INTRODUCTION

The practice of female genital mutilation/cutting (FGM/C) is considered a form of abuse that undermines girls’ and women’s dignity and violates their human rights.¹ Sexual and reproductive health (SRH) affects, and is affected by the intersectionality of people’s personal experiences and relationships and by the broader structural context of their lives, which shapes their overall health and well-being. This context includes gender inequality as a determinant on its own and in combination with other social and economic inequalities including the following: unequal power dynamics in interpersonal relationships, harmful gender and other socio-cultural norms and practices, limited economic circumstances, lack of access to education, limited employment opportunities, poor living conditions, disability, ethnicity, as well as the challenging political and legal environments where they live.

It has been demonstrated that harmful gender norms that promote male dominance over women prevent women from practicing safer sex, limit their use of contraceptives, and increase their risk of STIs, including HIV and gender-based violence.² Similarly, research has also shown a relationship between violation and neglect of human rights and negative health outcomes.

FGM/C IN THE SOCIAL CONTEXT

FGM/C includes all procedures involving partial or total removal of the female external genitalia or other injuries for non-medical reasons.³ The World Health Organization (WHO) has developed a clear typology of FGM/C to include the following: clitoridectomy (type I); excision (type II); infibulation (type III); and all other harmful procedures to the female genitalia for non-medical purposes (type IV). The practice has undergone considerable changes (shifts) in form and context shaped by both social and gender norms. Factors that enhance perpetuation of the practice include the following: that there are societies where its socially acceptable; it is thought to affirm fidelity; marriageability; manifestation of cleanliness and health; it is thought to prevent rape; provides income for circumcisers; and perceived esthetic appeal. Interventions are increasingly taking on a more holistic approach, including the healthcare and justice systems. Within the social sphere, interventions have evolved rapidly to include the following: policy directives; large-scale campaigns; education programs; skills building; and economic empowerment programming; community mobilization; participatory group education; awareness and capacity building; training; and service delivery in human rights. Such interventions aim to transform the social milieu using a trident approach, viz., to change the underlying attitudes and norms that support violence against women and girls related to FGM/C; empowering women and girls economically and socially; as well as promoting nonviolent, gender-equitable behaviors.^4,5,6

SOCIAL NORMS AND GENDER NORMS IN RELATION TO FGM/C

Social norms are integral to FGM/C, child marriage, and intimate partner violence. Harnessing insights from social norms' theory to catalyze change around gender inequity and harmful gender-related practices requires an in-depth understanding of indigenous knowledge systems; monitoring of the epidemiology associated with harmful practices; knowledge on gender theory and re-framing with alternative strategies and programmatic approaches that negotiate for new norms that dismantle harmful gender-related practices. Agency, power, norms, and values can be aligned or even exert opposite influences on people’s actions. It behooves therefore value clarification and attitude transformation stream in tandem with theories for change to culminate in transformative behaviors that are sustainable. Communication strategy is crucial to avert the “boomerang effect” with campaigns that emphasize the widespread prevalence of a harmful practice. The importance of “cultural-embeddedness” and engaging community members as leaders of the change process. In FGM/C, the social norms tend to be fraught with an idiosyncratic admixture of uncertainty, identity, reward, and enforcement.

Gender norms are both a source and a reinforcer of inequality between men and women.

There are differences between social and gender norms. Social norms are cross-disciplinary and include, amongst others, the following: sociology, anthropology, human science, philosophy, legal, and communication. They have an individual of collective social construct; can be sociable or moralistic; interdependent or independent; discordant norms and attitude or concordant norms and attitude; harmful or protective practices⁷ driving attitudes and behaviors. Norms can provide value – neutral information such as following the crowd, benchmarking with points of reference, efficient course of action, and having a common communication language. Norms can create external influencers such as role models, social pressure that can be enforced positively or negatively or can be anticipatory of rewards or punishment. Norms can be influenced internally based on innate values and preferences. Norms can evolve through a life cycle recognized as emergent if it is created, innovated, or ideated. Norms can be processed to become recognized and accepted with sub-stages of norm acquisition, assimilation, acceptance, learning, and socially learnt with adoption. Norms emerge in a group by spreading, transmission, and diffusion. Norms' establishment in society or in individuals is through stabilization and crystallization, institutionalization and internalization. Norms exist but are relevant in certain circumstances known by norm activation or their detection. Long-term persistence of a norm occurs through cultural continuity and stability. When norms change from their original form, they have undergone creative mutation. Norms either gain or decline in significance as they are either cascaded or diminished, respectively. When norms disappear, they are obsoleted. In addressing the FGM/C life cycle of norms and the various sub-stages, the norm target, drivers, beneficiaries, and victims need to be identified.⁸ It is therefore vital to comprehend the social context when planning, designing, and implementing programs and interventions.

