Female Genital Mutilation in Iraqi

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Female Genital Mutilation in Iraqi

Kurdistan: Description and Associated
Factors
a b
Rozhgar A. Saleem MBChB MSc , Nasih Othman MBChB PhD ,
c d
Fattah H. Fattah MBChB MSc , Luma Hazim BSc MSc & Berivan
e
Adnan MBChB MSc
a
Maternity Unit, Preventive Health Department , Sulaimaniyah ,
Iraq
b
Department of Community Health , Sulaimani Polytechnic
University , Sulaimaniyah , Iraq
c
Department of Health , Sulaimaniyah , Iraq
d
Preventive Health Department , Dohuk , Iraq
e
Preventive Health Department , Erbil , Iraq
Accepted author version posted online: 26 Jun 2013.Published
online: 12 Aug 2013.
To cite this article: Rozhgar A. Saleem MBChB MSc , Nasih Othman MBChB PhD , Fattah H. Fattah
MBChB MSc , Luma Hazim BSc MSc & Berivan Adnan MBChB MSc (2013) Female Genital Mutilation
in Iraqi Kurdistan: Description and Associated Factors, Women & Health, 53:6, 537-551, DOI:
10.1080/03630242.2013.815681
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DOI: 10.1080/03630242.2013.815681
Female Genital Mutilation in Iraqi Kurdistan:

Description and Associated Factors
ROZHGAR A. SALEEM, MBChB, MSc

Maternity Unit, Preventive Health Department, Sulaimaniyah, Iraq
NASIH OTHMAN, MBChB, PhD

Department of Community Health, Sulaimani Polytechnic University,

Sulaimaniyah, Iraq
FATTAH H. FATTAH, MBChB, MSc

Department of Health, Sulaimaniyah, Iraq
LUMA HAZIM, BSc, MSc

Preventive Health Department, Dohuk, Iraq
BERIVAN ADNAN, MBChB, MSc

Preventive Health Department, Erbil, Iraq
The high prevalence of female genital mutilation has been a

concern in Iraqi Kurdistan. This study was undertaken to estimate
its prevalence and describe factors associated with its occurrence.
A cross-sectional survey was undertaken from March to April
2011 of females aged up to 20 years using interviews and clinical
examination. The survey included 1,508 participants with mean
age of 13.5 years (SD 5.6). Overall female genital mutilation preva-
lence was 23%, and the mean age at which it had been performed
was 4.6 years (SD 2.4). Type I (partial or total removal of the
clitoris) comprised 76% of those who had had female genital muti-
lation; in 79% of cases the decision to perform it was made by the
mother; and in 54% of cases it was performed by traditional birth
Received November 10, 2012; revised June 7, 2013; accepted June 10, 2013.
The authors would like to thank the Ministry of Health in Iraqi Kurdistan for sponsoring
the research and all doctors and health staff who participated in data collection. The authors
also acknowledge the generous help and advice of Dr. Bakhtiyar Rasheed during the study.
Address correspondence to Nasih Othman, MBChB, PhD, Sulaimani Polytechnic
University, Department of Community Health, Qirga, Sulaimaniyah, Iraq. E-mail:
nasihothman@yahoo.com
537
538 R. A. Saleem et al.
attendants/midwives. Women aged 16 years and over were more

likely to have had female genital mutilation compared to children
aged below 6 years (OR 11.9, p < .001). Children of uneducated
mothers were eight times as likely to have had genital mutilation
compared to children of mothers with over nine years of education
(OR 8.0, p < .001). Among women aged 17 years and younger,
34% of those who were married had been circumcised versus 17%
of those who were not married (p < .001). Participants residing
in the northeast of Kurdistan region were more likely to have been
circumcised. The study results show that female genital mutilation
is a frequent practice in Iraqi Kurdistan. Attention and interven-
tion is needed to address this aspect of the well-being of girls and
women.
KEYWORDS female genital mutilation, Iraq, Kurdistan, survey,

risk factors
INTRODUCTION
Female genital mutilation (FGM) or female genital cutting is internation-

