This chapter reflects on the journey of one CSO, Somaliland Family Health Association (SOFHA), since 2016, as it engaged in a form of participatory community-based research (PCBR) to acquire an evidence-based understanding of FGM/C to inform and enhance its programmes. The subsequent learning has transformed SOFHA’s approach to working with communities and contributed to a range of initiatives promoting the abandonment of FGM/C.

Governments and international NGOs have tended to adopt a zero-tolerance stance on FGM/C, calling for the immediate elimination of all forms of female genital cutting. An anti-FGM/C policy was signed in Somaliland in September 2024, based on zero tolerance. This is a step towards FGM/C becoming illegal; however, many obstacles remain. The definition of what constitutes FGM/C in Somaliland is contested, with many defining it as only the pharaonic cut. Zero tolerance towards FGM/C is often seen as externally driven and counter-productive.

Many approaches have been used in Somaliland to end FGM/C, including: educating people about the potential health risks; providing alternative incomes for cutters; girl empowerment initiatives; school clubs; engaging community and religious leaders in dialogue; anti-medicalisation campaigns; engaging youth, especially via social media; community forums; and the engagement of men and boys. The choice is considerable, yet evidence of the effectiveness of these approaches, either individually or combined, in the Somaliland context, is limited.

SOFHA, a member association of the International Planned Parenthood Federation (IPPF), is a CSO established by Edna Adan, founder of the Edna Adan University Hospital, Hargeisa. Initially its remit was to establish a network of evidence-based community-based maternal health centres. With virtually all women and girls in Somaliland being cut, responding to FGM/C is a key aspect of maternal health.

PCBR involves an iterative process of capacity strengthening of civil society in research skills, resulting in a greater depth of inquiry. The concept of communities of identity, with members sharing a sense of identification and emotional connection, is central. In this case, researchers increasingly identified with community members, other CSOs, health professionals, teachers, and government ministries as they explored the sensitive issue of FGM/C. Additional principles of PCBR are variously described as facilitating collaborative partnerships, promoting co-learning through cyclical engagement, disseminating findings and knowledge to all partners, and integrating knowledge and action (Israel et al. 1998; Johnson et al. 2009).

The potential benefits of PCBR include enhanced relevance and acceptance of the research by all partners, improved quality and validity through drawing on local knowledge, strengthened collaborative networks, and enhanced skills in research and reflexivity. However, PCBR can be time-intensive. Challenges include establishing a shared agenda, fostering trust, managing power and control, identifying appropriate community representatives, differences in skills and experience, task allocation and reporting (Council for International Organizations of Medical Sciences 2016; Israel et al. 1998; Johnson et al. 2009; WHO 2021).

SOFHA was a research participant in the ActionAid baseline assessment. It wanted to adopt an evidence-based approach to its work as it embarked on a multi-year project funded by the Norwegian Agency for Development Cooperation (Norad) through the IPPF.

SOFHA supports the abandonment of all types of FGM/C and acknowledges the need for change to be locally led, combining collective decision-making while leaving space for individual responsibility. It recognises many communities need to take a stepwise approach to change, and that celebrating the abandonment of the most harmful cuts is important in maintaining the momentum for change. SOFHA was working with stakeholders to identify changes already happening and to support them in promoting further change. It intended to use the baseline assessment to: (a) measure future change; (b) strengthen its team and refine the nature of its programme interventions; and (c) contribute to the body of knowledge on FGM/C in Somaliland.

Crucially, SOFHA wanted to be fully involved in the process of enquiry. It wanted to be able to trust the data, own the findings, and engage in dissemination and informed debate. Amal Ahmed, Executive Director of SOFHA, recognised the need for capacity strengthening of SOFHA’s team and the adoption of a PCBR-type approach.

The knowledge gaps SOFHA wished to explore included the role of health professionals, access to health support, the role of schools, and the potential role of young men in abandoning FGM/C. Through its maternal health clinics, it was supporting pregnant women and girls who had undergone FGM/C, and providing medical advice on health complications for survivors. However, it lacked knowledge on how health professionals were perceived by community members, and the attitudes of health professionals towards FGM/C. SOFHA intended to establish school-based sessions for pupils and parents, but was unsure of the attitudes of teachers towards FGM/C and therefore the support that teachers might need to fulfil this role. Additionally, it recognised the need for young men, future husbands and fathers, to be actively involved in conversations about FGM/C, but was unsure of their existing knowledge, attitudes, and beliefs.