Gender norms provide other influencing factors such as the following: the role of power in structuring social relations; the role of childhood socialization practices in social learning; and the recognition that norms can be embedded in institutions and gender as "performance".⁹ Descriptive norms tend to be risk averse; Injunctive norms are oppositive in nature and tend towards formation of strategic alliances; and there are also Innate personal norms that are intrinsic to an individual. Effective change requires changing descriptive, injunctive, and personal norms. While strategies exist for changing the first two, less is available in the norms' literature about how to change behaviors motivated by rituals that are sacred and traditional. Rituals can be reconstructed with the help of traditional and/or religious authorities, preserving the sacred dimensions of the shared values.¹⁰ Change in society necessitates testing interventions that integrate norms within a wider framework. Therefore, successful social change interventions should intuitively integrate the symbiosis amongst norms, agency, and values, and possibly address them in the wider ecological context.

THE BIO-ECOLOGICAL MODEL

The bio-ecological model was developed by Bronfenbrenner and is illustrated in Figure 1. It highlights the patterns of development across time within the context of the interactions between the development of the child and the influencing environment.

The various components of Bronfenbrenner’s bio-ecological model include the following:

• Microsystem: Microsystems impact a child directly. These are the people with whom the child interacts such as parents, peers, and teachers. The relationship between individuals and those around them needs to be considered.
• Mesosystem: Mesosystems are interactions between the microsystems surrounding the individual. The relationship between parents and schools, for example, will indirectly affect the child.
• Exosystem: Larger institutions such as the mass media or the healthcare system are referred to as the exosystem. These have an impact on families and peers and schools who operate under policies and regulations found in these institutions.
• Macrosystem: We find cultural values and beliefs at the level of macrosystems. These larger ideals and expectations inform institutions that will ultimately impact the individual.
• Chronosystem: All of this happens in a historical context referred to as the chronosystem. Cultural values change over time, as do policies, legislature, and regulation of institutions or governments in certain political climates. Development occurs at a point in time.

Various studies have shown norm changes are not linear and influenced by the ecological environment; shaming; group dynamics, incentives¹² and the context. Other studies found correlations between cultural tightness, social order, and openness.^13,14 Examples include the grandmother project-change through culture;¹⁵ the medicalization of FGM/C thought to emanate in some communities from conformity to culture/tradition, religion, marriageability, fear of negative sanctions, as a rite of passage and with less complications and legal ramifications.¹⁶ These factors all imply that interventional designs need to be responsive to these challenges and their related implications. Often deviant norms break the tightest compliance offering for change. Some examples include the following: engagement and mobilization of communities for ownership and as leaders of the processes integrating science and traditional positive practices such as alternative rites of passage; witnessing of events such as campaigns, including the impact of the African Union Continental Initiative (Saleema) in Sudan¹⁷ and the power of disapproval of the FGM/C acts like the Prohibition of Female Genital Mutilation Act in Kenya.¹⁸

CHANGING SOCIAL NORMS VISIBLY

Steps for social norm change

The four core steps that result in social norm change includes the creation of a core group of participants in the intervention to renegotiate norms among themselves and develop skills to motivate others outside of the group. The second step is sustained values' deliberations, where participants discuss within the group the common values that underlie their support for a practice (e.g., love for our daughters underlies female genital cutting). Differentiating between values and practices ensures that participants do not resist the discussions around changing the practice, reassured that they are deliberating around the best ways to embody their common values. The third step is the organized diffusion of knowledge: first from participants to other community members and next to other surrounding communities. The fourth and final step is the coordinated shift to new practices, sealed by public events where community members commit to the new practice.^19,20,21 Unfortunately, often the emerging community of social norm change practitioners is fragmented, lacking theoretical clarity and validated measures, and has poorly documented the scale-up processes of social norm interventions. Advocacy needs to be sustained and replicable with documentation of processes and reporting of outcomes harvested.²²

Changing gender norms

Gender norms succeed where culture is treated as being and building on what exists. Gendered norms are embedded in social structures, operating to restrict the rights, opportunities, and capabilities, of women and girls, causing significant burdens, discrimination, subordination, and exploitation. FGM/C is an indicator of gender inequality and inequity. It is further linked to child marriage, forced sexual debut, and health complications across the life course. There is need to strengthen internal assets such as increasing knowledge, self-efficacy, and providing basic resources. Encouraging reflection critically on inequitable gender norms and roles. Harnessing socialization processes to form and transform gender norms and roles. Engaging men in sexual and reproductive health and rights outcomes, strengthening social networks and mobilizing economic and social support at key turning points. Empowering girls/women is key to them advocating for themselves and strengthening their ability to seek help and resist paths imposed upon them. Addressing structural issues such as girls’ education and access to resources and decision-making; and mobilizing communities to create enabling environments.²³ This can have a positive impact on gender relations, sexual and reproductive health choices, and health-related behavior, thus accelerating progress in elimination and abandonment of the FGM/C practice.^24,25,26

PRACTICE RECOMMENDATIONS