, it is important to determine the type of person who performed the 

FGC. 

In 16 of the 20 DHS surveys, respondents were asked who performed the circumcision. The question was asked in roughly the same way in all of the surveys. In three 

surveys (Egypt 2000, Ethiopia 2000, and Yemen 1997), respondents were not asked 

that question about themselves, but they were asked about who did the cutting on 

their circumcised daughter(s). The precoded answers in most DHS surveys included 

doctors, nurses, trained midwives, traditional birth attendants (TBAs), traditional 

practitioners, and “others.” In most cases there is also a code for “don’t know.” 

3.5 Respondents’ Accounts of Daughter’s Circumcision 

DHS surveys with FGC questions have asked about the circumcision of daughters in 

two ways. Until 1999, respondents who had at least one living daughter were asked 

whether their eldest daughter had been circumcised, and those who said “yes” were 

asked about the events surrounding the circumcision. Respondents who said “no” 

were asked whether they intended to have their daughter cut. Beginning in 1999, 

rather than asking about the eldest daughter, DHS surveys began asking respondents 

whether any of their daughters were circumcised. Those who said “no” were asked 

whether they intended to circumcise any daughters, and then they were asked about 

their individual perceptions of FGC. Those who said “yes” were then asked “How 

many?” and then they were asked about the circumcision experience of the daughter 

most recently circumcised. In most cases the same questions—age, type of FGC, and 

practitioner—that were asked about the respondent’s FGC experience were asked 

about the daughter’s experience as well. Only the earliest DHS surveys with FGC 

questions (Sudan 1989-90, Côte d’Ivoire 1994, and CAR 1995-94) failed to ask 

questions about the daughter’s experience with FGC. 

The current strategy of asking about daughters provides the percentage of respondents who had at least one daughter circumcised, the proportion of respondents who 

had none circumcised, and the number of daughters circumcised for each respondent. 

DHS tables show the proportion of respondents who had at least one daughter circumcised as well as the proportion whose daughters were not cut. Although not often 

calculated, it would be possible to estimate the proportion of daughters circumcised 

for each respondent from DHS data. FGC prevalence for daughters could be compared with that for respondents to check for trends over time, with the understanding 

that a certain number of daughters might still be circumcised. The effect of future 

cutting can be offset by limiting the age of daughters considered. 

Survey data on the type of circumcision undergone by the daughter are considered 

more reliable than the same information for the respondent, because the events in 

question occurred more recently and the mother is assumed to have played a major 

role in her daughter’s circumcision. Asking about the daughter most recently circumcised provides data on a more recent FGC event than that of the respondent. In fact, 

in a few surveys, questions about circumcision were only asked for daughters. Table 

3.2 shows which surveys asked about a daughter and the criteria for the choice of 

daughter asked about. The surveys in Egypt 1995 and Yemen 1997 also asked about 

the most recently circumcised daughter rather than the eldest daughter. 

The survey in Sudan was slightly different from the rest because interviewers asked 

each respondent with one or more living daughters whether all of her daughters had 

A comparison of the FGC 

experience of mothers 

and daughters allows 

researchers to examine 

trends over time. 
22 Development of FGC Questions in DHS Surveys

been circumcised. Despite this difference, the answers were coded in a way that made 

it possible to calculate the FGC prevalence rate for eldest daughters. 

Table 3.2 

Distribution of DHS surveys that included questions about FGC, according 

to the criteria used to identify the FGC experience of respondent’s 

daughter, DHS surveys 1989-2002 

Eldest daughter Most recently circumcised No daughter information 

Sudan (northern) 1989-90 Egypt 1995 Côte d’Ivoire 1994 

Eritrea 1995 Yemen 1997 Central African Rep. 1994-95 

Mali 1995-96 Guinea 1999 

Tanzania 1996 Egypt 2000 

Niger 1998 Ethiopia 2000 

Kenya 1998 Benin 2001 

Nigeria 1999 Mali 2001 

Côte d’Ivoire 1998-99 Mauritania 2000-01 

Burkina Faso 1998-99 Eritrea 2002 

In some countries it is possible to compare mothers and daughters according to 

specific aspects of the FGC event: age at circumcision, type of cutting, and the person who did the cutting. A comparison of mothers and daughters with regard to 

these variables allows researchers to examine trends over time. 

3.6 Perceptions of FGC 

Nearly all DHS surveys with FGC questions have asked about individual perceptions 

or opinions related to the practice of FGC. All surveys except for Côte d’Ivoire 1994 

and Tanzania 1996 asked respondents whether they thought FGC should continue 

or be stopped. This question is referred to in the text as the “support” question. In the 

1990s this question was placed right after the series of questions about the daughter 

and at the beginning of the questions on perception and opinion. Those who said 

FGC should continue were asked why it should continue, and those who said it 

should be stopped were asked why it should be stopped. 

In early 1999 DHS revised the FGC module and changed the series of questions 

about perceptions of FGC so the support question came toward the end of the module. In fact, two changes were made: the wording of questions that followed those 

inquiring about the daughter’s circumcision, and the position of the question on support of FGC. Surveys conducted from late 1999 on (Benin 2001, Egypt 2000, Eritrea 2002, Guinea 1999, Mali 2001, Mauritania 2000-01) asked about health complications of a daughter’s circumcision, the advantages of being circumcised, and the 

advantages of not being circumcised. Finally, after one or two other questions about 

perceptions of FGC, the respondent was asked the question on support for FGC. It 

is not possible to tell if the different positions of the support question in the questionnaire have affected respondent answers. Further fieldwork would be required to 

determine if this was the case. 

No matter where the question about support for FGC is positioned, ambiguities 

remain about how to interpret responses. In the survey context, which includes many 

yes/no questions and precoded answers, what significance should be attached to a 

woman’s response that she would like FGC to stop? Once it is known what proportion of women said “Yes, FGC should continue,” what does this tell us about the 

situation of FGC in that country? Will those who say the practice should end not 

circumcise their daughters? Will those who say FGC should continue be sure to have 

Nearly all DHS surveys 

with FGC questions have 

asked about individual 

perceptions or opinions 

related to the practice of 

FGC. 
Development of FGC Questions in DHS Surveys 23 

their daughters circumcised? What is the relationship between the proportion of 

women who say FGC should continue and the national prevalence rate? These are 

not easy questions to answer. 

In her study of FGC in Mali in 1997-98, Claudie Gosselin interviewed 223 

women in four regional capitals about a variety of subjects. These women were asked 

whether they supported the practice of FGC. Because the question was open-ended, 

the women were able to respond in many more ways than simply “yes” or “no.” 

Gosselin found that while a minority of women actively supported FGC, the majority 

were either indifferent or had never thought that not being circumcised was an option, or would not dare question the elders’ authority (Gosselin, 2000). Gosselin also 

noted that while the 1995-96 Mali DHS survey found that 75 percent of women reported wanting FGC to continue, that responses varied by level of education and urban-rural residence. These findings suggest that survey results based on yes/no responses to the FGC support question should be viewed with caution because the 

answer, “I think FGC should continue,” may have different meanings for different 

respondents. 

Nevertheless, the responses to this question do add to our understanding of the 

situation of FGC in specific countries. A declaration of support will likely be related 

to overall FGC prevalence and to the proportion of women who have at least one 

daughter circumcised. We would logically expect that most circumcised women will 

express support for FGC, and the data bear this out. However, because the question 

about FGC support is a normative one—and some respondents may say that they do 

not support FGC because of what they have heard in the media—we would expect 

that the proportion of women who support the continuation of FGC would be less 

than the overall prevalence rate. 

In four countries, comparable FGC data are available for two periods, allowing an 

examination of changes over time. From 1995 to 2002 in Eritrea, FGC prevalence 

dropped six percentage points (95 to 89 percent), and declarations of support 

dropped eight percentage points (57 to 49 percent). From 1995 to 2000 in Egypt, 

overall prevalence remained the same at 97 percent, whereas the statements of support dropped seven percentage points (82 to 75 percent). In Côte d’Ivoire, prevalence 

remained about the same in the two surveys (about 45 percent in 1994 and 1998-99). 

In Mali, the proportion in favor of FGC continuing was 75 percent in 1995-96 but 

increased to 80 percent in 2001, whereas FGC prevalence remained about the same 

(94 and 92 percent). 

Why would overall prevalence remain about the same in Mali while stated support 

for FGC increased in a five-year time period? Hypothetically, it is possible that some 

aspect of the anti-FGC campaign had the effect of getting more people to say they 

supported the tradition. However, it may also be that a shift in the position of the 

question in the questionnaire was the cause. In 1995, the question about FGC support followed a series of questions about the circumcision of the eldest daughter, 

whereas in 2001 the question followed a series of questions about the advantages of a 

girl being circumcised or not being circumcised, plus one question about whether 

FGC was required by religion. 

It is assumed that there is a relationship between the expression of support for or 

against FGC and whether or not a woman has a circumcised daughter. It is expected 

that the majority of women who support the continuation of FGC will have one or 

more of their daughters circumcised, and that most of those who want to stop the 
24 Development of FGC Questions in DHS Surveys

practice will not have their daughters circumcised. The relationship will be examined 

in the next chapter. 

Asking about the benefits and drawbacks of FGC provides answers that are somewhat more specific than asking why FGC should continue or be stopped, but the 

questions remain somewhat abstract. In addition, it is highly unlikely that respondents had ever heard these questions before. However, it does seem productive 

to ask respondents whether they want the practice of FGC to continue, since it 

makes possible the tracking of changes in the percentage of those who declare their 

support for FGC. 

Finally, a small number of questions were asked of men about their opinions of 

FGC in Eritrea in 1995 and in seven countries in West Africa (Benin 2001, Burkina 

Faso 1998-1999, Côte d’Ivoire 1998-99, Guinea 1999, Mali 2001, Mauritania 2000-

01, and Niger 1998). Men were asked about the advantages to women of having 

FGC, as well as the advantages of not having FGC, and whether they thought that 

FGC should continue or be stopped. In the surveys in which men were asked their 

opinions about FGC, a higher proportion of men than women said they thought 

FGC should be stopped (see Table 4.16). In several countries men were also asked 

whether their religion required FGC and whether they thought that FGC reduces 

the chances of sexual intercourse before marriage. In Guinea, where FGC was nearly 

universal in 1999, men were also asked whether they prefer to marry a circumcised 

woman or an uncircumcised woman, or whether it made no difference. One-third of 

the men interviewed said that they preferred to marry an uncircumcised woman or 

that it made no difference to them. 

In the surveys in which 

men were asked their 

opinions about FGC, a 

higher proportion of men 

than women said they 

thought FGC should be 

stopped. 
Discussion of FGC in DHS Survey Reports 25 

 4

Discussion of FGC in DHS Survey Reports 

n surveys that have used the FGC module as part of the Women’s Questionnaire, 

the final report includes a separate section on FGC data (Ethiopia excepted). This 

chapter compares the key findings from those surveys. The main topics covered are 

national prevalence rates, the distribution of FGC within countries, the circumstances of the event of circumcision for respondents and their daughters, and respondents’ opinions and perceptions of FGC as a practice. It is hoped that some of the 

comparisons presented here, as well as descriptions of the distribution of FGC within 

countries, will generate questions for further analysis in specific countries. 

4.1 National Rates of FGC Prevalence 

Researchers carrying out studies on FGC have long sought valid information about 

the proportion of girls or women circumcised in a given country and the distribution 

of circumcised women within regions or countries. Valid data on the occurrence and 

circumstances of FGC (who, when, how many) at a national or a regional level can 

serve many purposes: show how the practice is distributed; suggest associations with 

language, ethnicity, or other background characteristics; estimate the numbers of girls 

or women at risk in a given region; and facilitate the monitoring of trends over time. 

Data on a respondent’s own experience of FGC (e.g., age, type of FGC, instrument 

used, place where circumcision was carried out, and the person who performed the 

circumcision) can provide information on changes in the practice as well as allow 

some assessment of the likely health consequences. However, FGC prevalence at the 

country level is the key statistic sought by researchers and program specialists. 

The prevalence of FGC at the national level is important for estimating the size 

and scope of the practice in a country and for calculating the number of women circumcised annually. Table 4.1 shows the countries for which prevalence data are available at the national level (Sudan excepted) from a DHS survey. Since the countries 

are arranged by geographic regions, certain regional similarities are apparent. The 

sample (women age 15-49) for each survey is the number of women interviewed. In 

Egypt (1995 and 2000), Sudan, and Yemen, the sample included only ever-married 

women age 15-49, whereas in other surveys the sample was all women age 15-49. 