The initial research process was guided by Katy Newell-Jones, a practitioner- researcher for Orchid Project, UK. She facilitated the overall process of critical enquiry, providing mentor support, and training.1The baseline assessment was funded by Norad and supported by the Population Council-Kenya, with the latter providing ethical approval and technical support. Most members of the SOFHA team were new to research. However, they had a wealth of skills directly applicable to the research process, including a trusted network at national and community levels with stakeholders, and sound logistical and organisational skills to implement interventions across Somaliland. A mixed-methods, PCBR-informed approach was selected involving a community survey, supported by focus group discussions (FGDs) and key informant interviews (KIIs). From the outset, SOFHA was actively involved in establishing the research questions, selecting and devising the tools, framing the survey questions, and ensuring relevance, clarity, and rigour.

To strengthen SOFHA’s research capacity, a list was compiled of the components of the research process. SOFHA’s experience and proficiency in each component was assessed through a collaborative process, recorded narratively, and graded as high, medium, or low. These ‘assessments’ were updated periodically and informed the nature of ongoing support. As the SOFHA team enhanced their skills, they took increased responsibility for the research process.

The community survey took place in twenty communities across five of the six regions of Somaliland: Awdal, Maroodi Jeex, Saaxil, Sanaag, and Togdheer. Sool was not included due to the security situation at the time. A total of 1,847 individuals were interviewed: 53 per cent female / 47 per cent male; 47 per cent fifteen to twenty-four years of age; and 53 per cent over twenty-five years. An additional 106 community members took part in FGDs and KIIs. A similar number of individuals were interviewed for the mid-term evaluation.

The community survey questions were developed collaboratively by the consultant and the SOFHA team (Newell-Jones 2017:55). Translation by the SOFHA team included valuable discussions about the order and sensitivity of the questions, the appropriate terminology, and clarity.

Interviews for the community survey were conducted in Somali using smartphones, collecting quantitative and narrative data. The data was uploaded and responses were available online simultaneously in English and Somali. Eight community researchers, four female and four male, carried out the interviews. Half were SOFHA staff and half from the Ministries of Education (MOE) and Health (MOH). This ensured the formal approval of the research by these ministries, capacity strengthening of their staff, and their ongoing engagement. Training was provided on the principles of ethical research, differences between research and project implementation, informed consent, incentives, child protection, confidentiality, managing distress, and minimising researcher bias as well as the practicalities of sampling, data collection, and security. The SOFHA team coordinated the data collection process and accompanied the community researchers to the communities. The monitoring and quality assurance of the data collection process was the joint responsibility of the consultant and the senior SOFHA team.

The data analysis process was iterative, exploring attitudes, aspirations, and intentions of different stakeholder groups. Data was disaggregated by age, gender, and role/profession. The community survey data and the narrative from the FGDs and KIIs were used to triangulate and illuminate the findings.

The decision to adopt a PCBR approach inevitably brought challenges, including power, control, resource, and time pressures. Initially, it took time to establish strong collaborative relationships drawing on the different expertise each party brought to the process and which maintained the centrality of SOFHA’s research agenda. The funders and external researcher were balancing the external pressures to meet reporting deadlines with the desire to provide the flexibility SOFHA needed to embed its new learning across its work while responding to emerging challenges and shifting priorities. As an active CSO, SOFHA was balancing the competing priorities of the research process with implementing its existing programmes and reporting to donors.

There was brief, intensive training for the research team on ethical research, which included developing and piloting the tools. SOFHA was developing its understanding and skills in community research, moving from an intervention mentality to a research one, while embarking on the first of the community surveys. The community research team (data collectors), drawn from SOFHA, the MOH, and the MOE, each with different backgrounds and skills, needed to acquire the necessary knowledge and skills, and develop as a supportive and reflective team. The time and resources required for this process were underestimated. Further capacity strengthening before the first data collection would have been beneficial and might have increased the consistency among community researchers in the early interviews.