ally considered as violence against girls and women and a violation of
their human rights (Barstow, 1999). Therefore, call for action against and
support for the abandonment of FGM can be found in numerous interna-
tional and regional human rights treaties and documents (Dalal, Lawoko,
& Jansson, 2010). According to the World Health Organization (WHO) def-
inition, FGM covers all procedures that involve partial or total removal of
the external female genitalia, or other injury to the female genital organs
for non-medical reasons (WHO, 2010). Depending on the type and extent
of the procedure, the WHO classifies FGM into four types involving par-
tial or total removal of the clitoris (clitoridectomy or type I); partial or total
removal of the clitoris and the labia minora, with or without excision of
the labia majora (excision or type II); narrowing of the vaginal opening
(infibulation or type III); and other harmful procedures on female genitalia
for non-medical reasons such as pricking, piercing, incising, scraping, and
cauterization (type IV).
FGM is still practiced in many African countries including Egypt (El-
Zantay & Way, 2009), Sudan (Elmusharaf et al., 2006), Somalia (Mitike
& Deressa, 2009), Ghana (Oduro et al., 2006) and Nigeria (Onuh et al.,
2006). The WHO estimates that worldwide, 100–140 million women have
undergone FGM, and 3 million girls are annually at risk. The prevalence
of FGM in 30 African countries has been reported to range from 1% in
Uganda to as high as 98% in Somalia (WHO, 2008). In Egypt, according
to the health and demographic survey of 2008, 91% of Egyptian women
Female Genital Mutilation in Iraqi Kurdistan 539
aged less than 50 years had been circumcised (El-Zantay & Way, 2009).
Health consequences of FGM include bleeding, sepsis, shock, urogenital
complications, obstetrical problems, and psychological disorders (Utz-Billing
& Kentenich, 2008). A study on Kurdish girls reported increased levels of
posttraumatic stress disorder, anxiety, and depression disorders among girls
who have been circumcised (Kizilhan, 2011).
Iraqi Kurdistan, which occupies the northeastern part of Iraq, is inhab-
ited by over 4 million people of mainly Kurdish ethnicity. Islam is the main
religion, and in addition to Kurds, ethnic and religious minorities inhabit
the region, including Arabs, Turkmen, Christians, and Yazidis. This region
became a de facto self-ruled region within Iraq after parliamentary elec-
tions in 1992. Interest and concern has been increasing about the status
of Kurdish girls in terms of FGM for more than a decade, especially by

women’s organizations, local non-governmental organizations (NGOs), and
international human rights organizations. The local media and NGOs have
being raising awareness and reporting on the issue, and the local authori-
ties, especially the Ministry of Health, have been trying to respond to the
concerns by undertaking certain public activities to raise awareness of the
population on FGM and discourage its practice. While some studies and
reports have appeared on FGM, the real size of the problem still must be
estimated. The 2010 UN report on human rights in Iraq addressed FGM, and
while it noted that FGM did not occur frequently in most parts of Iraq, it
stressed that FGM remains a serious problem in the Kurdistan region and
urged the authorities to implement concrete steps to combat it as a matter
of urgency (UNAMI & OHCHR, 2011). According to a survey quoted by the
UN report and undertaken by an NGO (WADI) in 2010, the prevalence of
FGM was 78% in Kurdistan. WADI also reported that the prevalence of FGM
amongst women over 12 years of age was 50% in Kirkuk province (WADI,
2012). Another unpublished survey also supported by the Ministry of Health
in 2010 reported a prevalence of 41% in all ages. The Human Rights Watch
has published a report on FGM in Kurdistan and urged the authorities to
take all necessary steps to ensure compliance with international obligations
set out in the international human rights treaties and conventions (Human
Rights Watch, 2010). In 2011, a new law was passed in Iraqi Kurdistan for
fighting family violence in which FGM was considered illegal. A hotline is
now in operation to respond to calls from and provide support to FGM cases
in Kurdistan.
The current study, which was sponsored by the Ministry of Health of
Kurdistan Regional Government as part of its commitment to address the
issue, is the largest and most representative study undertaken to date cov-
ering the entire region of Kurdistan. It aimed to provide a more reliable
estimate of the prevalence of FGM and factors associated with this practice
to provide useful information for planning strategies for action to discourage
the practice of FGM in Kurdistan.
METHODS
Participants
This cross-sectional survey was undertaken in the three provinces of Iraqi
Kurdistan with a total population of over 4 million. Participants were
restricted to females aged from 6 months to 20 years of age. A total sample
of 1,500 was to be selected from the three provinces of Erbil, Sulaimaniyah,
and Duhok, with each province providing 500 participants. Within each
province, the allocated sample was selected to be proportional to the size of
the population served by each health district (a geographical division of the
health facilities used by the departments of health) of each province. Overall,
59 primary health care centers (PHCs) were included, covering all districts
of the three provinces. The required number of participants was recruited

