Am. J. Trop. Med. Hyg., 92(4), 2015, pp.

838–847
doi:10.4269/ajtmh.14-0074
Copyright © 2015 by The American Society of Tropical Medicine and Hygiene

Geographic Variation of Female Genital Mutilation and Legal Enforcement

in Sub-Saharan Africa: A Case Study of Senegal
Ngianga-Bakwin Kandala* and Paul N. Komba
Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom; Populations, Evidence
and Technologies Group, Warwick Evidence, Coventry, United Kingdom; Division of Epidemiology and Biostatistics,
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Wolfson College,
Centre of African Studies, University of Cambridge, Cambridge, United Kingdom

Abstract. This paper draws on household data to examine the prevalence of female genital mutilation (FGM) in
Senegal and the effectiveness of the country’s anti-FGM law in dealing with actual breaches and providing protection to
the victims. The 2010–2011 Senegal Demographic Health Survey and Multiple Indicators Cluster Survey (SDHS-MICS)
covers 14,228 women and their daughters. Logistic regression was used to investigate the geographic distribution of FGM
across regions. For the enforceability of anti-FGM, desk research was used. Overall prevalence among women and
daughters was 28.1% and 6.2%, respectively. Significant factors were sociodemographics, ethnicity, and region. This
analysis shows both advantages and vulnerabilities of the anti-FGM law in relation to the issue of enforcement. It
indicates that the law falls short of offering adequate protection to potential victims. FGM is a cultural and social norm
imbedded predominantly in rural settings and as such, drives resistance to jettisoning FGM. Legislation has been one of
the driving forces behind the eradication of the practice.

INTRODUCTION ages ranging from infants and toddlers to teenagers. It is fre-

quently carried out in unsterile conditions by traditional and
Female genital mutilation (FGM) has widely been described non-medically trained practitioners.1,3,6,9–20 The fact that FGM
as female genital cutting (FGC) and refers to practices involv- is conducted in such conditions is both the result of its traditional
ing the partial or complete ablation of the external female practice, especially in Sub-Saharan Africa (SSA), and its illegality.
sexual organs on non-medical grounds. The World Health In other words, public health burdens of FGM include both
Organization (WHO) distinguishes among four types of FGM consequences for mother or daughter mortality and ongoing
based on the invasiveness of the intervention, and these are morbidity concerns throughout their lifespans. As a potentially
described elsewhere.1–3 With the benefits of modern Western life-threatening procedure, FGM is now widely condemned as
medicine, women who have suffered mutilation can be treated. a violation of human rights and a criminal offense in many
Some experts suggest that specialist surgeons can reverse many national jurisdictions.2
of the FGM consequences.4,5 However, the view in this paper is Various studies give many reasons for practicing FGM
that the procedure is irreversible and that the modern medical around the world. One overriding reason in Africa and else-
procedures cannot replace the natural clitoris and remove the where is that marriage does not come easily without the
long-term psychological and physical effects caused by FGM. female having to prove her virginity.20 Other studies point to
Even if this was the case, such treatment may not be available other factors, such as an initiation of girls into womanhood;
in Senegal and other areas where FGM is prevalent. Also, even traditional views on female decency, control of female sexual-
where available, such treatment would not necessarily be ity or reduction of female sexual desires, enhancement of
attractive or requested by those who do not regard FGM to be fertility, and child survival; religious requirements, especially
a medical problem. According to recent estimates, between 100 for Muslim populations; a prerequisite for marriage in some
and 140 million girls and women today are forced to undergo communities, like the Fulani people of Senegal; and a means
FGM or circumcision.6,7 of avoiding perceived uncleanliness.20–24
Likewise, on the side of the law, it is suggested that no amount This paper examines the geographic variation of FGM and
of legislative measures would be sufficient to completely eradi- the effectiveness of an anti-FGM law in Senegal. The inten-
cate FGM. This is because FGM, once performed, is irrevers- tion is to provide information for specific and targeted inter-
ible.3 All that the law can do is perhaps dissuade or discourage vention in that country. Existing research does not sufficiently
the recurrence of the practice across present and future genera- reflect on household data to determine the degree of preva-
tions. It is in this sense that some international organizations lence of such a practice. It also suggests that the anti-FGM
consider the law to be one aspect of an effective campaign law has largely failed to secure meaningful prosecution25 and
against FGM around the world.8 Among certain ethnic groups that abandonment should be secured through harmonization
in Senegal, caregivers and families are still prepared to embrace between the law and efforts by non-government organization
the FGM procedure as part of accepted social norms, although (NGO) initiatives to engage in educational and awareness
it has tragic consequences (e.g., life-threatening hemorrhage, campaigns with local communities in Senegal. The main point
disabilities, and difficulties, such as infant death and medical of this paper is to revisit some of these claims, especially one
complications at birth). FGM is carried out on girls at different relating to the ineffectiveness of this law, and reassess the
question of both the prevalence of the FGM practice and the
contribution of any anti-FGM law in stamping out the FGM
*Address correspondence to Ngianga-Bakwin Kandala, Division of
Health Sciences, University of Warwick Medical School, Medical
practices across communities. We shall use the national rep-
School Building, Gibbet Hill Campus, Coventry CV4 7AL, United resentative household data of Senegal to examine country
Kingdom. E-mail: N-B.Kandala@warwick.ac.uk geographic variation at the regional level to highlight factors