The grouping of countries on the African continent reveals basic similarities by region in the overall prevalence of FGC. In northeastern Africa, prevalence varies from 

80 to 97 percent. In northern West Africa, prevalence varies from 71 percent (Mauritania) to 99 percent (Guinea), with the exception of Niger (5 percent). In southern 

West Africa prevalence ranges from 17 percent (Benin) to 45 percent (Côte d’Ivoire). 

Prevalence for the two countries in eastern Africa (Kenya and Tanzania) is 38 and 18 

percent, respectively. 

I 

The prevalence of FGC at 

the national level is 

important for estimating 

the size and scope of the 

practice in a country and 

for calculating the 

number of women 

circumcised annually. 
26 Discussion of FGC in DHS Survey Reports

Table 4.1 

Prevalence of FGC among women in DHS surveys by region, 1989-2002 

Region/country Year Prevalence Sample

Northeastern Africa 

Egypt1 1995 97 14,779 

Egypt1 2000 97 15,573 

Eritrea 1995 95 5,054 

Eritrea 2001-02 89 8,754 

Sudan (northern)1 1989-90 89 5,860 

Ethiopia 2000 80 15,367 

 

Northern West Africa 

Guinea 1999 99 6,753 

Mali 1995-96 94 9,704 

Mali 2001 92 12,849 

Burkina Faso 1998-99 72 6,445 

Mauritania 2000-01 71 7,728 

Niger 1998 5 7,577 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1994 43 8,099 

Côte d’Ivoire 1998-99 45 3,040 

Central African Rep. 1994-95 43 5,884 

Nigeria 1999 25 8,206 

Benin 2001 17 6,219 

 

Eastern Africa 

Kenya 1998 38 7,881 

Tanzania 1996 18 8,120 

 

Western Asia 

Yemen1 1997 23 10,414

1

 Sample consisted of ever-married women 

In five countries⎯Egypt, Eritrea, Sudan (northern), Guinea, and Mali⎯the practice of FGC is nearly universal, with prevalence ranging from 89 to 99 percent. In the 

countries of southern West Africa and the two countries in eastern Africa, FGC affects only a minority of the population. 

4.2 Disaggregation of Data in Country Reports 

DHS country reports present data on the prevalence of FGC at a national level disaggregated by standard demographic variables: age, urban-rural residence, and region 

or province. Many reports also show differentials by education, ethnicity, and religion. The education level of respondents is normally given in three categories: no education, primary, and secondary or higher. Ethnicity is sometimes expressed as specific 

named ethnic groups (e.g., Kikuyu, Bambara, Yoruba) and sometimes as larger 

groupings (e.g., Mandé du Nord). Religious affiliation is classified into the categories 

Muslim, Christian, animist, and no religion. In some countries, “Christian” is broken 

down further into “Catholic” and “Protestant.” 

Table 4.2 shows the variables used to disaggregate prevalence data from the 20 

surveys being examined. In countries with very high FGC prevalence (90 percent or 

more), disaggregation of the data by demographic variables shows little variation 

throughout the country. However, in countries where a substantial portion of the 

population does not practice FGC, prevalence varies widely and can be better understood by examining data disaggregated by sociodemographc variables. 
Discussion of FGC in DHS Survey Reports 27 

Table 4.2 

Sociodemographic variables used for disaggregation of FGC prevalence 

data in DHS surveys, 1989-2002 

 Age UrbanRegion/country group rural Regions Education Religion Ethnicity 

Northeastern Africa 

Egypt 1995 X X X X 

Egypt 2000 X X X X 

Eritrea 1995 X X X 

Eritrea 2002 X X X 

Sudan (northern) 1989-90 X X X X 

Ethiopia 2000 X X X X 

 

Northern West Africa 

Guinea 1999 X X X X X X 

Mali 1995-96 X X X X X X 

Mali 2001 X X X X X X 

Burkina Faso 1998-99 X X X X X X 

Mauritania 2000-01 X X X X 

Niger 1998 X X X X X 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1994 X X X X X 

Côte d’Ivoire 1998-99 X X X X X 

CAR 1994-95 X X X X X 

Nigeria 1999 X X X X 

Benin 2001 X X X X X 

 

Eastern Africa 

Kenya 1998 X X X X 

Tanzania 1996 X X X 

 

Western Asia 

Yemen 1997 X X X X 

4.2.1 FGC Prevalence by Age and Residence 

DHS final reports provide FGC prevalence disaggregated by age and area of residence (urban-rural) of respondents; prevalence is also presented by region in all but 

three surveys. It was expected that a higher proportion of women in the oldest cohorts than in the youngest cohorts would have been circumcised, and that FGC 

prevalence would be higher in rural than in urban areas. In fact, while FGC prevalence is higher in rural areas for more than half of the surveys, in three surveys (Eritrea 1995, Ethiopia 2000, and Mali 2001) urban and rural rates are either the same or 

differ only slightly. Furthermore, in four countries, FGC prevalence was substantially 

higher in urban than in rural areas: northern Sudan, Burkina Faso, Nigeria, and 

Yemen. In these cases, the confounding effect of ethnicity most likely explains the 

higher FGC rates in urban areas. 

4.2.2 FGC Prevalence by Region 

In most surveys, data on FGC prevalence are presented by region to be more useful 

to government and program personnel. FGC prevalence may vary by region in cases 

where anti-FGC programs have been conducted in selected regions or where ethnic 

identity varies with regional populations. In most cases where the data show regional 

differences in FGC prevalence, the differentials can be explained by confounding factors such as ethnicity and religion. In countries where the data are not disaggregated 

In most cases where the 

data show regional 

differences in FGC 

prevalence, the differentials 

can be explained by 

confounding factors such as 

ethnicity and religion. 
28 Discussion of FGC in DHS Survey Reports

by ethnicity, regional comparisons may reveal differences in FGC prevalence that 

derive from ethnic differences in regional populations. 

4.2.3 FGC Prevalence by Education 

The majority of DHS survey reports (16 of 20) present FGC prevalence by respondent’s level of education, along with a number of other sociodemographic variables. 

The underlying assumption in relating FGC status to education is that women with 

more education will be less likely to favor the practice FGC than those with little or 

no education. At first, it seems reasonable to present FGC prevalence by education 

because women’s education has been associated with many outcome variables related 

to health and well-being. However, in the case of FGC, it was found that disaggregation by level of education is not helpful, and can actually be misleading. This is because circumcision nearly always takes place before a woman’s education is completed, and often before it commences. The presentation of FGC prevalence data by 

level of education implies that there is a link between FGC status and education, 

even when there is none. 

The assumption of a relationship between FGC status and the effects of education 

can however be examined by comparing the educational level of mothers and the circumcision status of their daughters; that is, if the relationship is valid, highly educated mothers will be less likely to have circumcised daughters than will mothers 

with little education. In fact, the data point to a strong relationship between the educational level of a mother and the likelihood that her daughter is circumcised. 

Table 4.3 shows the distribution of FGC prevalence rates for eldest daughters in 

eight countries by mother’s level of education. In most countries there was a substantial difference in the proportion of eldest daughters circumcised among women with 

no education and among women with at least some secondary schooling. No consistent relationship is evident for Mali 1995-96 or for Nigeria 1999. The lack of a relationship in Nigeria may be due to the confounding factor of ethnicity, because FGC 

is practiced by Yoruba groups, who are also more likely to be educated. The lack of 

association in Mali 1995-96 may be related to the overall low level of education in 

the country—81 percent of respondents had never been to school, and only 7 percent 

had at least some secondary education. 

The data point to a strong 

relationship between the 

educational level of a 

mother and the likelihood 

that her daughter is 

circumcised. 
Discussion of FGC in DHS Survey Reports 29 

Table 4.3 

Among women with at least one living daughter, the percentage of 

eldest daughters circumcised, by mother’s education, DHS surveys 

1989-1999 

 Prevalence of FGC among eldest daughters 

 by mother’s education Number 

 ––––––––––––––––––––––––––––––––––––– of 

Survey No education Primary Secondary Total mothers 

Eritrea 1995 73.7 64.7 59.9 71.4 2,005 

Sudan (northern) 1989-90 62.7 57.2 30.5 57.7 4,386 

Mali 1995-96 73.6 73.6 75.0 73.6 6,399 

Burkina Faso 1998-99 47.3 35.1 16.1 45.5 3,499 

Niger 1998 16.3 6.7 2.2 14.2 1,348 

Côte d’Ivoire 1998-99 36.0 9.3 3.9 25.8 1,595 

Nigeria 1999 14.6 29.2 23.3 20.2 4,503 

Kenya 1998 23.2 10.4 5.8 11.3 4,554 

Tanzania 1996 10.7 4.8 0.5 6.7 4,753 

Table 4.4 shows the association between a respondent’s level of education and her 

having one or more daughters circumcised. The question used to generate the data in 

this table was “Have any of your daughters been circumcised?” The data in Table 4.4 

are similar but not equivalent to the data in Table 4.3 because asking about “any of 

your daughters” may involve more daughters for a mother than asking about only the 

“eldest daughter.” The actual prevalence rate among living daughters of respondents 

in the sample will be slightly lower than the figures found in Table 4.4, because some 

of the youngest daughters may get cut later. However, it should not affect the direction of the association between mother’s education and the circumcision of daughters. 

Table 4.4 

Among women with at least one living daughter, the percentage who had 

at least one daughter circumcised, by mother’s education, DHS surveys 

1995-2002 

 Prevalence of FGC among daughters, 

 by mother’s education Number 

 –––––––––––––––––––––––––––––– of 

Survey No education Primary Secondary Total mothers 

Egypt 1995 59.5 60.5 22.1 49.7 10,840 

Egypt 2000 64.7 62.6 21.2 49.5 11,540 

Eritrea 2002 67.5 59.4 40.0 62.5 4,604 

Ethiopia 2000 55.7 35.4 25.4 51.8 7,659 

Guinea 1999 54.7 44.0 55.1 53.9 4,275 

Mali 2001 73.1 73.9 64.8 72.8 8,094 

Mauritania 2000-01 77.4 60.6 41.1 70.9 3,606 

Benin 2001 11.1 2.5 0.7 8.2 2,759 

Yemen 1997 41.4 23.9 29.0 38.3 4,032 

Only in Guinea is there no relationship between the circumcision of daughters and 

mother’s level of education. In Guinea, 76 percent of respondents had no education, 

and 5 percent had some secondary schooling or higher. Overall, it can be seen that 

daughters of mothers who are more highly educated are less likely to be circumcised 

than daughters of mothers with little or no education. This relationship was found in 

15 of the 18 surveys where data were available. 
30 Discussion of FGC in DHS Survey Reports

4.2.4 FGC Prevalence and Religion 

Religious affiliation may help explain the distribution of FGC in some countries, but 

the relationship is not consistent. In the country reports, FGC prevalence rates are 

disaggregated by religion in 6 of the 16 countries (8 of 20 surveys), all countries with 

a large Muslim majority and, except for Sudan (northern), all located in West Africa. 

Table 4.5 shows the prevalence of FGC by religion (Muslim or Christian) for those 

eight surveys. Data on FGC prevalence and religion for the other surveys are presented in textual rather than in tabular form. 

Table 4.5 

FGC prevalence among women by religion (Muslim or 

Christian), DHS surveys 1989-2001 

Region/country Muslim Christian Total

Northeastern Africa 

Sudan (northern) 1989-90 90.0 46.8 89.2 

Northern West Africa 

Guinea 1999 99.4 93.8 98.6 

Mali 1995-96 94.3 84.6 93.7 

Mali 2001 91.9 75.5 91.6 

Burkina Faso 1998-99 77.9 66.0 71.6 

Niger 1998 4.5 (0)a 4.5 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1994 80.1 16.0 42.7 

Côte d’Ivoire 1998-99 78.7 17.0 44.5 

a

 Only four cases 

In countries, such as Sudan (northern) and Niger, which have a 98 to 99 percent 

Muslim population, whether the rest of the religions participate in FGC or not, 

hardly affects the overall prevalence. However, in Burkina Faso and Côte d’Ivoire, 

the size of the Christian population is large enough to affect the overall prevalence of 

FGC. In Burkina Faso, 27 percent of the population is Christian, while in Côte 

d’Ivoire, the proportion is 41 percent. At the same time, there is a marked contrast in 

the prevalence of FGC among Christians in Burkina Faso and Côte d’Ivoire (66 and 

17 percent, respectively). 