randomly from females who visited the health center for health consultation
or who were accompanying a sick person. All eligible persons (females aged
6 months to 20 years) who visited the health center during the data collec-
tion period were approached and asked if they were willing to be included
in the study; if verbal consent was obtained, they were recruited and inter-
viewed. A separate verbal consent was required for examination after the
interview, and participants’ autonomy (right to refuse and to withdraw from
the study at any time) and confidentiality were respected. Participants were
recruited until the required sample for that health district was reached. The
study protocol was sponsored and approved by the Ministry of Health and
was undertaken in its facilities. Because the Ministry of Health does not have
an ethics committee, this approval was not a true ethical approval, but it
ensured that participants’ interests and safety were safeguarded.
Data Collection
The interview team included trained female doctors (gynecologist or a gen-
eral practitioner) and female health staff. The questionnaire used for data
collection was developed specifically for this study using the local language
and administered by the interview team to the participants or the next of kin
(usually the mother) in the instances of children less than 15 years of age.
When a respondent reported circumcision, she was examined by the doctor
to confirm presence of circumcision and identify its type if she agreed to
be examined. Other questions regarding the circumcision were asked at this
stage. All interviewers were trained for one day on FGM types and diagno-
sis, administration of the survey questionnaire, and interviewing skills. Data
were collected during March to April 2011.
Data Analysis
All questionnaires were checked for completeness before being sent at
the end of the data collection to the maternity unit at the Department of
Health for data entry. Data analyses were performed using Stata version
9 (College Station, TX: Statacorp). Descriptive analyses were performed,
and numeric data were summarized as means or medians depending
on normality. Associations between categorical variables were tested by
chi-squared tests, and p-values equal to or smaller than .05 were con-
sidered statistically significant. Factors independently associated with FGM
were investigated by identifying the potential risk factors at the univari-
ate level using chi-squared tests. Multivariable analysis was then under-
taken by multiple logistic regression using Collett’s procedure (Collett,
2003) with a model initially including all variables which were associ-
ated with FGM in the univariate analyses at a level of significance equal
to or less than p = .20. Variables were removed one at a time, and
the models with and without the variable were compared using like-
lihood ratio test. Variables not significantly improving the model were
removed from the model. Interactions were examined using likelihood ratio
tests.
RESULTS
Sample Characteristics
The study collected information on 1,508 female participants with 100%
response rate in answering the questionnaire. The total number of partici-
pants who reported FGM was 348, of whom 109 participants refused clinical
examination (so that type of circumcision could not be determined), giv-
ing a response rate of 69% for the examination. The age of all participants
ranged from 6 months to 20 years with a mean age of 13.5 years (SD 5.6)
(Table 1). Participants were equally divided among the three provinces of
Erbil, Sulaimaniyah, and Duhok (33% each). In terms of birthplace, 39% of
participants were born in cities, 32% in districts, and 29% in sub-districts
and villages. Overall, 84% of participants were living in urban areas and
16% in rural areas. Most were Muslim, and 49% were married. In terms of
parental education, 29% of fathers and 46% of mothers did not have any
formal education.
Prevalence
The overall prevalence of FGM among participants was 23%: 37% in Erbil
province, 29% in Sulaimaniyah province, and 4% in Duhok province. The
prevalence was over 50% in more remote districts of Sulaimaniyah and Erbil,
including Rania (70%), Choman (61%), Soran (54%), and Pshdar (50%), which
are all adjacent areas in the northeast of Kurdistan bordering Iran. The
prevalence was lowest and below 1% in Duhok city and some surround-
ing districts, including Sumail, Zakho, and Amedi, which are further to the
north of Kurdistan bordering Turkey. The prevalence was highest among
TABLE 1 Background Characteristics of Participants
Characteristics Number Percent
Total 1,508 100