838
 FEMALE GENITAL MUTILATION IN SENEGAL 839

associated with the practice and the role of preventive pro- been cut before their fifth birthday. The most important rea-
grams for policy recommendations. The choice for Senegal as sons given for FGM were the social standing that it confers
a case study is based on the realization that the country rep- and the need to preserve girls’ virginity followed by the belief
resents today a limited success story in matters regarding that FGM is a religious duty. Of women who have been cut,
reduction in the prevalence of FGM. The success is ascribed 53% believe that the practice should be retained; of men, 12%
to combined efforts by NGOs and government bodies to build believe that the practice should be retained.3
awareness among communities about the adverse human It is against this background that the Committee on the
rights and health consequences of FGM and commit these Elimination of All Forms of Discrimination against Women
communities to initiatives designed to abort the practice. This issued its General Recommendation on Female Circumcision
means that reduction in the FGM prevalence is not based (General Recommendation No. 14), which calls on states to
on any idea that legislation alone is successful but different take appropriate and effective measures with a view to eradi-
ways of enforcing such laws in dialogue with communities. cating the practice and requests them to provide information
It is anticipated that other countries can learn from Senegal about measures being taken to eliminate FGM in their reports
to reduce the scale of FGM practices by looking at different to the Committee.2,28 Prominent among the harms to human
enforcement mechanisms. rights associated with FGC is the fact that those undergoing
the practice in Senegal are almost entirely minors (very young
BACKGROUND INFORMATION ABOUT SENEGAL children or infants at that) and incapable of meaningfully
AND FGM IN SENEGAL consenting to the procedure.25 In this context, parliamentar-
ians from throughout Africa met in Dakar on May 3 and 4,
Before exploring how Senegal has tackled FGM, we first 2010 to push for a continent-wide ban on FGM and called on
provide some background information about Senegal and the United Nations (UN) to pass a General Assembly resolu-
then present a small situation analysis of the prevalence of tion appealing for a global FGM ban to prevent violation of
FGM in the country. In essence, the Republic of Senegal is human rights. Members of parliaments from African nations
located on the coast of western Africa with a population also exchanged lessons learned and actions taken to achieve
of about 13 million, of which 94% are Muslims, 4% are the ban and resolution. Some 17 African states have banned
Christians, and 2% belong to traditional religions. There are FGM, among them Burkina Faso, Togo, Senegal, and Uganda.
about 20 different ethnic groups distributed across 14 prov- Since November 26, 2012, a resolution against FGM in the
inces. The largest ethnic groups are the Wolof, the Fulbe and UN General Assembly’s human rights committee has been
Toucouleur, the Serer, the Fulani, the Diola, and various adopted, and it is a major boost to civil society organizations
Mandingo groups. Women are disadvantaged in both eco- fighting for an end to the practice. This UN resolution places
nomic and societal terms as a result of their status and the FGM in a human rights framework and calls for a holistic
prevailing sociocultural norms. The literacy rate (defined as approach, stressing as it does the importance of empowerment
the percentage of persons aged 15 years old and over who can of women, promotion and protection of sexual and reproduc-
read and write) is 33% for women and 52% for men. The tive health, and breaking the cycle of discrimination and vio-
percentage of women aged 20–24 years old who were married lence.24 The rationale for a legal ban is that FGM differs from
before the age of 18 years old is 39%. Senegal has a popula- other forms of abuse of rights in that perpetrators also believe
tion growth rate of about 2.5% per year and a total fertility to act in the best interest of their victims. Thus, any legal ban
rate of 4.6 children born per woman.26 With a gross national is subject to challenges and controversy in communities where
product (GNP) per capita of US$1,900 (2012 estimation), it is to be enforced.29
around two-thirds of the population live on less than US$1 a
day, and Senegal is among the 30 least economically devel- MATERIALS AND METHODS
oped countries in the world, ranking 154 of 186 in 2012 in
terms of the human development index (HDI).26 Life expec- Materials. The Demographic and Health Survey (DHS),
tancy at birth is 63 years, and the national poverty rate is funded by the US Agency for International Development
46.7%.26 Senegal is a country with a huge gender inequality (USAID), is a well-established source of reliable population-
index (youth population [millions; 15–24 years old]: 65%; level data with a substantial focus on health. The objectives,
female youth, 56.2%; male youth, 74.2% [2009]; under 5 years organization, sample design, and questionnaires used in the
old mortality rates [per 1,000 live births]: 55.16). Maternal DHS surveys are described elsewhere.30
mortality ratio is estimated at 370 deaths of women per The 2010–2011 Senegal Demographic Health Survey and
100,000 live births.26,27 Multiple Cluster Survey (SDHS-MICS) is a nationally repre-
Most women who are cut in Senegal undergo excision (type sentative cross-sectional survey (multistage stratified random
II according to the WHO classification). This involves the sampling of households) of women of reproductive age (15–
partial or total removal of the clitoris and the labia minora. 49 years old). The resulting sample was representative of the
About 12% of women stated that they had been subjected to underlying populations of the different regions of Senegal.
infibulation (type III according to the WHO classification; i.e., It was carried out between October of 2010 and April of
narrowing of the vagina with [partial] removal of the labia 2011. Nationally representative samples of 15,688 women
minora and/or majora and/or the clitoris).1,3 Almost all inter- between 15 and 49 years old in all selected households and
ventions are performed by traditional circumcisers. Only 1.3% 4,929 men between 15 and 59 years old in one-third of
of girls had been cut by medically trained staff. The age at selected households were interviewed. Response rates were
which girls are cut did not vary much between the generation over 93% for individual women and over 87% at the house-
of mothers and the generation of daughters: almost three- hold level, and informed consent was obtained from partici-
quarters of women subjected to FGM in each age group had pants. The study protocol conforms to the ethical guidelines
840 KANDALA AND KOMBA

of the 1975 Declaration of Helsinki as reflected in a priori Table 1

approval by the institution’s human research committee. Eth- Baseline characteristics of the study population (women respondents;
ical approval was granted by the Ethics Committee of the SDHS, 2010–2011)
National Statistical Office of Senegal. Variable Women (N = 14,228) Daughters (N = 14,228)