A somewhat different pattern emerges from data for countries that do not report 

FGC prevalence by religion in their reports. For example, Ethiopia⎯with a population 51 percent Coptic Orthodox, 29 percent Muslim, and 16 percent Protestant⎯shows little difference in FGC prevalence by religion. If the missing cases 

(N=1,252) are set aside, 86 percent of the Orthodox, 93 percent of Muslims, and 81 

percent of Protestants have been circumcised. In Benin, 32 percent of the population 

is Catholic, 22 percent is Muslim, 17 percent is “other Christian” (non-Catholic or 

Protestant), and 17 percent follows traditional religion; the FGC prevalence rates for 

these groups were 49 percent for Muslims, 12 percent for traditional religion, 7 percent for Catholics, and 1 percent for “other Christians.” The fact that 89 percent of 

Fulani (Peulh) women are circumcised, and they are Muslim, affects the overall rate 

of Islamic groups in the country. 

In Nigeria, the relationship between Islam and FGC differs from that of other 

countries because the majority of Muslims there do not practice circumcision. In the 

1999 survey, 15 percent of Muslim respondents had been circumcised, whereas the 

Religious affiliation may 

help explain the 

distribution of FGC in 

some countries, but the 

relationship is not 

consistent. 
Discussion of FGC in DHS Survey Reports 31 

figure for various Christian groups was around 40 percent. Much of this distribution 

can be explained by ethnic identity, but the relevant evidence is not available in the 

data set. FGC prevalence data are available by regions in Nigeria: 2 percent in the 

northeast and 3 percent in the northwest, both largely Islamic regions; the southeast 

and southwest regions have prevalence rates of 37 and 48 percent, respectively. 

It is not possible to generalize about the association between religion and the practice of FGC except to say that in the majority of countries Muslims are more likely to 

practice FGC than Christians, and ethnicity confounds efforts to examine the role 

religion plays in FGC prevalence. 

4.2.5 FGC Prevalence and Ethnicity 

FGC prevalence rates are available by ethnic group in the DHS reports for 9 of the 

20 surveys in 7 of the 16 countries, all in West Africa with the exception of Kenya. 

DHS prevalence rates vary more by ethnicity than by any other social or demographic 

variable. This finding is not surprising because many researchers have noted that 

FGC prevalence varies with ethnicity or that FGC serves as an ethnic marker (e.g., 

Shell-Duncan and Hernlund, 2000; Gruenbaum, 2001). Although most surveys 

asked questions about ethnic identity, some countries have chosen not to include that 

variable in the data set. 

Table 4.6 shows the range of FGC prevalence among ethnic groups in eight countries, using three ethnic groups with the highest prevalence and two ethnic groups 

with the lowest prevalence. For example, in Ethiopia FGC prevalence ranges from 51 

to 100 percent, in Mali from 15 to 98 percent, and in Kenya from 1 to 97 percent. 

The table shows data for FGC prevalence in 8 of the 16 countries. Indirect evidence 

for similar ethnic variations is available for four other countries (Sudan (northern), 

Nigeria, Tanzania, and Yemen). 

Table 4.6 

Range of FGC prevalence among ethnic groups in eight DHS surveys, 

1998-2001 

Region/country Highest groups Lowest groups 

Northern West Africa 

Guinea 1999 99.7 99.6 99.5 99.4 89.0 

Mali 2001 98.0 97.9 97.2 40.8 15.3 

Burkina Faso 1998-99 92.6 90.1 89.3 47.8 46.4 

Niger 1998 30.4 13.4 8.6 1.5 1.1 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1998-99 74.7 74.6 69.6 13.4 2.0 

CAR 1994-95 83.9 71.0 42.0 5.6 3.0 

Benin 2001 88.4 77.4 72.0 0.3 0.0 

 

Eastern Africa 

Kenya 1998 97.0 88.8 54.2 1.6 1.2 

Despite such contrasts in prevalence within countries, it should be remembered 

that ethnic identity is but one of a number of factors that structure social relations 

and distribute power and privilege among groups. 

Table 4.7 shows how FGC prevalence varies by ethnicity in four countries: Burkina Faso, Côte d’Ivoire, Benin, and Kenya. The countries were selected because they 

exemplify variations in FGC prevalence by ethnicity in countries with different levels 

of overall FGC prevalence. 

In the majority of 

countries, Muslims are 

more likely to practice 

FGC than Christians, 

however, ethnicity 

confounds efforts to 

identify the role that 

religion plays. 
32 Discussion of FGC in DHS Survey Reports

In countries such as Côte d’Ivoire, Benin, and Kenya, some ethnic groups rarely or 

never practice FGC. Girls growing up in these groups are at little risk for being circumcised, whatever the national prevalence level. In Burkina Faso, a substantial segment of the population of most ethnic groups practices FGC. Interventions that seek 

to persuade people to abandon the practice of FGC will need to vary depending on 

the target population. 

Table 4.7 

FGC prevalence among women in specific ethnic groups in four DHS surveys 

1998-2001 

 Percentage Number 

 with of 

Country/region FGC women 

Burkina Faso 1999 

Dafing 92.6 104 

Senoufo 91.2 148 

Lobi 89.3 83 

Dagara 86.3 79 

Samo 86.9 140 

Bobo 84.8 302 

Bissa 74.8 224 

Mossi 74.1 3,787 

Fulani 68.4 417 

Other 66.9 292 

Gourmantché 47.8 527 

Gourounsi 46.4 340 

Total 71.6 6,445 

Côte d’Ivoire 1998-99 

Other 74.7 676 

Mandé du Nord 74.6 366 

Mandé du Sud 69.6 313 

Gur 66.5 442 

Krou 13.4 335 

Akan 2.0 907 

Total 44.5 3,040 

Benin 2001 

Fulani 88.4 236 

Bariba 77.4 511 

Yoa and Lokpa 72.0 227 

Other 27.6 54 

Yoruba 21.7 742 

Dendi 18.8 165 

Foreigners 18.7 229 

Bétamaribé 7.0 320 

Fon 0.3 2,797 

Adja 0.0 937 

Total 16.8 6,219 

Kenya 1998 

Kisii 97.0 860 

Masai 88.8 113 

Kalenjin 62.2 992 

Taita/Taveta 59.2 81 

Meru/Embu 54.2 564 

Kikuyu 42.5 1,414 

Kamba 33.0 1,008 

Other 19.2 234 

Mijikenda/Swahili 12.2 391 

Luhya 1.6 1,142 

Luo 1.2 1,074 

Total 37.6 7,881 

Interventions that seek to 

persuade people to 

abandon the practice of 

FGC will need to vary 

depending on the target 

population. 
Discussion of FGC in DHS Survey Reports 33 

What do leading FGC researchers say about the role of ethnicity in understanding 

the practice of female genital cutting? In her book on FGC and the various issues 

surrounding it, Ellen Gruenbaum remarks (2001:102): 

Female circumcision practices are deeply entwined with ethnic identity 

wherever they are found. Understanding this should provide an important insight into the tenacity of the practice and people’s resistance to 

change efforts, and it can help to explain why the practice may even 

spread in certain situations. 

Ethnic identity is not entirely fixed, children of parents of different ethnic groups 

may have a choice about the ethnic identity they affirm, and the groups identified as 

one single ethnic group may be an ethnic category with many subgroups. That is the 

situation in Côte d’Ivoire 1998-99, which lists Mandé du Nord, Mandé du Sud, and 

Akan as ethnic groups, when none of those labels really make up a single ethnic 

group. With ethnicity being flexible in some social contexts, answers to the question 

on ethnicity may vary. 

The main purpose of presenting FGC prevalence by ethnicity is to show that 

prevalence can vary substantially within a country. National-level FGC prevalence 

rates can leave the impression that the situation is roughly the same throughout the 

country, when this is clearly not the case. Thus, within most countries, the social 

situation confronting families with young girls will vary, with some girls growing up 

in a context where everyone is cut and others in a context where no one is cut. As 

Molly Melching said in a presentation about the Tostan Project in Senegal 

(Melching, 2003), “We go to villages that practice FGC, not ones that don’t. We all 

know which groups practice FGC and which do not.” 

4.3 Circumstances Surrounding the Circumcision 

In most countries, respondents were asked about their own experience with FGC and 

that of one of their daughters. The information most often sought was age at circumcision, type of cutting, and person who performed the operation. 

4.3.1 Age at Circumcision 

Data on age at circumcision are routinely collected for what they reveal about the 

FGC event and to monitor trends over time. Age at circumcision has an impact on 

the social significance of FGC because when girls are circumcised in the first few 

months of life, or even at four years of age, the ritual experience is minimal compared 

with that of girls cut at older ages. In contexts where the girls are 12 or 15 years of 

age, the event may be framed as an elaborate coming-of-age ritual (Gessain, 1960; 

Jackson, 1977; Kratz, 1994: Johnson, 2000). 

Table 4.8 shows the percentage of respondents cut at various ages among those 

who were circumcised. The ages at which large proportions of girls are circumcised 

vary substantially among countries. About 90 percent of girls in Egypt (both surveys) 

were circumcised between the ages of 5 and 14 years, while in Eritrea (both surveys), 

Ethiopia, Mali 2001, and Mauritania, 60 percent or more of girls underwent the operation before their fifth birthday. In most other West African countries, about onethird of girls were circumcised in their first five years of life. In Kenya and Tanzania, 

The main purpose of 

presenting FGC 

prevalence by ethnicity is 

to show that prevalence 

can vary substantially 

within a country. 
34 Discussion of FGC in DHS Survey Reports

Table 4.8 

Percent distribution of circumcised women by age when cutting occurred, DHS surveys 

1989-2002 

 Age when cutting occurred 

 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

 Don’t 

 know/ 

Region/country 0-4 5-9 10-14 15-19 19+ missing Total 

Northeastern Africa 

Egypt 1995 2.6 46.0 42.9 0.9 0.0 7.6 100.0 

Egypt 2000a 6.2 42.2 49.8 0.5 0.0 1.3 100.0 

Eritrea 1995 60.0 11.1 1.0 0.0 0.0 27.9 100.0 

Eritrea 2002 75.1 15.0 1.1 0.1 0.0 8.7 100.0 

Ethiopia 2000a 64.4 20.0 10.8 4.3 0.5 0.2 100.0 

 

Northern West Africa 

Guinea 1999 4.2 48.1 35.2 2.8 0.5 9.2 100.0 

Mali 1995-96 41.3 24.8 15.6 1.7 0.0 16.6 100.0 

Mali 2001 61.3 20.5 13.1 1.4 0.0 3.7 100.0 

Burkina Faso 1998-99 20.5 29.6 7.8 1.7 0.1 40.3 100.0 

Mauritania 2000-01 76.3 0.7 0.2 0.1 0.0 22.7 100.0 

Niger 1998 28.8 18.8 7.2 11.1 0.3 33.8 100.0 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1994 24.3 27.3 27.6 10.5 0.8 9.6 100.0 

Côte d’Ivoire 1998-99 55.1 17.3 18.2 6.7 1.5 1.4 100.0 

CAR 1994-95 2.4 29.3 59.2 8.0 0.9 0.1 100.0 

Nigeria 1999 30.8 5.0 3.6 4.0 1.9 54.6 100.0 

Benin 2001 34.0 40.0 18.6 3.6 0.8 3.0 100.0 

Eastern Africa 

Kenya 1998 2.7 18.9 43.1 29.7 2.2 3.5 100.0 

Tanzania 1996 5.1 19.6 37.0 19.3 3.8 15.1 100.0 

 

Western Asia 

Yemen 1997a 99.2 0.4 0.3 0.0 0.0 0.1 100.0

Note: Respondents were not asked about age at cutting in the Sudan survey. 

a

 Information based on respondent’s daughter 

about 60 to 70 percent of girls were circumcised when they were age 10-19. Finally, 

76 percent of girls in Yemen were circumcised during their first two weeks of life. 

Table 4.9 shows the cumulative proportion of respondents circumcised by age at 

circumcision. Thus, in CAR 1994-95 only 2 percent of respondents were cut by age 

four compared with 91 percent who were cut by age 14. In Eritrea, Ethiopia, and 

Yemen, the majority of girls were circumcised during the first year of life, while in 

Kenya 78 percent were not circumcised until after age nine. 