However, SOFHA feels strongly that the advantages of being so intimately involved in the research process, i.e. the capacity building of the team, the strengthening of relationships with key government ministries, and between SOFHA and communities, and the relevance of the findings to ongoing initiatives and challenges, outweighed the potential advantage of a more externally-led study.

Community members were more knowledgeable about types of FGM/C and the complications than expected. Women were familiar with many of the severe health risks associated with FGM/C, but had not made explicit connections between undergoing FGM/C and many life-long conditions, like frequent infections and abdominal pain. Most women (80 per cent) and men (68 per cent) considered that women suffer no harmful effects from the sunnah without stitches. Many of the young men, who it had been assumed were largely ignorant about FGM/C, were more knowledgeable than older men about the types of cut and concerned about the complications. Less than 10 per cent of young men (fifteen to twenty-four years old) wanted their future wives to have undergone the pharaonic cut, although over 70 per cent wanted them to have undergone some form of FGM/C.

The anti-FGM/C messages community members heard most frequently were from NGOs/CSOs and the radio, which primarily opposed only the pharaonic cut. Almost 90 per cent wanted to see some abandonment of FGM/C, although only 4 per cent wanted to see the abandonment of all types. Most mothers intended to cut their future daughters, with 62 per cent intending to only use the sunnah cut. The expectation that teachers were already equipped to be effective agents of change was found not to be the case. The majority (84 per cent) of teachers felt that schools had a role to play in relation to FGM/C, but only half of these (42 per cent) had spoken about FGM/C at school. Only 2 per cent of teachers wanted to see the abandonment of all types of cutting, with most only wanting to end the pharaonic type.

The research demonstrated that community members, male, female, young, and old, were largely aware of the harms caused by FGM/C, yet they still decided to cut their daughters. People from different backgrounds spoke about the decision-making dilemmas they face. For example, mothers who knew from personal experience the health risks of FGM/C feared life-long social isolation for their daughters if they remained uncut. Fathers who did not want to see their daughters harmed explained that if their daughters were uncut, they may lose local business and be less able to support their family. Midwives explained that by performing a lesser cut local girls were ‘saved’ from the consequences of being cut without anaesthetic and antibiotics by traditional cutters (see below).

People spoke about not having opportunities to engage with each other in discussion about the difficult decisions they face. They described how in most workshops, community meetings, and awareness-raising sessions, they were expected to be passive listeners, rather than active participants.

When offered opportunities to exchange experiences in FGDs, many were surprised to hear others’ perspectives. Some began to change their opinions. This finding had significant implications for how sessions with stakeholders were facilitated, and suggested that a more interactive and participatory approach would be more likely to result in attitudinal and behaviour change (Newell-Jones 2017:43).

Local stakeholders readily engaged in dialogue about the findings, questioning, challenging, and probing deeply. Due to its deep involvement, SOFHA could explain and discuss the research process. This sharing of evidence-based findings helped to demonstrate that change is happening in Somaliland, and to encourage meaningful dialogue about the implications.

Two series of knowledge-sharing workshops took place from 2017–19, involving CSOs,3Approximately forty-five CSOs in Somaliland were engaged in anti-FGM/C activities, of which thirty-four participated in the dissemination events. NGOs, and government ministries, providing opportunities to engage in dialogue on the research evidence and the implications. The workshops took place over three and four days respectively (Okondo 2018). They included concise presentations of research undertaken in Somaliland by SOFHA, Population Council-Kenya (Powell and Yussuf 2018), NAFIS (Johansson et al. 2021), and Candlelight.4Candlelight: https://candlelightsomal.org/service/6 [Accessed 2 September 2025]. Open dialogue techniques were used for participants to identify key themes, discuss how these could be applied to their work, and to devise action plans. Thirty-two of the thirty-four participating CSOs reported after six months that they had made significant changes to their programmes. They were engaging a wider range of stakeholders, especially youth, in dialogue and community-led initiatives. This arose largely from the finding that community members had considerable knowledge about the risks of harm caused by FGM/C. They were calling for more opportunities to engage in dialogue and support each other in making changes, rather than being re-told information on health risks. Secondly, CSOs had extended their reach significantly through integrating FGM/C across their work, including livelihoods programmes and health clinics, rather than seeing FGM/C as a separate discrete topic. CSOs reported that communities were engaging more with their work to end FGM/C, that trust was beginning to build, and youth were keen to use social media and peer-to-peer dialogue to bring about change for the next generation.