Data collected were representative at the national level, the Mean age* (SD) for respondent 27.9 (0.09) 27.8 (9.2)
urban/rural level, and the level of each administrative region Mean age* (SD) for partner 43.5 (0.17) 43.7 (14.2)
when tested using a number of sociodemographic and house- Education respondent
No education 57.9 62.2
hold indicators. There were few participants with missing data Primary education 21.8 20.0
for FGM and other covariates; thus, data analysis on FGM Secondary education 18.3 16.9
was based on 14,228 women with a complete set of data.30 Higher education 2.1 0.9
The 2010–2011 SDHS-MICS collected an optional addi- Education partner
No education 75.4 79.3
tional series of questions about FGM. The history of the devel- Primary education 11.9 10.4
opment of FGM questionnaire is discussed elsewhere.30 The Secondary education 9.2 7.8
questions are designed to generate information on prevalence Higher education 3.5 2.6
rates and types of FGM for the women themselves and their Place of residence
daughters. Respondents’ attitudes toward FGM are also col- Urban 49.3 39.5
Rural 50.7 60.5
lected. Since 2000, United Nations Children’s Fund (UNICEF) Religion
MICS has used a similar module to collect information on Muslim 95.4 95.4
FGM in selected countries. Both the DHS and the MICS pro- Christian 4.2 4.0
vide FGM prevalence data. Female respondents are asked if Animist/other 0.4 0.6
Wealth index
they have ever heard of FGM; then, those who have heard of Poorest 16.5 23.7
the practice are asked about their own experience of it. The Poorer 17.9 22.8
responses to these questions are used to calculate national Middle 19.9 22.7
prevalence rates of FGM.30–32 Richer 22.3 17.4
Experts generally assume that women respond truthfully Richest 23.5 13.4
Respondent circumcised†
when asked about their own experience. If bias exists in some Yes 28.1 28.1
of the responses, it has not been documented. It is hypotheti- No 71.9 71.9
cally possible that some women may not admit to having Daughter circumcised†
undergone FGM in countries where the practice has been Yes 9.4 9.4
No 90.6 90.6
forbidden, but no solid evidence of this has been found. Ethnicity
The module on FGM included questions on whether the Wolof 38.7 33.0
woman herself had undergone FGM and if she had daughters, Poular/Fulani 26.5 31.5
whether they had also undergone the practice (Table 1) or Serer 15.0 12.6
whether she intended that they should. Mandingue 4.2 6.6
Diola 4.0 4.8
We use the binary outcome whether a woman or dependent Soninke 2.3 2.3
daughter has undergone FGM, and for the daughters’ analy- Other 9.3 9.2
sis, the unit of analysis was circumcised daughters from any State of residence
women because of interpretability reasons, because with the Dakar 26.0 8.7
Ziguinchor 3.7 6.0
binary outcome, one can estimate the likelihood of FGM in a Diourbel 11.8 9.1
given region of Senegal, while accounting for a number of Saint-Louis 6.7 6.9
potential covariates. Tambacounda 4.6 7.2
The main exposure variable investigated was the respon- Kaolack 7.5 8.9
dent’s geographic location (i.e., the region of residence at the Thies 12.9 8.4
Louga 7.2 8.1
time of the survey) (Figure 1) in addition to various individual- Fatick 4.6 6.7
level control variables, such as sociodemographics known Kolda 4.1 6.9
to be associated with FGM. The respondent and her part- Matam 3.8 6.6
ner’s age at the time of the survey were also included as an Kaffrine 3.7 6.6
Kedougou 0.7 3.2
indicator of the birth cohort of the women. Other socio- Sedhiou 2.9 6.7
demographic covariates were religion (Catholic versus other
*Age ranges from 15 to 49 years of age.
Christian, Islam, traditionalist, and other), wealth index †Data are expressed as means (SEMs) or percentages using the population weight.
(poorest versus poorer, middle, richer, and richest), and edu-
cation of the respondent and partner (no education versus
primary, secondary, and higher education). Finally, environ- woman/daughter was not circumcised. The standard measure
mental factors included place (locality) of residence (rural of effect was the odds ratio (OR) and 95% confidence interval
versus urban) and region of residence of the women, includ- (95% CI).
ing her ethnicity. The analysis was carried out using the STATA 12 software
Methods. To account for geographic variation in the prev- package (Stata Corp, College Station, TX). The statistical
alence of FGM at the regional level in Senegal, we used a significance of associations between potential risk factors
logistic regression model to investigate the geographic distribu- and the prevalence of FGM was explored with c2 and
tion of FGM across the 14 regions while accounting for indi- Mann–Whitney U tests as appropriate. Adjusted marginal
vidual-level risk factors. The response variable was defined as ORs of FGM risk across regions were obtained from stan-
yi = 1 if the woman/daughter was circumcised and yi = 0 if the dard logistic regression models, with Diourbel used as the
 FEMALE GENITAL MUTILATION IN SENEGAL 841

Figure 1. Political map of Senegal.