4.3.2 Type of Circumcision 

Information about the type of circumcision can help anticipate the extent of medical 

consequences likely to follow the cutting. Data are available from six surveys about 

the distribution of the three main WHO types of FGC: clitoridectomy, excision, and 
Discussion of FGC in DHS Survey Reports 35 

Table 4.9 

Among circumcised women, the cumulative percent circumcised, by age when cutting occurred, DHS surveys 1989-2002 

 Age when cutting occurred 

 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

 Don’t 

 know/ 

Region/country <1 0-4 0-9 0-14 0-15+ missing Total

Northeastern Africa 

Egypt 1995 0.6 2.6 48.6 91.5 92.4 7.6 100.0 

Egypt 2000a 1.3 6.2 48.5 98.3 98.6 1.3 100.0 

Eritrea 1995 44.1 60.0 71.1 72.1 72.1 27.9 100.0 

Eritrea 2002 62.2 75.1 90.1 91.2 91.3 8.7 100.0 

Ethiopia 2000a 52.5 64.1 81.2 94.7 99.4 0.6 100.0 

 

Northern West Africa 

Guinea 1999 0.3 4.2 52.3 87.5 90.8 9.2 100.0 

Mali 1995-96 28.6 41.3 66.1 81.7 83.4 16.6 100.0 

Mali 2001 6.9 61.3 81.8 94.9 96.3 3.7 100.0 

Burkina Faso 1998-99 10.6 20.5 50.1 57.9 59.7 40.3 100.0 

Mauritania 2000-01 18.8 76.3 77.0 77.2 77.3 22.7 100.0 

Niger 1998 12.5 28.8 47.6 54.8 66.2 33.8 100.0 

 

Southern West Africa/ 

MiddleAfrica 

Côte d’Ivoire 1994 15.8 24.3 51.6 79.2 90.5 9.6 100.0 

Côte d’Ivoire 1998-99 0.3 55.0 72.4 90.6 98.8 1.3 100.0 

CAR 1994-95 0.2 2.4 31.7 90.9 99.8 0.2 100.0 

Nigeria 1999 41.6 49.4 57.5 63.3 72.7 27.3 100.0 

Benin 2001 0.1 34.0 74.0 92.6 96.8 3.1 100.0 

 

East Africa 

Kenya 1998 0.0 2.7 21.6 64.7 96.6 3.5 100.0 

Tanzania 1996 0.6 5.1 24.7 61.7 84.8 15.1 100.0 

West Asia 

Yemen 1997 99.2 99.6 99.9 99.9 99.9 0.1 100.0

Note: Respondents were not asked about age at cutting in the Sudan survey. 

a

 Circumcision of daughters, not respondents 

infibulation. In five of the surveys, respondents were asked to identify—based on 

three categories—the type of FGC they had undergone. In Niger, women were asked 

to name what was done to them, and local specialists then classified their answers 

into the three main types of FGC. Table 4.10 presents the data. 

Table 4.10 

Percent distribution of circumcised women by type of FGC received 

(prompted), DHS surveys 1995-1999 

 Number 

 Clitori- Infibu- Other/ of 

Region dectomy Excision lation missing Total women 

Eritrea 1995 61.5 4.4 34.0 0.1 100.0 4,775 

Mali 1995-96 52.1 46.9 0.5 0.5 100.0 9,097 

Burkina Faso 1998-99 26.2 56.3 0.6 16.9 100.0 5,539 

Niger 1998 66.5 4.8 0.0 28.7 100.0 340 

Nigeria 1999 50.8 4.2 2.3 42.7 100.0 3,327 

Tanzania 1996 56.6 35.3 5.1 3.0 100.0 1,476 

In Niger, women were 

asked to name what was 

done to them, and local 

specialists then classified 

their answers into the 

three main types of FGC. 
36 Discussion of FGC in DHS Survey Reports

Respondents in Sudan (northern) were asked to identify the type of circumcision 

they had undergone from a list of three categories: Pharaonic (82 percent), intermediate (3 percent), or sunna (15 percent). The categories correspond closely to the 

WHO types used in many surveys: Pharaonic as infibulation, intermediate as excision, and sunna as clitoridectomy. Sudan (northern) showed a high rate of infibulation (82 percent), far higher than that of any other country for which DHS data are 

available. During the 1998-99 survey in the Côte d’Ivoire, respondents were asked 

what was done to them, but the answers were never classified into discrete categories. 

The term sunna, from the Arabic, refers to an obligation or requirement of the 

Muslim religion, as interpreted by local populations, to circumcise in a particular way. 

However, opinion as to what constitutes sunna FGC varies among countries. For 

example, in Sosso society in Guinea, sunna refers to the circumcision the Sosso believe is required by Islam, which for them means excision: removal of the clitoris and 

labia minor (Yoder et al., 1999). In Chad, sunna refers to a partial clitoridectomy 

(Leonard, 2000). 

Table 4.10 shows the large proportion of women in Eritrea who have been infibulated and the small proportions elsewhere. However, there are problems with such 

data on the type of FGC. First, it is difficult to know to what extent the respondent 

understood what was being asked when the types were identified. If there happened 

to be close correspondence between the three types of FGC and three local terms for 

FGC, the data may reflect the situation on the ground. If, however, there was no 

close correspondence between the types of FGC and local terminology, it may be 

difficult to determine how closely responses to questions relate to women’s experiences. Several studies mentioned in chapter 2 examined the degree of correspondence 

between women’s reports and a gynecological examination, but the correspondence 

reported just involved whether or not the respondent was circumcised. Nothing was 

said about correspondence between the type of FGC reported and the type observed. 

Additionally, large numbers of the responses are listed as “other” or “missing.” In 

Nigeria this situation is likely due to problems with data collection. In Niger, it 

reflects difficulty in classifying what women said was done to them. 

Respondents were not asked about the type of circumcision for themselves or their 

daughters in the other DHS surveys. In three surveys (Eritrea 2002, Mali 2001, and 

Benin 2001), respondents were asked whether the vaginal area had been sewn shut. 

Assuming that “yes” indicates infibulation, the percentage of women with infibulation (among whose who were circumcised) was 39 percent in Eritrea 2002, 2 percent 

in Mali 2001, and 4 percent in Benin 2001. The rate of infibulation was lower in Eritrea and Mali in the earlier surveys (Table 4.10). 

The practice of infibulation affects a large proportion of women in two countries 

where DHS surveys have been conducted: Eritrea, where 39 percent of circumcised 

women have been infibulated, according to the 2002 survey, and Sudan (northern), 

where 82 percent of women have been infibulated, according to the 1989-90 survey. 

4.3.3 Identity of Person Who Performed FGC 

In nearly all surveys, DHS collected data on the type of practitioner who performed 

the circumcision, because the identity of the practitioner is a critical part of understanding how FGC is practiced. Table 4.11 shows the proportion of women circumcised by a traditional practitioner and the percentage circumcised by medical personnel. The term traditional includes local specialists known for performing 

The rate of infibulation 

was lower in Eritrea and 

Mali in the earlier 

surveys, indicating that 

the practice has increased 

in recent years. 
Discussion of FGC in DHS Survey Reports 37 

circumcisions (exciseuses), traditional birth attendants, and older women without further designation. The term medical refers to doctors, nurses, and certified midwives. 

The term other refers to any other response plus the missing answers. 

Table 4.11 shows that in most countries, the large majority of women are circumcised by traditional practitioners, most often older women known to be specialists in 

circumcision. Medical personnel are involved in the practice of FGC in only a few 

countries. The highest rate for use of medical personnel for FGC was found in Egypt 

(61 percent), with relatively high rates in northern Sudan (36 percent) and Kenya (34 

percent). In Guinea, Nigeria, and Yemen, from 9 to 13 percent of circumcisions are 

carried out by medical personnel. 

Table 4.11 

Percent distribution of circumcised women by person who did the cutting 

(traditional practitioner or medical personnel), DHS surveys 1989-2002 

 Number 

 Traditional Medical Don’t of 

Survey practitioner personnel know Other Total women 

Northeastern Africa 

Egypt 1995 79.6 17.3 1.7 1.4 100.0 14,330 

Egypt 2000a 38.3 61.4 0.3 u 100.0 5,709 

Eritrea 1995 95.0 0.2 4.8 u 100.0 4,775 

Eritrea 2002 92.2 0.6 4.9 2.3 100.0 7,765 

Sudan (northern) 1989-90 63.9 35.6 0.2 0.3 100.0 5,226 

Ethiopia 2000a 98.4 0.8 0.8 u 100.0 3,984 

 

Northern West Africa 

Guinea 1999 89.8 9.4 0.8 u 100.0 6,656 

Mali 1995-96 87.7 2.0 10.2 0.1 100.0 9,097 

Mali 2001 91.4 2.3 6.3 u 100.0 11,767 

Burkina Faso 1998-99 86.3 0.8 12.1 1.0 100.0 5,539 

Mauritania 2000-01 70.9 1.1 27.5 0.6 100.0 5,508 

Niger 1998 93.1 2.6 2.4 1.9 100.0 340 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1994 90.5 0.9 4.7 3.9 100.0 3,459 

Côte d’Ivoire 1998-99 93.2 0.4 5.1 1.3 100.0 1,354 

Nigeria 1999 72.8 12.9 12.0 2.3 100.0 2,088 

Benin 2001 95.9 0.5 3.7 u 100.0 1,047 

 

East Africa 

Kenya 1998a 62.2 34.4 3.3 0.3 100.0 516 

Tanzania 1996 81.6 3.5 6.2 7.4 100.0 1,476 

 

West Asia

Yemen 1997 90.8 8.6 0.7 u 100.0 1,546

Note: No data were available for CAR 

a Question asked about the daughter’s experience, not the experience of the woman. 

u = Unknown (not available) 

The phenomenon of FGC being carried out by medical personnel rather than 

traditional practitioners is sometimes referred to as the “medicalization” of FGC. The 

medicalization of FGC has increased substantially in recent years, particularly in 

Egypt, Guinea, and Mali (see chapter 5). 

4.4 Health Consequences from Survey Data 

It has been difficult to find ways to assess the overall impact of FGC on women’s 

health. DHS surveys include little information about the possible consequences of 

FGC on women’s health. In 9 of the 20 surveys, respondents were asked one or more 
38 Discussion of FGC in DHS Survey Reports

questions about the health consequences of FGC for themselves or their daughters, 

but no such questions were asked in the other 11 surveys. 

In the 1995 and 2002 surveys in Eritrea, respondents were asked whether they had 

any health problems during sexual relations or during delivery as a result of FGC. In 

the Eritrea 1995 survey, 19 percent of women reported that they had experienced 

problems during sexual intercourse or during delivery as a result of circumcision. 

That figure dropped to 13 percent in 2002. In the Egypt 1995 survey, mothers were 

asked whether they had experienced any complications after being cut, and 5 percent 

reported that they had health complications after being circumcised. Similarly, respondents in Yemen were asked whether their daughter had any complications after 

the FGC operation and what those complications were. Eleven percent of respondents reported that their daughter had experienced health problems after being circumcised. In the Central African Republic 1994-95 survey, where respondents were 

simply asked whether they had any problems after their circumcision, 27 percent reported that they had experienced health problems, primarily excessive bleeding and 

pain. 

In four other surveys (Guinea 1999, Mali 2001, Mauritania 2000-01, Benin 

2001), DHS used a question about medical complications that became part of the 

FGC module. Respondents who had at least one daughter circumcised were asked 

whether the daughter most recently circumcised had any of the following consequences: excessive bleeding, infection or a fever, difficulty in urinating, swelling, or 

slow healing. This question was asked about the daughter most recently circumcised 

in an effort to make the recall period as short as possible. Table 4.12 shows the results 

of this question for the four surveys. 

Table 4.12 

Percentage of daughters who experienced specific health consequences 

after their circumcision according to mothers’ reports, DHS surveys 

1999-2001 

 Number 

 Slow of 

Survey Bleeding Urination Infection Swelling healing daughters 

Guinea 1999 30.9 16.8 12.4 4.4 10.2 2,340 

Mali 2001 16.8 21.1 7.8 4.6 u 5,999 

Mauritania 2000-01 24.6 25.1 32.4 11.6 22.6 2,574 

Benin 2001 11.5 14.8 13.1 8.7 u 246 

u = Unknown (not available) 

In Mali and Benin, the responses for infection and slow healing were combined, so 

an unknown portion of the percentage who reported an infection were also slow in 

healing. The proportion of daughters who experienced medical complications after 

circumcision is higher in Mauritania than in the other countries. 