Mean age in years (SD) 13.5 (5.6)
Female genital mutilation
Yes 348 23.1
No 1,160 76.9
Province of residence
Erbil 502 33.3
Sulaimaniyah 503 33.4
Duhok 503 33.4
Urban/Rural
Urban 1,225 83.6
Rural 240 16.4

Marital status if aged 16 years and
over
Not married 355 50.4
Married 345 49.0
Separated/Divorced 4 0.6
Religion
Muslim 1,475 98.0
Other 30 2.0
Education if aged 6 years and over
None 146 11.4
Basic (1–9 years) 905 70.4
High school/Higher 234 18.2
Mother’s education
None 691 46.3
Basic (1–9 years) 671 44.9
Father’s education
None 436 29.2
Basic (1–9 years) 777 52.0
women aged over 16 years (32%) and lowest among children aged below
6 years (5%).
Types and Characteristics of the FGM

The age at which of FGM was performed was normally distributed and
ranged from 0 to 12 years with a mean age of 4.6 years (SD 2.4) (Table 2).
Over 53% of the girls were circumcised when they were less than five years
of age. Of those who were examined, 76% had type I circumcision, according
to the WHO classification. No statistically significant difference was observed
between the profession of the person performing FGM and the type of FGM.
In 79% of cases, the decision to undertake FGM for the child was made by
the mother, and in 54% of cases the procedure was performed by a traditional
birth attendant/midwife. Children had their FGM performed in cities, smaller
TABLE 2 Characteristics of Participants with FGM
Characteristics Number Percent
Total 348 100

Age at FGM (years)
0–2 68 20.9
3–4 106 32.6
5–6 83 25.5
7 and older 68 20.9
Mean age of FGM in years (SD) 4.6 (2.4)
FGM type (in 239 cases examined)∗
Type I 182 76.2
Type II 32 13.4
Type III 0 0.0
Type IV 25 10.5
Person deciding on FGM
Mother 255 79.2
Grandmother 36 11.2
Father 11 3.4
Other 20 4.0
Person performing FGM
Traditional birth attendant, midwife 181 53.7
Other health staff 52 15.4
Other (relatives) 104 30.9
Place where FGM performed
City 89 25.9
District 88 25.6
Sub-District 113 32.9
Village 54 15.7
Reason for performing FGM
Religion 156 50.3
Social 126 40.7
Purity 28 9.0
Main complications of FGM
Pain 230 71.4
Bleeding 14 4.4
Psychological 19 5.9
Infection 4 1.2
None/Unknown 55 17.1
∗
109 cases refused examination.
towns, and villages alike. In half of the cases, religion was given as the jus-
tification for performing FGM, and the major complication of the procedure
was reported as pain by 71% of the respondents.
Characteristics Associated with FGM

The mean age at interview was significantly different between those with
FGM and those without FGM (16 years vs. 12.7 years, p < .001) (Table 3).
Over 53% of FGM cases were from Erbil, 41% were from Sulaimaniyah,
and only 5% were from Duhok, a statistically significant difference from
TABLE 3 Comparison of Characteristics of Persons with and without FGM
With FGM Without FGM
Characteristics Number Percent Number Percent p-Value
Total 348 100 1, 159 100

Mean age in years (SD) 16.0 (4.1) 12.7 (5.8) p < .001∗
Age (years)
0–5 10 2.9 204 17.6 χ 2 = 84.7
6–10 29 8.3 189 16.3 p < .001
11–15 74 1.3 263 22.7
16–20 235 67.5 503 43.4
Province of residence
Erbil 186 53.4 316 31.0 χ 2 = 171.7
Sulaimaniyah 144 41.4 359 27.2 p < .001
Duhok 18 5.2 485 41.8