reference category because of its lowest crude FGM preva- On average, circumcised women were older than their
lence (Table 2). non-circumcised counterparts and their partners, more
likely to have a lower education and have non-educated
RESULTS partners, more likely to be living in rural areas, and more
likely to be Muslim. In addition, circumcised women were
Baseline characteristics of the study population are more likely to be in the poorest quintile of the wealth
displayed in Table 1 (weighted data) for the overall sample index, from the Mandingue ethnic group, and living in
and their daughters (N = 14,228) and in Table 2 (unweighted Kedougou (Table 2). For the daughters, on average, circum-
data) with participants split within the two categories of cised daughters were from older women and partners than
circumcised women versus not circumcised, with circumcised their non-circumcised counterparts, more likely to come
status of daughters listed in Table 3 (N = 14,228). The bivari- from non-educated parents, more likely to be living in rural
ate results show that, overall, 5,689 (i.e., 39.98%) of women areas, and more likely to be Muslim. In addition, circum-
had undergone FGM; 1,340 (9.4%) women reported that they cised daughters were more likely to be in the poorest quin-
had daughters who had undergone FGM, and 3,330 (23.4%) tile of the wealth index, from the Mandingue ethnic group,
women reported that they intended the practice of FGM con- and living in Kedougou (Table 2).
tinue. Overall, mean age of participants was 27.9 (0.09) years, Table 3 displays both ORs of FGM among women and
and for their partners, the mean age was 43.5 (0.17) years. daughters across the selected study characteristics. Results of
The percentage of participants with no education was high both multivariate logistic regression analyses of women and
(57.9%), and it was 75.4% among their partners; 49.3% of daughters do not support the role of modernization (women’s
participants were living in an urban area, 95.4% were Muslim, wealth and education) and religion as factors associated with
16.5% were in the poorest quintile of the wealth index, and FGM. However, our results support the idea that FGM is a
38.7% were from the Wolof ethnic group. Prevalence values cultural norm, and living in a rural setting is a risk factor
of FGM among respondent women and daughters were for the likelihood of being circumcised for both women and
28.1% and 6.2%, respectively, with variation across provinces their daughters.
and ethnic groups ranging from 0.7% in Diourbel to 92.0% in Specifically, women from the Mandingue ethnic group (OR =
Kedougou and from 2% among the Wolof to 89.6% among 96.06; 95% CI = 69.0, 133.7) and the Soninke ethnic group
the Mandingue ethnic group for respondent women. For (OR = 72.0; 95% CI = 49.3, 105.1) followed by the Diola
daughters, the prevalence of FGM varies from 0.3% in Thies (OR = 40.4 ; 95% CI = 29.1, 56.0) and Poular/Fulani ethnic
to 26.9% in Sedhiou and from 0.2% among the Serer/Wolof groups (OR = 37.6; 95% CI = 30.2, 46.8) from rural settings
to 22.1% among the Mandingue ethnic group. (OR = 1.18; 95% CI = 1.01, 1.38) were consistently associated
842 KANDALA AND KOMBA

Table 2 Table 3
Baseline characteristics of the study population by women’s FGM Baseline characteristics of the study population by daughters’ FGM
status (SDHS 2010) status (SDHS 2010)
Circumcised Not circumcised Circumcised Not circumcised
Variable (N = 5,689) (N = 8,539) P value* Variable (N = 1,340) (N = 12,888) P value*

Mean age* (SD) for respondent 28.2 (9.3) 27.9 (9.2) 0.08 Mean age* (SD) for daughters 31.4 (7.6) 27.7 (9.3) < 0.001
Mean age* (SD) for partner 42.7 (15.1) 43.9 (14.3) 0.46 Mean age* (SD) for partner 45.2 (13.7) 43.6 (14.2) < 0.001
Education respondent < 0.001 Education daughters < 0.001
No education 3,727 (42.4) 5,067 (57.6) No education 1,123 (12.8) 7,671 (87.2)
Primary education 1,108 (38.9) 1,741 (61.1) Primary education 181 (6.3) 2,668 (93.7)
Secondary education 833 (34.0) 1,614 (66.0) Secondary education 36 (1.5) 2,411 (98.5)
Higher education 21 (15.2) 117 (84.8) Higher education 0 (0.0) 138 (100.0)
Education partner 0.005 Education partner < 0.001
No education 3,315 (43.1) 4,380 (56.9) No education 1,056 (13.7) 6,639 (86.3)
Primary education 486 (46.7) 554 (53.3) Primary education 121 (11.6) 919 (88.4)
Secondary education 337 (42.7) 452 (57.3) Secondary education 66 (8.4) 723 (91.6)
Higher education 93 (34.8) 174 (65.2) Higher education 13 (4.9) 254 (95.1)
Place of residence < 0.001 Place of residence < 0.001
Urban 2,081 (35.6) 3,773 (64.5) Urban 303 (5.2) 5,551 (94.8)
Rural 3,608 (43.1) 4,766 (56.9) Rural 1,037 (12.4) 7,337 (87.6)
Religion < 0.001 Religion < 0.001
Muslim 5,578 (40.9) 8,064 (59.1) Muslim 1,320 (9.7) 12,322 (90.3)
Christian 84 (16.5) 426 (83.5) Christian 12 (2.4) 498 (97.6)
Animist/other 27 (35.5) 49 (64.5) Animist/other 8 (10.5) 68 (89.5)
Wealth Index < 0.001 Wealth index < 0.001
Poorest 1,850 (55.9) 1,459 (44.1) Poorest 548 (16.6) 2,761 (83.4)
Poorer 1409 (45.5) 1,691 (54.5) Poorer 368 (11.9) 2,732 (88.1)
Middle 1,356 (41.7) 1,895 (58.3) Middle 297 (9.1) 2,954 (90.9)
Richer 746 (29.0) 1,829 (71.0) Richer 101 (3.9) 2,474 (96.1)
Richest 328 (16.5) 1,665 (83.5) Richest 26 (1.3) 1,967 (98.7)
Ethnicity < 0.001 Ethnicity < 0.001
Wolof 89 (2.0) 4,464 (98.0) Wolof 15 (0.3) 4,538 (99.7)
Poular/Fulani 3,243 (69.4) 1,432 (30.6) Poular/Fulani 852 (18.2) 3,823 (81.8)
Serer 67 (4.0) 1,586 (96.0) Serer 4 (0.2) 1,649 (99.8)
Mandingue 909 (89.6) 105 (10.4) Mandingue 224 (22.1) 790 (77.9)
Diola 392 (59.5) 267 (40.5) Diola 61 (9.3) 598 (90.7)
Soninke 270 (76.3) 84 (23.7) Soninke 42 (11.9) 312 (88.1)
Other 719 (54.5) 601 (45.5) Other 142 (10.8) 1,178 (89.2)
State of residence < 0.001 State of residence < 0.001
Dakar 266 (20.4) 1,036 (79.6) Dakar 28 (2.2) 1,274 (97.8)
Ziguinchor 529 (61.8) 327 (38.2) Ziguinchor 91 (10.6) 765 (89.4)
Diourbel 9 (0.7) 1,284 (99.3) Diourbel 2 (0.2) 1,291 (99.8)
Saint-Louis 438 (45.0) 535 (55.0) Saint-Louis 114 (11.7) 859 (88.3)
Tambacounda 953 (87.0) 142 (13.0) Tambacounda 261 (23.8) 834 (76.2)
Kaolack 86 (8.0) 994 (92.0) Kaolack 4 (0.4) 1,076 (99.6)
Thies 47 (3.8) 1174 (96.2) Thies 4 (0.3) 1,217 (99.7)
Louga 59 (5.5) 1,008 (94.5) Louga 25 (2.3) 1,042 (97.7)
Fatick 84 (10.1) 748 (89.9) Fatick 5 (0.6) 827 (99.4)
Kolda 898 (85.9) 147 (14.1) Kolda 251 (24.0) 794 (76.0)
Matam 869 (86.9) 131 (13.1) Matam 225 (22.5) 775 (77.5)
Kaffrine 113 (11.7) 857 (88.3) Kaffrine 11 (1.1) 959 (98.9)
Kedougou 447 (92.0) 39 (8.0) Kedougou 48 (9.9) 438 (90.1)
Sedhiou 891 (88.4) 117 (11.6) Sedhiou 271 (26.9) 737 (73.1)
Data are expressed as means (SDs) or percentages. Data are expressed as means (SDs) or percentages.
*P values for comparison between circumcised and not circumcised subjects. *P values for comparison between circumcised and not circumcised subjects.