Answers to a question about the health consequences of a woman’s circumcision 

tell very little about what impact the circumcision event had on the woman’s health 

because respondents rely on recall and their own impressions about what is expected 

and what is out of the ordinary. Asking about a daughter’s health problems following 

circumcision has fewer recall problems, but still suffers from the ambiguity of what is 

considered ordinary and what is considered excessive. Some insight into the health 

consequences of circumcision could be gained through further analysis, such as looking at the relationship between the specific consequences (e.g., bleeding, fever, pain) 

In the Eritrea 1995 

survey, 19 percent of 

women reported that they 

had experienced 

problems during sexual 

intercourse or during 

delivery because of 

circumcision. 
Discussion of FGC in DHS Survey Reports 39 

and the type of FGC practiced, or verifying that the question was well understood, or 

determining what consequences respondents consider normal and therefore not 

worth reporting in a survey. In societies where a premium is placed on the endurance 

of pain and suffering during FGC, girls may be less likely to report health problems. 

In contexts with an aggressive media campaign against FGC, mothers may minimize 

the effects of the FGC experience to avoid criticism. 

4.5 Individual Perceptions of FGC 

All of the DHS surveys asked respondents questions about their opinions and perceptions of FGC, but the specific patterns of questioning varied greatly. As seen in 

Table 3.1, all surveys except for Côte d’Ivoire 1994 and Tanzania asked respondents 

whether they thought the practice of FGC should continue. As discussed in Chapter 3, in early surveys, respondents were asked why they supported or opposed FGC, 

while in later surveys, they were asked about the advantages to girls of being circumcised or not being circumcised. 

4.5.1 Support for FGC among Women 

It was expected that women who had been circumcised would be more likely to support FGC than those who had not been cut and that most women who had not been 

circumcised would not be supportive of the practice. The question is, what proportion of women who have been circumcised say they would like the practice to be 

abolished? Would this be a very small number? How would this vary from one country to another? Would there be systematic differences between high- and lowprevalence countries? 

Table 4.13 provides information related to some of these questions. The table 

shows the proportions of circumcised women who stated that they wanted FGC to 

be abolished and those who wanted it to continue. The key number in the table is the 

proportion of circumcised women who say they want the practice abolished, for those 

are the women most likely to turn against FGC. 

The surveys in northeastern Africa—conducted in countries with FGC prevalence 

rates of 80 percent or above—vary widely in the expression of support for FGC. It 

would be expected that some of the circumcised women who state that they want 

FGC to be abolished would do so in response to media campaigns in many countries 

that have urged people to abolish the practice. The surveys in Egypt and Sudan 

(northern) indicate that 10 to 14 percent of circumcised women are against the practice, whereas the figure for Ethiopia is 25 percent. A large proportion of circumcised 

women in Eritrea said that they want FGC to stop (36 percent in 1995 and 44 percent in 2002). 

Data from a number of countries indicate that a large proportion of survey respondents who are themselves circumcised want to end the practice of FGC. For example, 

in Eritrea, a country with high FGC prevalence (89 percent in 2002) and a high rate 

of infibulation (39 percent), 49 percent of women want the practice to stop and the 

same proportion want it to continue. In that same survey, 63 percent of respondents 

with a daughter had at least one daughter circumcised. Among those who want FGC 

to stop, 42 percent still had at least one of their daughters circumcised. Such findings 

in Eritrea raise the question, what does it mean to declare opposition to the practice 

of FGC in Eritrea? 

Data from a number of 

countries indicate that a 

large proportion of survey 

respondents who are 

themselves circumcised 

want to end the practice. 
40 Discussion of FGC in DHS Survey Reports

It is possible that some of the circumcised women decided very recently that they 

want to stop the practice of FGC, after a daughter was circumcised. However, some 

respondents may have given the answer they thought was preferred by the interviewer. For others, the answer to the support question is not compatible with their 

behavior because they were involved in having their daughter cut even though they 

reported being opposed the practice. 

Table 4.13 

Percent distribution of circumcised women by whether they support the 

continuation of FGC or want it to stop, DHS surveys 1989-2002 

 Number 

 Don’t of 

Region/country Continue Stop know Total women 

Northeastern Africa 

Egypt 1995 84.0 10.4 5.6 100.0 14,332 

Egypt 2000 76.9 13.3 9.7 100.0 15,153 

Eritrea 1995 59.3 36.2 4.5 100.0 4,775 

Eritrea 2002 53.3 44.2 2.5 100.0 7,765 

Sudan (northern) 1989-90 86.0 13.9 0.0 100.0 5,226 

Ethiopia 2000 70.5 24.8 4.7 100.0 12,280 

 

Northern West Africa 

Guinea 1999 68.8 21.6 9.5 100.0 6,656 

Mali 1996 79.7 10.0 10.2 100.0 9,097 

Mali 2001 85.2 8.7 6.0 100.0 11,767 

Burkina Faso 1999 23.8 63.7 12.5 100.0 4,615 

Mauritania 2001 77.7 13.1 9.1 100.0 5,508 

Niger 1998 70.0 21.2 8.7 100.0 340 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1999 57.4 35.5 7.1 100.0 1,354 

Central African Republic 1994 61.3 33.5 5.2 100.0 2,555 

Nigeria 1999 54.4 37.0 8.6 100.0 2,056 

Benin 2001 14.0 75.7 10.3 100.0 1,047 

 

East Africa 

Kenya 1998 40.9 56.7 2.5 100.0 2,965 

West Asia 

Yemen 1997 78.2 16.6 5.2 100.0 2,354

Note: Question was not asked in Côte d’Ivoire 1994 or Tanzania 1996. 

With the exception of Niger (5 percent), the countries of northern West Africa 

have high (71 to 98 percent) FGC prevalence rates, and their levels of support for 

FGC vary from 64 to 80 percent, except for Burkina Faso, where only 24 percent of 

circumcised women said that the practice should continue, and 64 percent said it 

should be abolished. The high rate of declarations in favor of stopping FGC may be 

related to the anti-FGC activities that began very early in Burkina Faso under Thomas Sankara (President, 1983-87) as well as the fact that the practice of FGC is 

banned in the country. Women were asked whether they knew there was a law banning FGC in Burkina Faso. Among those who responded “yes” to that question (78 

percent), a total of 74 percent said that FGC should be stopped, while 16 percent 

said it should continue, and 9 percent did not know. 

The countries in southern West Africa have higher proportions of respondents 

who say they want to abolish FGC, which may be related to the relatively low overall 

FGC prevalence rates (17 to 45 percent) in those countries. Benin stands out from 

the rest, with 76 percent of circumcised women being against FGC. In Benin, 60 

The high rate of 

declarations in favor of 

stopping FGC may be 

related to the anti-FGC 

activities that began very 

early in Burkina Faso. 
Discussion of FGC in DHS Survey Reports 41 

percent of the population is from either the Fon or Adja ethnic groups, who do not 

practice FGC. Most of the circumcision in Benin takes place among the Fulani, 

Bariba, and Yoa minorities—prevalence ranging from 72 to 88 percent—who make 

up just 19 percent of the population. Another set of ethnic groups in Benin that 

make up 19 percent of the population has a prevalence rate of around 20 percent, and 

most of these women reported being opposed to FGC. Nevertheless, 27 percent of 

the women who opposed FGC in Benin had one of their daughters circumcised. 

Table 4.14 examines whether women who declare they want the practice of FGC 

to stop have had their eldest daughters circumcised. In seven surveys, respondents 

were asked about their support of FGC and about the circumcision status of their 

eldest daughter. Table 4.14 shows the FGC prevalence rates among daughters of 

mothers who support FGC and those who do not, using as the denominator all circumcised women with at least one living daughter. The table indicates that there is 

some difference between the two groups in all countries except for Mali. 

Table 4.14 

Among circumcised women with at least one living 

daughter, the prevalence of FGC among eldest daughters, by whether the mother supports or opposes FGC, 

DHS surveys 1995-1999 

 Prevalence of FGC 

 among eldest daughters Prevalence 

 –––––––––––––––––––––– of FGC 

 Mother Mother among 

 wants FGC wants FGC all eldest 

Survey to stop to continue daughters 

Eritrea 1995 60.3 79.4 73.5 

Mali 1995-96 75.8 77.3 77.2 

Burkina Faso 1998-99 47.9 61.7 51.7 

Niger 1998 33.7 57.7 52.4 

Côte d’Ivoire 1998-99 37.5 55.6 49.2 

Nigeria 1999 35.4 76.2 59.8 

Kenya 1998 16.2 39.9 24.8 

The results for Kenya differ from those for the other countries because of the low 

prevalence of FGC among eldest daughters of circumcised women in Kenya (25 percent), and because of the substantial difference in prevalence between the daughters 

of the two groups of women: 16 percent of those who oppose FGC had their eldest 

daughters cut, compared with 40 percent of those who support FGC. In the other 

surveys, the prevalence of FGC among daughters ranges from 49 to 77 percent. 

Excluding Kenya, from one-third to three-fourths of circumcised women who say 

FGC should be stopped have had their eldest daughter circumcised. Although some 

mothers may have changed their minds since their daughter was cut, or the daughter 

was cut against the mother’s will, the literature suggests that these are few in number. 

So why would so many women⎯having been cut themselves and who say they oppose FGC⎯participate in their daughter’s circumcision? Gerry Mackie argues that 

while women truly oppose FGC, they are unable to stop it by themselves, so they 

continue the practice (Mackie, 2000). 

It is also possible that a response to a single question presented in a survey context 

does not reflect the actual views of these women because there is often discordance 

between such responses and individual actions. Researchers in health communication 

have long debated the reasons differences exist between declared desires and individExcluding Kenya, from 

one-third to three-fourths 

of circumcised women 

who say FGC should be 

stopped have had their 

eldest daughter 

circumcised. 
42 Discussion of FGC in DHS Survey Reports

ual actions. Those who support diffusion theory argue that changes in such stated 

support can be a precursor to changes in behavior. It is common however for health 

education campaigns to yield major changes in knowledge but without any subsequent changes in behavior (Hornik et al., 2002). 

4.5.2 Reasons to Continue FGC 

In 11 surveys, after respondents were asked whether they thought FGC should continue, those who wanted FGC to continue were asked why they held this view. The 

precoded answers included 1) custom and tradition, 2) good tradition, 3) religion 

demands it, 4) cleanliness/hygiene, 5) virginity/morality, and 6) better marriage prospects. Table 4.15 shows the responses given most frequently to support the continuation of FGC. Respondents were allowed to give more than one answer. 

A large proportion of respondents cited “tradition,” or “custom,” as their first answer to the question. These two terms are used in essentially the same manner and 

thus are considered equivalent in their meaning. “Good tradition” was another possible coding in some countries, and many respondents mentioned it. “Religion” here 

refers to answers that say that religion requires FGC to be done. “Virginity” refers to 

answers that say, for example, that FGC protects a girl’s virginity, prevents her from 

becoming promiscuous, and prevents immoral behavior. “Marriage prospects” refers 

to the belief that a girl cannot be married unless she is circumcised, and that she will 

not be acceptable to her husband unless she is circumcised. “Hygiene and cleanliness” 

refers mostly to aesthetic judgments of the body’s appearance rather than to being 

clean or dirty. 

Table 4.15 

Among women who want FGC to continue, percentage who gave specific 

reasons for continuing FGC, DHS surveys 1989-1999 

 Custom/ Good Hygiene/ Marriage

Survey tradition tradition Virginity Religion cleanliness prospects 

Egypt 1995 u 58 9 31 36 9 

Eritrea 1995 69 53 15 12 15 4 

Sudan (northern) 1989-90 68 19 7 14 8 5 

Mali 1995-96 61 28 5 13 6 3 

Burkina Faso 1998-99 71 u 10 9 10 4 

Niger 1998 22 u 27 6 2 29 

Côte d’Ivoire 1998-99 68 u 15 11 17 36 

CAR 1994-1995 70 26 13 <1 1 9 

Nigeria 1999 50 35 14 2 5 7 

Kenya 1998 56 42 30 5 4 18 

Yemen 1997 36 12 6 33 46 3 

u = Unknown (not available) 

It should be noted that denominators in these surveys vary widely, and only those 

women who said they wanted FGC to continue were asked why they held that opinion. For example, in Egypt 1995, 82 percent of respondents (84 percent of those circumcised) said that they wanted FGC to continue, and 58 percent of those said FGC 

should continue because of tradition. In Kenya, only 20 percent of respondents said 

that the practice should continue, and among them, 56 percent mentioned custom or 

tradition as a reason for continuing FGC. 