Urban/Rural
Urban 288 87.5 937 82.5 χ 2 = 4.8
Rural 41 12.5 199 17.5 p = .03
Marital status if aged 16 and over
Not married 99 42.3 256 54.5 χ 2 = 9.6
Married 134 57.3 211 44.9 p = .01
Separated/Divorced 1 0.4 3 0.6
Religion
Muslim 348 100 1, 127 97.4 χ 2 = 9.2∗∗
Other 0 0 30 2.6 p = .001
Education if aged 6 years and over
None 40 11.8 106 11.2 χ 2 = 3.3
Basic (1–9 years) 226 66.9 679 71.7 p = .2
High school/Higher 72 21.3 162 17.1
Mother’s education
None 233 67.5 458 39.9 χ 2 = 86.0
Basic (1–9 years) 103 29.9 568 49.5 p < .001
Father’s education
None 138 39.8 298 26.0 χ 2 = 30.0
Basic (1–9 years) 168 48.4 609 53.1 p < .001
∗
t-test for difference in age (2-tailed).
∗∗
Fisher’s exact test.
those without FGM (χ 2 = 171.7, p < .001). All FGM cases were Muslim,
and none were from other religions including Christians and Yazidis (χ 2 =
9.2, p = .001). FGM was also significantly associated with early marriage.
While 57% of those with FGM were married, only 45% of those without FGM
were married (χ 2 = 9.6, p = .01). The education of the person herself was
not significantly associated with FGM, but poor parental education was a
significant risk factor. While 68% of the mothers of those with FGM had no
formal education, only 40% of the mothers of those without FGM had no
education (χ 2 = 86.0, p < .001). Similarly, while 40% of the fathers of those
with FGM had no formal education, only 26% of the fathers of those without
FGM had no education (χ 2 = 30.0, p < .001).
The factors which were significant at p ≤ .20 were considered for

inclusion in the multiple logistic model. These were age, marital sta-
tus, urban/rural residence, province of residence, father’s education, and
mother’s education. In the multiple logistic model, only age, mother’s edu-
cation, and province of residence remained statistically significant. No signif-
icant interactions or multicollinearity were observed among these variables.
The Hosmer-Lemeshow test for goodness of fit for the multivariable model
was not significant (χ 2 = 3.5, 8 df, p = .9). The highest VIF for the variables
in the model was 3.7 (mother’s education) and the mean VIF was 2.3. The
logistic model explained 27% of the variability in FGM.
In multiple logistic models, compared to children aged 0–5 years, older
children were more likely to have had FGM; females aged over 15 years of
age had the highest odds of having had FGM (OR 11.9, 95% CI 6.0–23.6)
(Table 4). Residing in Erbil province was most strongly associated with FGM
with an odds ratio of 28.8 (95% CI 17.0–48.8). Poor maternal education was
also a strong risk factor. Children of mothers with no education had an eight-
fold (95% CI 3.8–16.5) odds of FGM compared to children of mothers with
high school or higher levels of education.
Attitudes Toward FGM

The majority (61%) of girls and women over 12 years of age who had under-
gone FGM were against the practice, 28% supported the practice, and 11%
were not decided. Those who had a positive attitude toward FGM were
significantly more likely to have poor education (Table 5). While 51% of the
TABLE 4 Adjusted ORs (and 95% CI) for Factors Significantly Associated with
FGM in Iraqi Kurdistan
Wald test
Risk factor OR (95% CI) z p-Value
Age (years)
0–5 Reference group
6–10 3.2 (1.5−6.9) 3.0 .003
11–15 7.9 (3.8−16.1) 5.7 <.001
16–20 11.9 (6.0−23.6) 7.1 <.001
Residence
Duhok Reference group
Erbil 28.8 (17.0−48.8) 12.5 <.001
Sulaimaniyah 14.0 (8.3−23.5) 9.9 <.001
Maternal education
High school/Higher Reference group
Basic education 3.2 (1.5−6.6) 2.1 .002
None 8.0 (3.8−16.5) 5.6 <.001
Log likelihood = −592.2, LR test χ 2 = 429.2, 7 df, p < .001.
TABLE 5 Association Between Level of Education and Attitude About FGM
Opinion on FGM Would do for own child
Favored Against Undecided Yes No

number number number number number
Education (%) (%) (%) (%) (%)
None 21 (51.2) 20 (48.8) 0 (0) 17 (43.6) 22 (56.4)