with higher odds of being circumcised. Also, daughters from the older women (age group = 36–49 years; OR = 2.61; 95% CI =
Poular/Fulani ethnic group (OR = 6.79; 95% CI = 4.93, 9.35) 2.16, 3.16 and age group = 26–35 years; OR = 3.07; 95% CI =
from the rural settings (OR = 1.24; 95% CI = 1.04, 1.48) were 2.60, 3.61) were more likely to be circumcised compared with
consistently associated with higher odds of being circumcised daughters from younger women (age group less than 25 years
than their counterparts of the Madingue and Soninke ethnic old) (Table 4).
groups. The associations of women and partner education, With regard to FGM status, in the regression analyses,
wealth index, and religion with FGM risk were not statistically there was a striking variation in FGM risk across regions for
significant. Moreover, there were linear associations between both women and their daughters, with the highest risk being
women’s age and FGM status: the risk of undergoing FGM in Kedougou region (OR = 162.0; 95% CI = 98.0, 269.7)
increased with age. In other words, older women from the age followed by Tambacounda (OR = 84.0; 95% CI = 56.9,
group 36–49 years (OR = 1.37; 95% CI = 1.16, 1.62) and age 124.2), Sedhiou (OR = 64.3; 95% CI = 42.9, 96.5), and Kolda
group 26–35 years (OR = 1.18; 95% CI = 1.02, 1.37) were more (OR = 62.5; 95% CI = 42.0, 91.4) and the lowest risk being
likely to be circumcised compared with their counterparts in the in Louga (OR = 0.78; 95% CI = 0.52, 1.18) and Diourbel
younger age group less than 25 years old. Also, daughters from for women respondents. For daughters, the highest risk was
 FEMALE GENITAL MUTILATION IN SENEGAL 843