In 9 of the 11 surveys, between 50 and 71 percent of women mentioned “custom 

and tradition” as a reason for continuing FGC. A substantial proportion also mentioned “good tradition” as a reason. What might this really mean? It suggests that 

In 9 of the 11 surveys, 

between 50 and 

71 percent of women 

mentioned “custom and 

tradition” as a reason for 

continuing FGC. 
Discussion of FGC in DHS Survey Reports 43 

among the women who think FGC should continue, half to two-thirds regard circumcision as part of their commonsense understanding of what parents should do for 

their daughters⎯that they are doing what they think is appropriate. 

In two countries, only a small proportion of respondents invoked tradition or custom to explain why FGC should continue: Niger (22 percent) and Yemen (36 percent). These are also countries with low FGC prevalence: Niger (5 percent) and 

Yemen (23 percent). 

Respondents who said that FGC should be stopped were asked why they thought 

it should be abolished. They mainly gave two answers: “medical complications” and 

“bad tradition.” In six of the surveys, “medical complications” was the most common 

response, ranging from 37 to 67 percent, while “bad tradition” was the most frequent 

response in the five other surveys, ranging from 50 to 72 percent. There is no apparent relationship between FGC prevalence and reasons for wanting FGC to be 

stopped. The countries with high FGC prevalence are not different from those with 

low FGC prevalence in terms of the reasons given for wanting to stop FGC. It is interesting that in half of the surveys the main reason given for continuing FGC was 

“tradition,” while the main reason given for stopping FGC was “bad tradition.” These 

findings suggest that further research is necessary to explain the significance of such 

normative responses. 

In six of the most recent surveys, women were asked, what were the benefits of 

getting a girl circumcised? Then they were asked, what were the benefits of not circumcising a girl? In four surveys the main benefit cited was social approval (35 to 65 

percent). In Benin 2001, 41 percent said that they did not know, and in Egypt 2000, 

58 percent said that it was to “uphold tradition.” Responses given regarding perceived 

drawbacks of FGC varied substantially. In Egypt 2000, 75 percent of women said 

that there were no drawbacks, as did 59 percent of those in Mali 2001. For Eritrea 

2002, the percentage was 43 percent. In Benin 2001, 48 percent of women said that 

they did not know of any drawbacks to FGC. 

4.5.3 Support for FGC among Men 

Men were asked questions about FGC in seven countries in West Africa, and in Eritrea. One of the questions was whether they think FGC should continue or be 

stopped. Table 4.16 compares women and men regarding support for the practice of 

FGC. The denominators are those who have heard of FGC. 

The table shows that higher proportions of women than men favor the continuation of FGC in all the countries surveyed, although support among women and men 

is about equal in Benin 2001 (5 percent each). The percentage who say that FGC 

should be stopped is consistently higher for men than that of women. Does this mean 

that more women than men favor the continuation of FGC? How can this difference 

be explained? Three explanations are worth considering. 

It is likely that women in most of these countries consider their daughter’s circumcision their responsibility, while men are expected to play a more peripheral role in 

the planning and activities associated with it. These views were expressed frequently 

in interviews with men and women in a qualitative research study carried out by 

ORC Macro in Guinea (Yoder et al., 1999). The same views were documented in 

The Gambia, according to Ylva Hernlund (2003). If women believe that they are 

responsible for seeing that their daughters are circumcised, it would be expected that 

more women than men would support the practice. 

Higher proportions of 

women than men favor 

the continuation of FGC 

in all the countries 

surveyed. 
44 Discussion of FGC in DHS Survey Reports

Table 4.16 

Percentage of women and men who 

said that FGC should continue, DHS 

surveys 1995-2001 

Survey Women Men 

Eritrea 1995 57 46 

Guinea 1999 68 52 

Mali 2001 80 73 

Burkina Faso 1998-99 21 17 

Mauritania 2000-01 64 37 

Niger 1998 32 14 

Côte d’Ivoire 1998-99 30 23 

Benin 2001 5 5 

It may be that support for FGC in these countries has diminished in the past few 

years as more social and political leaders speak out against the practice and as more 

people are living in urban areas. If this is the case, it is likely that men will come more 

quickly to oppose FGC than women because they are more likely to participate in 

public life than women. 

The difference may also be related to education because, as shown earlier, there is 

a close relationship between a woman’s level of education and the probability of having a daughter circumcised. The pattern implies that spending more time in school 

has an impact on the way individuals view the practice of circumcision, particularly as 

it applies to their daughters. In all of these countries, more men than women are educated and men remain in school longer than women. Therefore, whatever effect education has on reducing support for FGC is likely to be expressed first in men. 
Changes Over Time 45 

 5

Changes Over Time 

5.1 Tracking Changes in the Practice of FGC 

ecent studies of female genital cutting in African societies have shown that the 

practice of FGC varies widely in how it is conducted and that it is undergoing 

changes in some societies (Shell-Duncan and Hernlund, 2000; Gruenbaum, 2001). 

The literature on FGC suggests that girls in many countries are being cut at earlier 

ages, that the ceremonial aspects have been reduced, that larger proportions of girls 

are being cut by medical personnel rather than by traditional practitioners, and that 

overall prevalence is decreasing. Is there statistical evidence for these impressions? 

Are there changes in the practice of FGC that can be identified therough the analysis 

of data from DHS surveys? 

This chapter examines evidence for changes over time in FGC prevalence, in the 

ways FGC is conducted, and in declarations of support for the continuation of FGC. 

Using DHS data to monitor changes in the practice of FGC is difficult because of 

the lengthy retrospective periods involved. Respondents are asked about an experience that occurred some years in the past, often when they were very young. For girls 

age 15-19, most respondents are reporting on an event that took place 10 to 15 years 

earlier. For example, in Mali 2001, 61 percent of circumcised girls were cut before 

the age of five and 81 percent were cut before the age of ten. A 17-year-old respondent in the youngest age group (15-19) would be answering questions about an event 

that occurred 10 to 15 years in the past, that is, between 1986 and 1991. This means 

that any changes seen in the data occurred prior to the anti-FGC campaigns that began in the 1990s. More recent data are needed for Mali to determine the impact of 

the anti-FGC campaigns. 

Evidence for changes over time can be obtained by comparing the FGC experiences of different age cohorts, by comparing data on mothers and daughters, and in a 

few countries, by comparing the results of surveys conducted at two points in time. 

Data are available from successive surveys in four countries: Egypt, Eritrea, Mali, and 

Côte d’Ivoire. In these countries, FGC prevalence, descriptions of the FGC procedure, and individual perceptions of FGC can be compared to identify changes that 

occurred over a five-year period. 

5.2 Comparison of Age Cohorts 

The division of respondents (women age 15-49) into seven age cohorts allows for the 

comparison of women’s experience with FGC at different times in the past. Table 5.1 

shows the prevalence of FGC by five-year age groups for each of the 16 countries. In 

9 of the 16 countries, there is a marked decrease in FGC prevalence in the younger 

age groups (15-19 and 20-29), while in the other seven age groups, prevalence remains at roughly the same level. These age-specific rates suggest that in 9 of the 16 

countries, prevalence of FGC has decreased over the past few decades. However, eviR 

Evidence for changes over 

time can be obtained by 

comparing the FGC 

experiences of age 

cohorts, by comparing 

data on mothers and 

daughters, and by 

comparing the results of 

surveys conducted at two 

points in time. 
46 Changes Over Time

dence for decreased FGC is weaker in Eritrea and Burkina Faso than in the other 

countries. The countries with the highest prevalence show little change over time. 

Table 5.1 

Percentage of women circumcised, by age, DHS surveys 1989-2002 

 Age group 

 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

Region/country 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total 

Northeastern Africa 

Egypt 2000a 99.1 97.4 97.2 96.7 97.4 96.9 97.9 97.3 

Eritrea 2002 78.3 87.9 90.8 93.4 92.6 94.1 95.0 88.7 

Sudan (northern) 1989-90a 86.8 89.7 88.6 89.7 89.0 89.0 90.9 89.2 

Ethiopia 2000 70.7 78.3 81.4 86.1 83.6 85.8 86.8 79.9 

 

Northern West Africa 

Guinea 1999 96.6 98.5 99.1 99.1 99.1 99.3 99.5 98.6 

Mali 2001 91.2 91.3 91.9 92.1 92.3 91.2 91.0 91.6 

Burkina Faso 1998-99 64.2 70.7 75.0 73.7 74.1 76.7 74.1 71.6 

Mauritania 2000-01 65.9 71.1 73.4 74.2 71.7 76.5 68.6 71.3 

Niger 1998 5.0 4.8 4.3 5.3 3.8 3.3 3.3 4.5 

 

Southern West Africa 

Middle Africa 

Côte d’Ivoire 1998-99 41.2 42.7 42.4 49.0 44.5 51.4 51.0 44.5 

CAR 1994-95 34.6 42.7 44.3 44.1 47.5 51.4 53.1 43.4 

Nigeria 1999 8.8 19.6 26.4 31.3 31.0 37.9 48.3 25.1 

Benin 2001 12.1 13.4 16.9 18.4 18.3 25.1 23.7 16.8 

 

Eastern Africa 

Kenya 1998 26.0 32.2 40.4 40.9 49.3 47.4 47.5 37.6 

Tanzania 1996 13.5 15.9 19.6 20.8 18.7 21.3 22.2 17.9 

Western Asia 

Yemen 1997a 19.3 22.2 21.3 22.9 23.6 25.1 25.0 22.6

a

 Ever-married women 

Although some countries with FGC levels below 50 percent showed lower prevalence in the younger cohorts, this was not the case for Niger or Yemen. The Niger 

results may be due to the small number of cases involved and an overall prevalence of 

just 5 percent, or they may indicate there was no change. In Yemen, there appears to 

have been no change in FGC prevalence. 

While age at circumcision is declining in some countries, overall, the countries in 

this analysis fall into three categories according to the age of circumcision of most 

respondents: 1) those countries where circumcision is done at a relatively advanced 

age (9-13 years old) (Egypt, Guinea, the Central African Republic, and the two 

countries of eastern Africa [Kenya and Tanzania]), 2) those countries where circumcision occurs at an intermediate age (5-7 years old) (Mali, Burkina Faso, Niger, and 

Benin), and 3) those countries where circumcision is done at a very young age (first 

few weeks to 2-3 years) (Eritrea, Ethiopia, Mauritania, Côte d’Ivoire, Nigeria, and 

Yemen). The survey in Sudan did not ask for age at circumcision. It should be kept 

in mind, however, that presenting national-level figures obscures the variation in age 

at circumcision that is found in subgroups within countries. 

The median age at circumcision has declined substantially in four countries: Mali, 

Burkina Faso, Côte d’Ivoire, and Kenya. In other countries the age at circumcision 

has declined slightly or stayed the same. In Mali the median age at circumcision for 

women age 30-45 was about three, while for those age 15-29, it was less than one 

The median age at 

circumcision has declined 

substantially in four 

countries: Mali, Burkina 

Faso, Côte d’Ivoire, and 

Kenya. 
Changes Over Time 47 

year. No trend was apparent in the other countries, although in Mauritania this was 

because the median age at circumcision was less than one year for all age groups. 

Table 5.2 shows the percentage of respondents circumcised by a medical professional. For four surveys (Egypt 2000, Ethiopia 2000, Kenya 1998, and Yemen 1997), 

the data are derived from the FGC experience of daughters (as reported by their 

mothers) rather than the experience of the respondents themselves. In seven countries 

(nine surveys), less than 1 percent of girls were circumcised by a medical professional 

and there was no discernable trend over time. Tanzania can also be included in this 

group because the proportion of circumcisions by medical professionals was less than 

4 percent, with no trend over time. Overall, half of the surveys show a trend toward 

medicalization of FGC. 

On the other hand, in six countries (eight surveys), circumcision by a medical professional was higher in the youngest age groups. This trend appears particularly in 

Egypt 1995, northern Sudan 1989-90, and Guinea 1999. In the surveys where at 

least 9 percent of girls were circumcised by a medical practitioner, the trend toward 

increased medicalization is clear. In Mali 2001, where overall only 2.3 percent of circumcised women have been cut by a medical professional, the rate for the youngest 

age group (15-19) is 5 percent, compared with less than 1 percent for the oldest age 

group (45-49). 