Basic 55 (26.8) 125 (61.0) 25 (12.2) 65 (33.2) 131 (66.8)
High school/Higher 13 (18.1) 50 (69.4) 9 (12.5) 11 (16.2) 57 (83.8)
Total 89 195 34 93 210
χ 2 , p-Value χ 2 = 17.4, .002 χ 2 = 10.3, .006
participants with no education favored FGM, only 27% of those with basic
education and 18% of those with high school/higher education favored it (χ 2
= 17.4, p = .002). When asked whether they would have FGM performed
for their female children, 69% of participants responded negatively, and 31%
responded that they would prefer their daughter to have FGM. This willing-
ness to have their own daughters have FGM was also significantly associated
with poor education. While 44% of the participants with no education were
willing to do so, only 33% of those with basic education and 16% of those
with high school/higher education were willing to have FGM performed on
their female children (χ 2 = 10.3, p = .006).
DISCUSSION
Key Findings
This study showed that overall the prevalence of FGM in Iraqi Kurdistan was
23% with a wide variation between different localities, rising up to 70% in
some areas. The mean age at circumcision was 4.6 years, the majority of
circumcisions were type I, the practice was mainly justified by participants
for religious reasons, and the decision to have the procedure was made by
the mother in most cases. FGM practice was significantly associated with
age, province of residence, poor maternal education, and being of Muslim
religion.
Interpretation and Comparison with Other Studies

The study results justify the concerns of civil society organizations, NGOs,
and international organizations about the problem of FGM in Iraqi Kurdistan.
Yet, the overall prevalence of 23% was lower than that reported by previous
studies which were specific to certain localities. Higher prevalence was
reported by previous studies, such as 78% (UNAMI & OHCHR, 2011) in
Sulaimaniyah province and 50% in Kirkuk province (WADI, 2012). These

studies probably did not cover all districts, and their results represented
only certain areas in Kurdistan. Consistent with these studies, even in the
current study, a prevalence of over 50% was observed in areas including
Rania (70%) in Sulaimaniyah province and Choman (61%) and Soran (54%)
in Erbil province. An unpublished survey in 2010, which included all ages,
found a prevalence of 41% which also indicated a high prevalence of FGM
in Kurdistan. The prevalence in Kurdistan was higher than in Ghana (14%)
amongst a similar age group (Oduro et al., 2006), but it was lower than in
countries traditionally known for FGM, such 91% in Egypt (El-Zantay & Way,
2009) and up to 98% among Somali women (WHO, 2008). The researchers
are not aware of any FGM studies among Kurds of other countries such as
Turkey, Iran, and Syria.

FGM was justified on religious, social, and purity grounds by respon-
dents, which is consistent with studies conducted elsewhere (Anuforo,
Oyedele, & Pacquiao, 2004; Eke & Nkanginieme, 1999). However, these
justifications do not explain the variation in prevalence of FGM through-
out Kurdistan. The factors which were significantly associated with a higher
prevalence in multivariate analysis were older age, province of residence
(Erbil and Sulaimaniyah), less maternal education, and Muslim religion. FGM
was less likely among daughters of mothers with more years of education, a
fact that underscores the power of education on changing attitudes of people
toward FGM. In 90% of FGM cases, the mother or the grandmother made the
decision to do FGM for the child. This also indicates that fathers were less
likely to be involved in such important decisions affecting their daughters.
FGM was restricted to Muslims in the current study, and religion was given as
a justification by half of the respondents. However, this is probably an under-
standing of religion that occurs more often among less-educated parents and
is not shared by more-educated people of the same religion. The reasons
for wide variation of prevalence in Kurdistan could not be explained by the
findings of this study. Generally, the prevalence was lowest in the northern
part of Iraqi Kurdistan bordering Turkey and highest in Rania and surround-
ing districts bordering Iran. These findings may be related to local cultural
tradition and may suggest that FGM might also be frequent among Kurds of
Iran living adjacent to these areas of Iraqi Kurdistan.
Age was significantly associated with FGM independent of other risk
factors. The older the respondents, the more likely they were to have had
FGM; women aged 16 years and over were 12 times more likely to have
had FGM than girls aged below 6 years (OR 11.9). Because the overall mean
age of FGM was 4.6 years, this finding suggests that prevalence of FGM
has being decreasing during the past 15 years. The association between
FGM and early marriage was only found in bivariate analyses and may have
indicated common background characteristics of the families of girls who
were subjected to FGM and those who subsequently married at an earlier
age. Cultural and tribal traditions that favor FGM could also favor early
marriage of girls and other acts of discrimination against women. However,
early marriage was not significant in multivariate analyses and thus may be
explained by the changing prevalence or differences in prevalence by region.
The majority of FGM cases aged over 12 years (61%) were against
the practice of FGM, but 28% approved it, and 11% were undecided. This
indicates how deep-rooted these FGM-favoring attitudes are amongst a sub-
stantial proportion of the population. This FGM-favoring attitude was also
associated with poor education. While 51% of FGM cases with no education
approved FGM, only 18% of those with over 9 years of education did so.
While the difference was strongly significant, it still indicated that one out
of five FGM cases was happy with the practice. As an indication that this
practice will continue to affect future generations unless substantial work is