Table 4 the observed and model findings shown in Tables 2–4 for both
Marginal ORs of women and daughters across selected covariates women and daughters.
(SDHS, 2010) Even after multiple adjustments of the urban environment
Women marginal OR Daughter marginal OR and other risk factors, findings for both women and daugh-
Variable (95% CI)* (95% CI)†
ters confirm the fact FGM is lower in the largest urban
Age groups of respondent
(years)
province Dakar.
£ 25 1.00 1.00
26–35 1.18 (1.02–1.37) 3.07 (2.60–3.61)
36–49 1.37 (1.16–1.62) 2.61 (2.16–3.16)
Age groups of partner DISCUSSION
(years)
£ 30 1.00 1.00 This combined epidemiological and legal study offers a
31–40 0.75 (0.60–0.94) 0.94 (0.75–1.17) unique opportunity to examine the geographic variation
41+ 0.68 (0.55–0.83) 0.56 (0.45–0.70) of the FGM prevalence and the effectiveness of the law in
Education respondent Senegal. We used the most recent data from the 2010–2011
No education 1.00 1.00
Primary education 0.64 (0.55–0.75) 0.52 (0.43–0.63)
SDHS-MICS, a large nationwide sample of women and their
Secondary education 0.52 (0.44–0.63) 0.18 (0.13–0.26) children across the 14 regions of Senegal. Then, we consid-
Higher education 0.32 (0.17–0.60) 1.00 ered the effectiveness of the legal responses to the issue of
Place of residence FGM prevalence in that country.
Urban 1.00 1.00 The overall prevalence of FGM in Senegal was 28.1% using
Rural 1.18 (1.01–1.38) 1.24 (1.04–1.48)
Religion the most recent survey, the 2010–2011 SDHS-MICS. However,
Muslim 0.01 (0.00–0.01) 0.02 (0.01–0.03) according to the DHS conducted in 2005, 28% of women aged
Christian 0.001 (0.000–0.001) 0.007 (0.003–0.014) between 15 and 49 years old in Senegal have been subjected to
Animist/other 1.00 1.00 FGM. Comparing the previous survey with the recent survey, it
Wealth index
Poorest 0.76 (0.58–1.01) 0.76 (0.54–1.08)
indicates a zero change in prevalence in the 5 years separating
Poorer 0.84 (0.65–1.09) 0.71 (0.50–0.99) the surveys. However, there were large geographic variations
Middle 0.95 (0.75–1.19) 0.73 (0.53–1.01) within the country by region. For instance, Kolda region
Richer 1.04 (0.84–1.29) 0.54 (0.38–0.76) changed from a prevalence of 94% in 2005 to a prevalence of
Richest 1.00 1.00 86%, an 8% decrease during the 5-year period. There were
Ethnicity
Wolof 1.00 1.00 also other regions with similar decreases in percentages, such
Poular/Fulani 37.55 (30.2–46.8) 6.79 (4.93–9.35) as Tambacounda. However, the prevalence of FGM was still
Serer 2.28 (1.62–3.22) 0.25 (0.09–0.70) high, even after Senegal signed on to the Maputo Protocol
Mandingue 96.06 (69.0–133.7) 6.35 (4.37–9.23) in 2006. According to the 2010 DHS data, in urban areas, the
Diola 40.37 (29.1–56.0) 4.04 (2.49–6.54)
Soninke 71.96 (49.3–105.1) 6.22 (3.87–9.99)
prevalence was 35.6%, and rural residents reported a preva-
Other 22.75 (17.55–29.5) 4.23 (2.92–6.13) lence of 43.1%.
State of residence In this study, we investigated social, demographic, and eco-
Dakar 4.85 (3.41–6.89) 0.51 (0.31–0.85) nomic factors associated with FGM in Senegal. In summary,
Ziguinchor 23.54 (15.9–34.8) 2.69 (1.70–4.26) living in a particular region in the south of the country
Diourbel 1.00 1.00
Saint-Louis 12.32 (8.66–17.5) 1.76 (1.18–2.63) (Kedougou, Sedhou, and Kolda), living in a rural area, coming
Tambacounda 84.03 (56.9–124.2) 2.84 (1.93–4.18) from a particular ethnicity (Madingue, Soninge, and Poular), or
Kaolack 1.62 (1.09–2.40) 0.08 (0.03–0.22) being a Muslim were all associated with a higher likelihood of
Thies 1.27 (0.82–1.97) 0.11 (0.04–0.31) undergoing FGM for women and their daughters. Age of the
Louga 0.78 (0.52–1.18) 0.27 (0.16–0.45)
Fatick 3.47 (2.29–5.25) 0.21 (0.08–0.54)
respondent, education, and household socioeconomic status
Kolda 62.51 (42.7–91.4) 2.90 (1.97–4.26) were no longer associated with the likelihood of FGM after
Matam 61.40 (42.0–89.8) 2.66 (1.82–3.90) multiple adjustments of other factors.
Kaffrine 4.16 (2.80–6.18) 0.20 (0.10–0.41) Returning to the relationship between women’s own experi-
Kedougou 162.6 (98.0–269.7) 0.87 (0.54–1.42) ence of FGM and that of their daughters, we found that the
Sedhiou 64.34 (42.9–96.5) 3.56 (2.38–5.33)
difference between the percentage of younger and older
*Adjusted OR from standard logistic regression models for the sample of women respondents.
†Adjusted OR from standard logistic regression models for the sample of daughters. women whose daughters had undergone FGM was much
greater than the difference between the percentages of respon-
dents who had undergone FGM themselves. This could repre-
in Sedhiou region (OR = 3.5; 95% CI = 2.38, 5.33), Kolda sent an important change in cultural norms with decreased use
(OR = 2.90; 95% CI = 1.97, 4.26), and Tambacounda (OR = of FGM, whereby younger women are less willing to have their
2.84; 95% CI = 1.93, 4.18) and the lowest risk was in Kaolack daughters undergo FGM. This offers possible hope that the
region (OR = 0.08; 95% CI = 0.03, 0.22) and Thies (OR = practice may be reducing over time. However, this finding
0.11; 95% CI = 0.04, 0.31). could also represent a cohort effect—younger women have
The above results for covariate-adjusted province variation younger children who are not yet at risk. We found a large
of FGM status show a clear pattern of regions with higher risk difference in Senegal in the risk of FGM between regions and
of FGM (mostly the southeastern regions of Kolda, Sedhiou, ethnicity, with some regions and ethnic groups having a higher
and Tambacounda, including the eastern region of Kedougou, risk of FGM. It is worth investigating these findings further,
which was associated with a higher prevalence of FGM, because spatial variation and ethnicity may be indicative of an
whereas provinces in the west and north were associated with association of place of residence with FGM practice as a proxy
a lower FGM prevalence). These geographic patterns confirm for social norms.
844 KANDALA AND KOMBA