Table 5.2 

Percentage of circumcised women who were cut by a medical professional, by age, DHS surveys 1989-2002

 Age group 

 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

Survey 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total

Northeastern Africa 

Egypt 1995 32.4 25.4 20.2 17.3 14.9 10.8 9.1 17.3 

Egypt 2000a 0.0* 57.3* 68.0 66.5 62.7 62.6 56.5 61.4 

Eritrea 1995 0.6* 0.2* 0.2* 0.1* 0.0* 0.0* 0.0* 0.2* 

Eritrea 2002 1.2* 0.6* 0.7* 0.1* 0.5* 0.1* 0.2* (0.6) 

Sudan (northern) 1989-90 46.7 46.3 38.6 36.7 28.3 26.4 24.4 35.6 

Ethiopia 2000a 0.0* 0.1* 0.2* 0.9* 1.6* 1.1* 0.5* (0.9) 

Northern West Africa 

Guinea 1999 21.8 16.2 7.7 (5.2) 2.2* 0.4* 0.8* 9.4 

Mali 1995-96 3.6 (2.5) (2.8) 1.4* 1.1* 0.6* 0.2* 2.0 

Mali 2001 4.8 3.2 (2.6) 0.8* 1.4* 0.4* 0.3* 2.3 

Burkina Faso 1998-99 0.7* 0.9* 0.5* 0.2* 0.4* 0.2* 0.0* (0.5) 

Mauritania 2000-01 1.5* 1.3* 1.0* 0.5* 0.2* 0.4* 0.0* (0.9) 

Niger 1998 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Southern West/ 

Africa Middle Africa 

Côte d’Ivoire 1994 1.1* 0.8* 0.7* 1.4* 0.9* 0.6* 0.3* (0.9) 

Côte d’Ivoire 1998-99 0.4* 1.2* 0.3* 0.3* 0.0* 0.0* 0.0* 0.4* 

Nigeria 1999 (20.5) 17.8 14.7 (10.6) (13.2) 7.4* 6.8* 12.7 

Benin 2001 2.1* 0.0* 0.5* 0.6* 0.0* 0.0* 0.0* 0.5* 

Eastern Africa 

Kenya 1998a 0.0* 0.0* 56.5 53.6 41.6 17.2 25.2 34.4 

Tanzania 1996 3.1* 4.1* 2.6* 3.1* 7.3* 2.8* 1.5* 3.5 

 

Western Asia 

Yemen 1997a 8.2* (13.7) 8.2* (7.9) (8.6) 7.8* 5.6* 8.6

Note: Question was not asked in the CAR survey. Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk 

indicates that a figure is based on fewer than 25 unweighted cases. 

a

 Based on information about daughter (eldest daughter or the most recently circumcised daughter) 

A trend toward 

medicalization of FGC 

was seen in half of the 

surveys. 
48 Changes Over Time

DHS data indicate that in some countries, respondents are being circumcised at a 

younger age than previously, that in a few countries a higher proportion of respondents are being circumcised by medical professionals than previously, and that the 

overall prevalence of FGC is declining. While these data do not provide any direct 

evidence of changes in the importance of the ceremonial aspects of FGC, it is likely 

that the movement toward circumcision at younger ages will reduce the social and 

ceremonial significance of FGC. 

In all countries except Côte d’Ivoire 1994 and Tanzania 1996, women were asked 

whether they think FGC should continue or be stopped. The answer to the question 

is used to indicate the degree of “support” for FGC in a particular population. Table 

5.3 shows the percentage of women who declared their support for FGC by age 

group for 14 countries. The denominators in this table are women who have heard of 

FGC. 

In the countries with the highest prevalence (Egypt 1995 and 2000, Sudan (northern) 1989-90, Guinea 1999, and Mali 1995-96 and 2001) there is no discernable 

trend toward decreasing support for FGC by age group, with the exception of 

Guinea, where support is somewhat lower in the two youngest age groups. Table 5.3 

shows that the largest difference in respondent support for FGC by age group is between the youngest and oldest age groups. Further analysis of DHS data to identify 

the characteristics of those who support and those who oppose the continuation of 

FGC should yield more insight into the situation in each country. 

Table 5.3 

Percentage of women who support FGC, by age, DHS surveys 1989-2002

 Age group 

 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

Region 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total

Northeastern Africa 

Egypt 1995 84.8 83.9 81.7 79.2 81.3 80.8 82.2 81.6 

Egypt 2000 80.5 75.4 75.7 72.6 74.8 75.5 76.7 75.3 

Eritrea 1995 40.9 49.0 59.0 60.9 68.2 66.6 71.2 56.8 

Eritrea 2002 36.1 44.4 46.0 54.0 54.7 60.3 63.2 48.4 

Sudan (northern) 1989-90 77.1 74.4 76.7 78.9 81.2 82.2 81.3 78.5 

Ethiopia 2000 53.4 57.0 58.5 65.2 63.6 66.3 66.7 59.7 

 

Northern West Africa 

Guinea 1999 60.5 65.7 72.1 69.9 70.7 72.8 71.5 68.3 

Mali 1995-96 70.0 75.9 78.2 77.0 76.9 75.4 74.7 75.3 

Mali 2001 78.3 78.6 81.0 78.1 77.9 79.0 78.9 78.8 

Burkina Faso 1998-99 18.2 17.2 20.0 17.2 16.9 17.1 21.2 18.1 

Mauritania 2000-01 58.0 59.9 61.7 59.2 54.1 62.7 60.8 59.4 

Niger 1998 7.3 8.1 9.6 9.9 9.4 10.5 11.5 9.0 

 

Southern West Africa/ 

Middle Africa 

Côte d’Ivoire 1998-99 25.8 27.2 25.3 29.2 32.5 31.6 38.0 28.4 

CAR 1994-95 27.6 30.6 30.2 30.5 30.2 31.2 35.5 30.2 

Nigeria 1999 6.3 13.2 15.4 19.2 17.5 22.3 29.9 15.4 

Benin 2001 4.2 4.0 2.5 2.7 2.6 4.4 3.2 3.4 

 

Eastern Africa 

Kenya 1998 20.6 19.5 20.2 17.1 19.4 20.5 21.9 19.8 

Western Asia 

Yemen 1997 17.5 22.3 19.2 20.2 22.5 20.8 23.4 20.8

Note: Question was not asked in Côte d’Ivoire 1994 and Tanzania 1996. 

The largest difference in 

the percentage of 

respondents who support 

FGC by age cohort is 

between the oldest and 

youngest age cohorts. 
Changes Over Time 49 

5.3 Mother-daughter Comparisons 

The limitations of comparing FGC prevalence for mothers and daughters were discussed earlier (section 3.5). However, it may be useful to compare the circumcision 

status of eldest daughters and their mothers. Table 5.4 shows this correlation, based 

on information from all women who have heard of FGC and who had at least one 

living daughter at the time of the survey. The last column in the table shows the 

overall prevalence of FGC for eldest daughters. 

Table 5.4 

Circumcision status of eldest daughters and their mothers, based on information from women who have heard of FGC and have at least one living 

daughter, DHS surveys 1995-1999 

 Eldest daughter Eldest daughter not 

 circumcised circumcised 

 ––––––––––––––––––––––––––– ––––––––––––––––––––––––––– Percentage 

 of 

 Mother Mother eldest 

 not Mother not Mother daughters 

Survey circumcised circumcised circumcised circumcised circumcised 

Eritrea 1995 19.5 73.8 80.5 26.2 71.4 

Mali 1995-96 11.6 77.4 88.4 22.6 73.6 

Burkina Faso 1998-99 7.6 54.4 92.4 45.6 47.4 

Niger 1998 7.5 50.1 92.5 49.9 14.2 

Côte d’Ivoire 1998-99 1.3 49.2 98.7 50.8 25.8 

Nigeria 1999 1.9 59.2 98.1 40.8 20.2 

Kenya 1998 0.6 24.9 99.4 75.1 11.3 

Tanzania 1996 0.6 30.4 99.4 69.6 6.8 

Given the evidence of decreasing FGC prevalence among the youngest women in 

all of the countries except Niger, it is expected that the prevalence of FGC among 

daughters will be less than that among mothers. This can be seen in Table 5.4 by 

comparing columns 2 and 5. Note that the small proportion of eldest daughters circumcised in Kenya and Tanzania probably reflects the older age at circumcision in 

those countries (about 12 years); some of the daughters who were not circumcised at 

the time of the survey will likely be circumcised in the future. 

5.4 Comparison of Survey Results at Two Points in Time 

By the end of 2002, FGC data were available for multiple surveys in four countries: 

Egypt, Eritrea, Mali, and Côte d’Ivoire, enabling FGC data from two points in time 

for the same country to be compared. By the end of 2004, four more countries were 

added to the list: Burkina Faso, Nigeria, Kenya, and Tanzania. 

Table 5.5 presents the findings on FGC prevalence and on support for the practice 

of FGC for the first four countries. Only Eritrea shows a measurable decrease in the 

prevalence of FGC. The small observed increase in Côte d’Ivoire may not constitute 

a real change because the differential is small and within the range of sampling error. 

The percentage of women who support FGC dropped by 6 to 8 percentage points 

in Egypt and in Eritrea, but no drop was seen in Mali. However, in Mali 1995-96, 

the question about whether FGC should be continued was asked right after questions 

about the daughter’s circumcision, whereas in Mali 2001, the question was preceded 

by four questions on the advantages and disadvantage of being circumcised, and one 
50 Changes Over Time

on religion. It is possible that the different position of the question in the two surveys 

resulted in a higher showing of support for FGC in the Mali 2001 survey. 

Table 5.5 

FGC prevalence and support for FGC in 

four countries where two DHS surveys 

were conducted, DHS surveys 1994-2002 

 FGC Support 

Country prevalence (%) for FGC (%)

Egypt 1995 97.0 81.6 

Egypt 2000 97.3 75.3 

Eritrea 1995 94.5 56.8 

Eritrea 2002 88.7 48.8 

Mali 1995-96 93.7 75.3 

Mali 2001 91.6 80.3 

Côte d’Ivoire 1994 42.7 u

Côte d’Ivoire 1998-99 44.5 30.0

u = Unknown (not available) 

Table 5.6 compares the surveys by variables from respondents’ reports of their experience with FGC, or (in the case of Egypt) their daughter’s experience with FGC. 

In three of the four countries, the proportion of girls circumcised before the age of 

five increased, suggesting that girls are being circumcised at younger ages. In the fiveyear period between the surveys, the percentage of women circumcised before the age 

of five doubled in Côte d’Ivoire, from 24 to 55 percent. Similarly, in Mali, the proportion cut before the age of five increased from 41 to 61 percent. No changes were 

observed for the percentage infibulated, but the number of cases was small in Mali 

and Côte d’Ivoire, and the question was changed in Eritrea. 

Table 5.6 

Comparison of two surveys in four countries by characteristics of the 

FGC experience, DHS surveys 1994-2002 

 Percentage Percentage

 Percentage cut by cut by 

 cut before Percentage medical traditional 

Country age 5 years infibulated professional practitoner

Egypt 1995 5.0a u 54.8a 42.4 

Egypt 2000 6.2a u 61.4 a 38.3a

 

Eritrea 1995 60.0 34.0 0.1 95.0 

Eritrea 2002 75.1 38.6b 0.6 91.2 

Mali 1995-96 41.3 0.5 2.0 87.7 

Mali 2001 61.2 1.9 b 2.3 91.4 

 

Côte d’Ivoire 1994 24.3 u 0.9 90.6 

Côte d’Ivoire 1998-99 55.0 2.3 0.4 92.8 

a

 Figures are for daughters, not respondents. 

b Question was quite different. 

u = Unknown (not available) 

There was an increase in the proportion of girls circumcised by a medical professional in Egypt, along with a slight decrease in the proportion circumcised by a traditional practitioner. 

In Egypt, there was an 

increase in the proportion 

of girls circumcised by a 

medical professional. 

along with a slight 

decrease in the 

proportion circumcised by 

a traditional practitioner. 
Changes Over Time 51 

Overall, in many countries girls are being cut at younger ages than in the past. 

However, at the same time, FGC prevalence is lower for the youngest age groups in 

half of the countries examined. In a few countries, more circumcisions are being done 

by medical personnel than in the past. DHS data on FGC point to many opportunities for further analysis that would increase understanding of the practice and promote implementation of more effective anti-FGC programs. The countries that have 

shown the greatest amount of change, or have exhibited surprising findings deserving 

of more investigation, are Eritrea, Burkina Faso, and Benin. 

Conclusion: Use of DHS Data on Female Genital Cutting 53 

 6

Conclusion: Use of DHS Data on 

Female Genital Cutting 

he DHS data on female genital cutting collected in 16 countries from 1989 to 

2002 show substantial variation in FGC prevalence between and within countries. FGC prevalence varies from a high of 99 percent in Guinea (1999) to a low of 5 

percent in Niger (1998). With FGC data now available from population-based surveys, it is possible to examine a number of background variables to better understand 

the dynamics of this social phenomenon. In countries where FGC occurs, the DHS 

program will continue to include questions on FGC in future surveys. 