done to prevent it, 31% of FGM cases expressed their determination to do
the same for their daughters in the future. This determination to have FGM
performed on their daughters was 44% among uneducated FGM cases and
only 16% amongst those with over nine years of education. The influence of
education on changing attitudes toward FGM was again obvious. The effect
of education on attitudes toward discontinuing FGM has also been reported
by studies elsewhere (Dalal et al., 2010; Anuforo et al., 2004; Arbesman,
Kahler, & Buck, 1993).
In the current study, 54% of FGM cases were performed by traditional
birth attendants and midwives. These people included trained midwives
as well as women who had learned from tradition to assist in deliver-
ies, which in turn included traditional birth attendants (TBAs) known to
and licensed by health authorities as well as unlicensed TBAs. Another
31% of FGM cases were performed by relatives and 15% by other health
staff excluding midwives. Traditional midwives have also been reported
as the main actors by other studies (Abu Daia, 2000; Barstow, 1999).
Therefore, trained midwives, traditional midwives, and other female health
staff must be at the center of any strategy for prevention of FGM. FGM
is not legal in Iraqi Kurdistan; therefore, it may not be performed in
health facilities. Anecdotal evidence indicates that FGM is usually per-
formed at home for around $5 per case. Some women also perform
FGM as a favor for their neighbors and relatives because of their con-
viction that FGM is essential for girls, but this requires further research
documentation.
Complications reported by respondents included pain, bleeding, psy-
chological trauma, and infection. These and other complications have been
reported by other studies, such as urinary and gynaecological and obstetric
symptoms (Arbesman et al., 1993; Banks et al., 2006; Eke & Nkanginieme,
1999). A systematic review concluded that evidence about urinary, obstetric
and gynaecological consequences of FGM were mixed and inconclusive
(Obermeyer, 2005).
Strengths and Limitations