LEGAL ENFORCEMENT AND but subsequently pardoned in the same year. Records of arrest
EXTRATERRITORIALITY ISSUES and prosecution, however, remain patchy, and there has been
no way to obtain overall nationwide figures of convictions for
One response to the prevalence of FGM has been to enact offenses under the law. It is, however, the case that prosecution
anti-FGM legislation. In this respect, numerous provisions fails, because like any crime, FGM is performed in secret and
exist to combat the practice of FGM. These provisions consist apparently not talked about in public. There are metaphors
of international human rights standards, which Senegal has used among females who have had FGM performed.
incorporated into its domestic system as well as the Senegalese Moreover, FGM is accepted as common as male excision,
1999 anti-FGM law. The commitment to international human which leaves disability in many cases. Also, prosecuting author-
right standards was shown through the ratification of impor- ities are the products of their communities and cultures and
tant treaties, such as the Convention on the Elimination of may not feel it a matter of public interest to expend resources
All Forms of Discrimination against Women (CEDAW), the to prosecute a practice that had stood the test of time and
UN Convention on the Rights of the Child (CRC), the African been handed down from generation to generation. Successful
Charter on the Rights and Welfare of the Child, and the attempts to enforce the law depend on gathering evidence to
Maputo Protocol (to the African Charter on Human and Peo- make a positive prosecution case against the perpetrator of
ples’ Rights) on the Rights of Women in Africa. FGM. However, obtaining such evidence can prove exceed-
At the domestic level, the Senegalese Government adopted ingly difficult. Additionally, as stated before, there is some
Article 299 of the Penal Code, which imposes a maximum reluctance for prosecuting officials to take on the case where
penalty of 5 years imprisonment for performing FGM. Subse- the public interest test is not satisfied in enforcing the law. Such
quently, the Ministry of Family Affairs produced and adopted evidence might come from several potential sources. One is
Action Plan 2000–2005, according to which FGM is to be erad- from health professionals who may have come into contact
icated in Senegal by 2015. The main objectives were to improve with these children, and the law enforcement officials look to
networking and coordination among actors involved in efforts them to blow the whistle on those suspected of having commit-
to combat the practice, explaining the legal framework to them ted FGM. Another source is the victims themselves, who may
and integrating the issue into formal and non-formal education. have suffered as a result of the practice. The difficulty with the
An evaluation of the Action Plan conducted in 2008 notes that, first source of evidence is that health professionals might be
of 5,000 or so villages previously practicing FGM, a total of breaking their duty of confidentiality to patients. The duty to
3,300 had forsworn the practice by 2008 in public declarations. disclose information would, in that situation, conflict with the
There are, however, still areas in which the practice is still duty of confidentiality. It might be suggested that FGM is a
strongly defended. It is also important to ensure the sustain- criminal practice after the 1999 law, and therefore, confidenti-
ability of what has been achieved. The Second National Action ality should be waived to give way to the legal duty to disclose.
Plan 2010–2015, which was adopted in February of 2010, is to Likewise, some may consider the failure to disclose as
step-up action against FGM. The objective remains the com- amounting to conspiracy to a crime. However, that argument
plete eradication of the practice by 2015.26,34 is tenuous, because it would be nonsensical to call someone an
Returning now to 1999 Senegalese Law no. 99–5, it should be accomplice when the crime was committed without their
stressed that FGM was legally called a violation of human knowledge or participation. Moreover, before any charge can
rights, and such a law superseded social norms and the relevant be brought against those who fail to report, evidence of their
provisions of the criminal code. It made carrying out FGM on a knowledge of FGM commission may prove difficult to estab-
child or woman against the law and carried a maximum penalty lish. It is also questionable how the police can possibly collect
of 5 years and/or a fine. A spokesperson for the human rights such evidence when health professionals refuse to record
group The African Assembly for the Defense of Human Rights FGM information or do not feel that they ought to ask the
(RADDHO) pointed out that, although adopting the law was FGM question for fear of discriminating or being prejudiced
an important step forward, only its enforcement would ensure against other people’s culture.35
that women derive the most benefit from it. One way in which Apart from the paucity of prosecution cases, the 1999 law
enforcement is achieved is through prosecution and deterrence. has only a limited extraterritorial effect, consistent with the
However, despite this law and indeed, human right stan- French tradition on which Senegal law is based. Such law does
dards, FGM cases have rarely been brought before a court of not clearly state what happens to cases where believers in FGM
law. Only a few notable exceptions exist. For example, since cross Senegalese borders to have their daughters mutilated. In
the law went into effect, only a limited number of arrests were other words, the current uncertainty in Senegalese law can be
made. In January 1999 the law has seen only two arrests but illustrated as follows. A woman living in the southern regions
no convictions. In July of 1999, the public prosecutor in of Senegal (e.g., Ziguinchor, Kolda, and Tambacounda) can
Tambacounda ordered the arrest of the grandmother and easily cross the border into Guinea and have her daughter or
mother of a 5-year-old girl after a complaint filed by the girl’s herself mutilated and return safely back to Senegal. There is
father alleged that the two women had ordered FGM per- nothing that anyone who attempts to prosecute the perpetrator
formed on his daughter. The practitioner was also charged. in Guinea or the person who sought his/her assistance can do
After emotional public outcry in the region, however, the cases when FGM is not illegal in Guinea.
were not pursued, and no convictions resulted. The press has The 2007 legislative reforms incorporate traditional inter-
suggested that the passage of the law has driven the practice national crimes (e.g., genocide and crime against humanity)
underground.27 In July of 1999, Mrs. X was reportedly con- into the Senegalese Criminal Code (UN, 2011, Convention
victed for allowing the excision of her young daughter. In Contre la torture et autres peines ou traitements cruels,
November of 2001, three people aged 55 to 75 years old were inhumains ou degradants). The extraterritorial jurisdiction
arrested in the Velingana province for breaking the 1999 law has so far been tested over the Hissene Habre saga.36
 FEMALE GENITAL MUTILATION IN SENEGAL 845