Both DHS data and the literature on FGC indicate there is substantial variation in 

the prevalence of FGC among countries, in the manner in which FGC is practiced, 

and in the relative importance attached to the ritual aspects of the circumcision event. 

The average age at circumcision varies from a few weeks in Yemen to 12 years in 

Kenya and Tanzania. The amount of cutting varies from a symbolic nick to excision 

of external female genitalia and partial closure of the vaginal area (infibulation). The 

ritual aspects vary from the simple cutting of an infant in the household context to 

the cutting of a group of adolescent girls in a ritual context (coming-of-age ceremonies), followed by seclusion for a period of weeks or months. 

DHS data indicate that the practice of FGC has changed in recent years. Data 

from several countries indicate that girls are being circumcised at younger ages and 

there is less cutting than in the past. There is a trend toward medicalization of the 

practice in some countries, particularly Egypt. Such changes in the practice of FGC 

should be monitored so program specialists can design the interventions best suited 

to specific situations. 

Given the variation in the way FGC is practiced in different countries, it would be 

useful to prepare country profiles that describe the FGC situation in each country. 

The profiles should cover national prevalence, FGC distribution, types of cutting, 

degree of medicalization of the practice, and the relative importance of ritual in the 

circumcision event. Such country profiles, or situation analyses, would assist in planning effective programs to promote the abandonment of FGC. Anti-FGC programs 

should ideally be country specific, adapted to the situation of each country. It may 

also be useful for some programs to adapt their campaigns to accommodate regional 

or ethnic differences in the practice. For example, a program may want to develop 

one strategy for a population in which FGC is nearly universal and another for a 

population that includes considerable diversity in the practice. 

There has been little use of DHS data sets to examine the distribution of FGC 

within specific countries or to examine how the practice has changed over time. In 

countries where the full FGC module was included in the DHS survey, a great deal 

can be learned about the social context of FGC. Questions to be explored include the 

role of residence (urban-rural), ethnicity, and religion in the distribution and practice 

T 

Ideally, anti-FGC 

programs should be 

country specific, adapted 

to the situation of each 

country. Attention should 

also be given to 

campaigns that 

accommodate regional or 

ethnic differences in 

practices. 
54 Conclusion: Use of DHS Data on Female Genital Cutting

of FGC. A more detailed study of the FGC experiences of mothers and daughters 

would also be insightful. 

There is an ongoing need for research on current practices of female circumcision. 

Ethnographic studies of how the cutting is organized, who participates and in what 

fashion, who pays the costs, and what happens to the girls/women after the circumcision would provide information useful for planning anti-FGC programs that are responsive to local customs and beliefs. 
References 55 

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59

Appendix 

Female Genital Cutting Module for the Women’s Questionnaire 

Female Genital Cutting Module for the Men’s Questionnaire 

Appendix 61 

FEMALE GENITAL CUTTING MODULE 1

(For Female Questionnaire) 

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 

001 Have you ever heard of female circumcision?2 YES ............................................. 1

NO ............................................... 2

─3⁄4003 

002 In a number of countries, there is a practice in which a 

girl may have part of her genitals cut. Have you ever 

heard about this practice? 

YES ............................................. 1

NO ............................................... 2 ─3⁄4END

003 Have you yourself ever had your genitals cut? YES ............................................. 1

NO ............................................... 2 ─3⁄4009

004 Now I would like to ask you what was done to you at this 

time. 

Was any flesh removed from the genital area? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

─3⁄4006 

005 Was the genital area just nicked without removing any 

flesh? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

006 Was your genital area sewn closed? YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

007 How old were you when this occurred? 

IF THE RESPONDENT DOES NOT KNOW THE EXACT 

AGE, PROBE TO GET AN ESTIMATE. 

AGE IN COMPLETED ┌───┬───┐

YEARS .......................│░░░│░░░│

└───┴───┘

DURING INFANCY ................... 95

DON’T KNOW ........................... 98

008 Who cut (or nicked) the genitals?3 TRADITIONAL 

TRAD. “CIRCUMCISER”....... 11

TRAD. BIRTH ATTENDANT . 12

OTHER 

TRADITIONAL 16

(SPECIFY) 

HEALTH PROFESSIONAL 

DOCTOR............................... 21

TRAINED NURSE/MIDWIFE 22

OTHER HEALTH 

PROFESSIONAL 26

(SPECIFY) 

DON’T KNOW ........................... 98

009 CHECK 214 AND 216: 

 HAS AT LEAST ONE ┌───┐ HAS NO LIVING ┌───┐

 LIVING DAUGHTER ├───┘ DAUGHTER └───┴─────────────────────────

 À

─3⁄4019
62 Appendix

010 Have any of your daughters had her genitals cut? 

IF YES: How many? 

NUMBER ┌───┬───┐

CIRCUMCISED..........│░░░│░░░│

└───┴───┘

NO DAUGHTER 

CIRCUMCISED......................... 95 ─3⁄4018 

011 To which of your daughters did this happen most 

recently? 

(DAUGHTER’S NAME) 

INTERVIEWER: CHECK 212 AND RECORD THE LINE 

NUMBER FOR THE DAUGHTER 

DAUGHTER’S LINE ┌───┬───┐

NUMBER FROM Q212│░░░│░░░│

└───┴───┘

012 Now I would like to ask you what was done to (NAME 

OF THE DAUGHTER FROM Q.011) at this time? 

Was any flesh removed from her genital area? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

─3⁄4014 

013 Was her genital area just nicked without removing any 

flesh? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

014 Was her genital area sewn closed? YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

015 How old was (NAME OF THE DAUGHTER FROM 

Q.011) when this occurred? 

IF THE RESPONDENT DOES NOT KNOW THE AGE, 

PROBE TO PROBE TO GET AN ESTIMATE. 

AGE IN COMPLETED ┌───┬───┐

YEARS .......................│░░░│░░░│

└───┴───┘

DURING INFANCY ................... 95

DON’T KNOW ........................... 98

016 Who cut (nicked) the genitals?3 TRADITIONAL 

TRAD. “CIRCUMCISER”....... 11

TRAD. BIRTH ATTENDANT . 12

OTHER 

TRADITIONAL 16

(SPECIFY) 

HEALTH PROFESSIONAL 

DOCTOR............................... 21

TRAINED NURSE/MIDWIFE 22

OTHER HEALTH 

PROFESSIONAL 26

(SPECIFY) 

DON’T KNOW ........................... 98
Appendix 63 

017 At the time of the genitals were cut or afterwards, did 

(NAME OF THE DAUGHTER FROM Q.012) have any of 

the following: 

Excessive bleeding? 

Difficulty in passing urine or urine retention? 

Swelling in the genital area? 

Infection in the genital area? / Wound that did not heal 

properly? 

 YES NO DK

EXCESSIVE 

BLEEDING ................1 2 8

DIF. IN PASSING URINE/ 

URINE RETENTION .1 2 8

SWELLING....................1 2 8

INFECTION/NOT HEAL 

PROPERLY...............1 2 8

─┐

│

├3⁄4019 

│

│

─┘

018 Do you intend to have this genital cutting done to any of 

your daughters in the future? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

019 What benefits do girls themselves get if they undergo 

this genital cutting? 

PROBE: Any other benefits? 

RECORD ALL MENTIONED. 

CLEANLINESS/HYGIENE ..........A

SOCIAL ACCEPTANCE .............B

BETTER MARRIAGE 

PROSPECTS ............................. C

PRESERVE 

VIRGINITY/PREVENT 

PREMARITAL SEX.............. D

MORE SEXUAL PLEASURE 

 FOR THE MAN E 

RELIGIOUS APPROVAL ............F

OTHER X

 (SPECIFY) 

NO BENEFITS ............................Y

020 What benefits do girls themselves get if they do not 

undergo this genital cutting? 

PROBE: Anything else? 

RECORD ALL MENTIONED. 

FEWER MEDICAL PROBLEMS .A

AVOIDING PAIN .........................B

MORE SEXUAL PLEASURE FOR H

MORE SEXUAL PLEASURE FOR T

FOLLOWS RELIGION ................E

OTHER X

 (SPECIFY) 

NO BENEFITS ............................Y

021 Would you say that this practice is a way to prevent a girl 

from having sex before marriage or does have no effect 

on premarital sex? 

PREVENT SEX ........................... 1

NO EFFECT................................ 2

DON’T KNOW ............................. 8

022 Do you believe that this practice is required by your 

religion? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

023 Do you think that this practice should be continued, or 

should it be discontinued? 

CONTINUED............................... 1

DISCONTINUED......................... 2

DEPENDS................................... 3

DON’T KNOW ............................. 8
64 Appendix

024 Do you think that men want this practice to be continued, 

or discontinued? 

CONTINUED............................... 1

DISCONTINUED......................... 2

DEPENDS................................... 3

DON’T KNOW ............................. 8

1

 This module can be inserted in different places of the questionnaire according to the other modules 

used. For this reason, the module is now numbered 000. 

2

 Wording should be adapted locally. 

3

 Coding categories to be developed locally and revised based on information collected before the survey 

and on the pretest; however, the broad categories must be maintained. We are only interested in the 

detailed coding categories for “health professional” in the countries where health professionals perform a 

large amount of circumcisions. 
Appendix 65 

FEMALE GENITAL CUTTING MODULE 1

(For Male Questionnaire) 

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 

001 Have you ever heard of female circumcision?2 YES ............................................. 1

NO ............................................... 2

─3⁄4003 

002 In a number of countries, there is a practice in which a 

girl may have part of her genitals cut. Have you ever 

heard about this practice? 

YES ............................................. 1

NO ............................................... 2 ─3⁄4END

003 What benefits do girls themselves get if they undergo 

this genital cutting? 

PROBE: Anything other benefits? 

RECORD ALL MENTIONED. 

CLEANLINESS/HYGIENE ..........A

SOCIAL ACCEPTANCE .............B

BETTER MARRIAGE 

PROSPECTS ............................. C

PRESERVE VIRGINITY/ 

 PREVENT PREMARITAL 

SEX ........................................ D

MORE SEXUAL PLEASURE FOR T

RELIGIOUS APPROVAL ............F

OTHER X

 (SPECIFY) 

NO BENEFITS ............................Y

004 What benefits do girls themselves get if they do not 

undergo this genital cutting? 

PROBE: Anything else? 

RECORD ALL MENTIONED. 

FEWER MEDICAL PROBLEMS .A

AVOIDING PAIN .........................B

MORE SEXUAL PLEASURE FOR H

MORE SEXUAL PLEASURE FOR T

FOLLOWS RELIGION ................E

OTHER X

 (SPECIFY) 

NO BENEFITS ............................Y

005 Would you say that this practice is a way to prevent a girl 

from having sex before marriage or does have no effect 

on premarital sex? 

PREVENT SEX ........................... 1

NO EFFECT................................ 2

DON’T KNOW ............................. 8

006 Do you believe that this practice is required by your 

religion? 

YES ............................................. 1

NO ............................................... 2

DON’T KNOW ............................. 8

007 Do you think that this practice should be continued, or 

should it be discontinued? 

CONTINUED............................... 1

DISCONTINUED......................... 2

DEPENDS................................... 3

DON’T KNOW ............................. 8

008 Do you think that women want this practice to be 

continued, or discontinued? 

CONTINUED............................... 1

DISCONTINUED......................... 2

DEPENDS................................... 3

DON’T KNOW ............................. 8

1

 This module can be inserted in different places of the questionnaire according to the other modules 

used. For this reason, the module is now numbered 000. 

2

 Wording should be adapted locally.

DHS Comparative Reports Series 

1. Westoff, Charles F. 2001. Unmet Need at the End of the Century. 

2. Westoff, Charles F. and Akinrinola Bankole. 2002. Reproductive Preferences in Developing 

Countries at the Turn of the Century. 

3. Rutstein, Shea O. 2002. Fertility Levels, Trends, and Differentials 1995-1999. 

4. Mahy, Mary. 2003. Childhood Mortality in the Developing World: A Review of Evidence from the 

Demographic and Health Surveys. 

5. Westoff, Charles F. 2003. Trends in Marriage and Early Childbearing in Developing Countries. 

6. Rutstein, Shea O. and Kiersten Johnson. 2004. The DHS Wealth Index. 

7. Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhuni. 2004. Female Genital Cutting 

in the Demographic and Health Surveys: A Critical and Comparative Analysis.