The current study used a large sample, covering all districts of the Kurdistan
region, which makes the results more accurate and representative. The pres-
ence of FGM and its type was confirmed by trained doctors for the majority
of respondents who reported FGM, making the results more reliable than
merely depending on self-report. However, because only participants who
reported FGM were examined, the possibility of recall bias or reporting bias
still remained. In addition, 31% of those who reported FGM refused examina-
tion, and thus the condition could not be confirmed, and the type could not
be decided. Self-reporting in these cases could be a source of reporting bias.
Misclassification could have resulted from failure to examine persons who
reported no FGM and those who reported FGM but refused examination. It is
possible that some women had forgotten or were not willing to provide the
true information about their FGM status, a situation leading to underestima-
tion of the prevalence. It is equally possible that some women misreported
their status and subsequently refused examination which could have led to
overestimation of the prevalence. Use of WHO criteria has probably mini-
mized errors in accurate classification of FGM types, but as type IV usually
does not leave observable signs, its estimation depended on self-reporting
which could be subject to reporting bias leading to misclassification.
Another limitation was the setting of the study. As the study was con-
ducted through PHCs, the representativeness could not be as good as a
community-based study. However, selecting a large number of PHCs spread
out in all districts somewhat minimized the effect of this source of selec-
tion bias. A further limitation was that the questions used in the survey
were developed for this study and did not use standard instruments so that
misclassification of information may have occurred, and the results cannot
be directly compared to other studies that used standard instruments. Finally,
the study was limited to females up to 20 years of age; therefore, the findings
should be interpreted within this age limitation.
CONCLUSIONS
FGM was a prevalent practice in Iraqi Kurdistan and was associated with
higher age, Muslim religion, poor maternal education, and area of resi-
dence in Erbil and Sulaimaniyah provinces. The practice was deep-rooted
as reflected in attitudes of a substantial proportion of respondents favor-
ing it. Therefore, strong, long-term, and committed multidisciplinary action
involving relevant government authorities, NGOs, and influential groups is
required to address it. Such actions should target parents, traditional birth
attendants, midwives, and the female health staff, particularly in areas of
higher prevalence. The Ministry of Health and its partners are committed
to address this problem, and certain actions have already been initiated.
Awareness campaigns, legal actions, targeted community interventions, advo-
cacy, and educational programs must be considered. Enforcement of the
recently adopted family violence law, which also prohibits FGM, is essen-
tial. Several NGOs are currently active in Kurdistan in the field of protecting
women and promoting their rights. The relevant local authorities, especially
health, education, legal, and police authorities, must take FGM more seri-
ously and coordinate their response to this problem using interventions
mentioned earlier. Recommendations set out in the Human Rights Watch
report (Human Rights Watch, 2010) provide a good basis for action to reduce
prevalence of FGM in Iraqi Kurdistan. Further qualitative research is required
to explore and understand the sociocultural dynamics of families and com-
munities that practice FGM and investigate the reason for so much difference
in the prevalence of FGM in Iraqi Kurdistan.
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Female Genital Mutilation in Iraqi

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This article was downloaded by: [University of Illinois Chicago]

On: 17 October 2014, At: 17:54

Women & Health

Female Genital Mutilation in Iraqi

To link to this article: http://dx.doi.org/10.1080/03630242.2013.815681

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Female Genital Mutilation in Iraqi Kurdistan:

ROZHGAR A. SALEEM, MBChB, MSc

NASIH OTHMAN, MBChB, PhD

Department of Community Health, Sulaimani Polytechnic University,

FATTAH H. FATTAH, MBChB, MSc

LUMA HAZIM, BSc, MSc

BERIVAN ADNAN, MBChB, MSc

The high prevalence of female genital mutilation has been a

attendants/midwives. Women aged 16 years and over were more

KEYWORDS female genital mutilation, Iraq, Kurdistan, survey,

Female genital mutilation (FGM) or female genital cutting is internation-

of Kurdish girls in terms of FGM for more than a decade, especially by

of the three provinces. The required number of participants was recruited

TABLE 1 Background Characteristics of Participants

Characteristics Number Percent

Total 1,508 100

Rural 240 16.4

Types and Characteristics of the FGM

TABLE 2 Characteristics of Participants with FGM

Characteristics Number Percent

Total 348 100

Characteristics Associated with FGM

TABLE 3 Comparison of Characteristics of Persons with and without FGM

With FGM Without FGM

Characteristics Number Percent Number Percent p-Value

Total 348 100 1, 159 100

Duhok 18 5.2 485 41.8

The factors which were significant at p ≤ .20 were considered for

Attitudes Toward FGM

Risk factor OR (95% CI) z p-Value

TABLE 5 Association Between Level of Education and Attitude About FGM

Opinion on FGM Would do for own child

Favored Against Undecided Yes No

None 21 (51.2) 20 (48.8) 0 (0) 17 (43.6) 22 (56.4)

Interpretation and Comparison with Other Studies

Sulaimaniyah province and 50% in Kirkuk province (WADI, 2012). These

Turkey, Iran, and Syria.

practice will continue to affect future generations unless substantial work is

Strengths and Limitations

Abu Daia, J. M. 2000. Female circumcision. Saudi Med J 21(10):921–3.

Kizilhan, J. I. 2011. Impact of psychological disorders after female genital mutilation

among nurses. J Natl Med Assoc 98(3):409–14.

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