In principle, the notion that the state should apply justice law is regarded as critical to effect change of social attitudes
only to offenses committed within its territorial borders can toward FGM as a social norm.
be qualified by principles, such as passive personality, where What Senegal has achieved so far suggests that FGM can be
the Senegalese court would look at the nationality of the significantly reduced in the regions identified in this paper.
FGM victim as the basis for taking jurisdiction.37 The reflec- However, the law can only contribute to efforts to stamp
tion of the passive personality principle would be a reformed out the practice if there are sufficient resources to accelerate
Senegalese law stating that those taking children abroad to be the campaigns and secure a social contract between cam-
mutilated will face prosecution on return to Senegal.1 paigners and targeted populations (for similar arguments, see
Although the principle of passive personality applies in rela- Mackie39). The achievements of Senegal can be accounted for
tion to FGM, that alone would not necessarily lead to a mean- by the responses brought by various national and interna-
ingful prosecution. This is because the issue will arise as to how tional NGOs,41,42 such as TOSTAN (meaning “breakthrough”,
to bring the perpetrator leaving abroad into Senegalese juris- as in the hatching of an egg, in the west African language of
diction. Some jurisdictions have controversially resorted to kid- Wolof), and civil society’s positive responses to the anti-FGM
napping as one possible approach to such a move (see the case standards. These NGOs’ campaigns bring the knowledge of the
of Machain versus USA, 1992 S. Ct 2188). Other jurisdictions law to the people and commit local communities to abandon-
are unlikely to use this method (see the case of R v Horsferry ment plans. Those who subscribed to the plan and then are
Magistrates, 1994 1 AC 42). found to practice FGM can be fined by village chiefs who act
One viable approach is to have recourse to extradition laws as legal enforcers at the grassroots level. TOSTAN, for exam-
as stated in Senegalese law nos. 71–77 of December 28, 1971. ple, ensures that education programs are disseminated to
However, Article 5 of this law suggests that extradition will be encourage voluntary renunciation, although education spreads
allowed only where the person is of Senegalese nationality fear of what might happen on the legal and healthcare fronts if
and the offense has been committed on Senegalese soil (see FGM is practiced. The core of these education programs is to
Belgium v Senegal, General List No. 144, Judgment).38 stimulate social change through non-formal education. The
Another way could be to ensure that an anti-FGM treaty is various modules of its Community Empowerment Program
signed between Senegal and its immediate neighbors, such as tackle FGM as both a health issue and a human rights issue.
the Gambia, Guinea, and Mauritania, or harmonize anti-FGM Mostly, the education provided within the framework of
legislation at regional or African levels. the program leads to a public declaration condemning FGM.
Another limitation of the current law in Senegal is that it Such a declaration is deemed to be an expression of intended
seeks to provide legal redress for those females who have social change. Since 1999, GTZ (German Agency for Techni-
already suffered FGM and does not offer sufficient protection cal Cooperation; GTZ as of January 1, 2011)40 has been
to females yet to be mutilated. As stated above on the point of implementing the project Ending Female Genital Mutilation
extraterritoriality of the 1999 anti-FGM law, there is little the on behalf of the German Federal Ministry for Economic
law would do to save Senegalese women and girls from under- Cooperation and Development (BMZ). In Senegal, the GTZ’s
going FGM in neighboring Mauritania, Guinea, or the Gambia. FGM project supported various activities, including TOSTAN’s
As with the laws in many countries in the region, the projects to overcome FGM in the Kolda region in the south of
Senegalese anti-FGM law is more effective in terms of facil- the country over a period of several years. After 2002, efforts
itating prosecutions of those who violate the law rather than focused on advising the GTZ FANKANTA (A German–
protecting women and girls who have yet to undergo FGM Senegalese project to fight against FGM) project, which was
from the practice. There are some efforts from the govern- attached to the Senegalese Ministry of Health. This project
ment on how to prevent FGM and provide protection for supported family planning and HIV education in various
those who have not yet been cut. For policy strategies to regions of the country. In Kolda region, the issue of FGM
prevent FGM, it is, instead, multilateral agencies, such as was incorporated into the project work because of the high
UNICEF, in conjunction with the WHO, German Federal prevalence level there until FANKANTA was replaced by an
Ministry for Economic Cooperation and Development, and integrated Casamance-wide program in 2005.
NGOs, such as the United States-based Population Refer- The FGM activities that were part of the FANKANTA
ence Bureau (PRB), that have played a crucial role in advo- program aimed above all to raise the level of acceptance of
cating the end of FGM in the region. This is also true for the legal ban on FGM with the help of education and sensiti-
countries such as Senegal, where NGOs,41 such as TOSTAN, zation. In view of the difficult political situation in the
are using community-led approaches that have been proven Casamance, it aimed to ensure that the local population did
to be effective in eradicating the practice.2 not see the ban as a central government meddling in their
Despite the shortcomings of the legislation identified above affairs but something that is well-founded and rational.
(i.e., paucity of prosecution of cases and lack of sufficient Thanks to this approach, FANKATA found many supporters
protection to potential victims), it must be noted that the and advocates among not only local NGOs and action groups
1999 law and human right norms present many advantages. but also, religious and social leaders who were influential
The first is that no national group or NGO would have been within their communities. In cooperation with the project,
engaged in the eradication campaign unless it believed that they developed various educational materials in local lan-
their actions were legally justified under the Senegal law. guages which were used widely within the scope of numerous
Also, the law stands as a formal framework, which confers special events. They also made education activities possible
on public officials the power to ensure legal protection of after the project per se had been completed (GTZ 2011 Project:
women. Although the law is not always enforced, its existence Ending Female Genital Mutilation).
may send deterrent signals to the perpetrators who might fear This involvement of multifarious stakeholders suggests that
criminal prosecution. In this respect, the adoption of the 1999 the solution to banning FGM cannot simply be strict legal
846 KANDALA AND KOMBA

enforcement. The Senegal model can be regarded as the best 2. World Health Organization, 2008. Eliminating Female Genital
exemplar for the rest of the world for dealing with FGM. Mutilation: An Interagency Statement. Available at: http://www
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