Representatives from six government ministries participated in dissemination events. The MOH and MOE had been involved from the inception. The Ministry for Employment, Social Affairs and Family was leading the process of redrafting the Somaliland anti-FGM/C policy. The Ministry of Religious Affairs was drafting the fatwa, published in 2018, in response to the increased dialogue on FGM/C. The Ministries of Justice and Planning were both part of the FGM/C task force. Changes in policy making take longer to come to fruition than changes to programmes. A by-product of the workshops was that ministries had widened their knowledge of the sector and subsequently consulted more with CSO representatives on policy development. For example, SOFHA and the Ministries of Health and Education have collaborated on producing curriculum materials on FGM/C, for use in schools.

The findings highlighted the changes taking place in relation to FGM/C and the motivations for continuing the practice across different segments of society. This deeper understanding shifted the way FGM/C was understood by individuals, communities, and organisations, starting with the SOFHA team but going far wider. The impact falls into four broad areas, arising from the approach taken in conducting the research. There was both personal growth and learning among individuals, and collective insights which emerged from dialogue about the findings. These led to programmatic changes by CSOs and relevant government ministries. Finally, the findings influenced international perspectives by demonstrating the depth and breadth of knowledge that can be generated through a community-led approach.

The SOFHA team, community researchers from the ministries, and CSO staff found themselves asking questions about FGM/C in their own households, such as: ‘Are we practising what we preach?’ … ‘Is cutting happening in my own household?’ … ‘How do I really feel about the sunnah cut?’ … ‘How can we expect there to be real change in our society, if those of us at the forefront of this fight for eradication are not making changes in our own homes?’ Previously, it was common to hear those in the field say: ‘They want to continue the cutting because …’ and ‘to raise awareness in the community we need to do this so that they …’. People working in the field of FGM/C distanced themselves from the wider community, as though it was their issue. The research and dissemination process forced everyone to acknowledge that it was ‘our’ issue. The language of the discourse changed noticeably. The research team were identifying with, and making emotional connections with, those with whom they were in dialogue. The process expanded, as different stakeholders interacted with each other, bringing their own perspectives, biases, and challenges. Everyone’s outlook was broadened, revealing the complexity of FGM/C beyond the statistical data, shedding light on the nuanced realities in the local context. This willingness to listen and engage with these diverse voices helped shape a more holistic understanding of FGM/C.

There was a realisation of misreporting and misinterpretation associated with the Somali terms used to describe the practice and a general lack of clarity. Many did not consider the sunnah prick or snip to be FGM/C. Terms like gudniinka fircooniga, which translates as the pharaonic cut, were commonly used to refer to FGM/C, instead of gudniinka hablaha, which translates as the circumcision of girls, and includes all types of cutting. The dissemination and knowledge-sharing workshops sparked discussion about the importance of language, leading many CSOs to adopt gudniinka hablaha in their future work. The terminology also shifted from vague references to intermediate or sunnah to more specific terms: sunnah with sutures, sunnah with cutting, and sunnah with no sutures or flesh removal. This new, more specific language, arising through dialogue, became an important adjustment for clearer communication, and ultimately choices.

The research also revealed nuanced motivations behind the continuation of FGM/C. While societal pressure to ensure girls’ marriageability was often viewed as the primary driver, the study highlighted a complex web of factors, including cultural identity, religious interpretations, and evolving norms around sexuality. These insights required SOFHA, and other organisations, to adjust their community engagement strategies, shifting from a purely health-focused approach to a rights-based one. However, this pivot needed to be handled delicately to avoid alienating communities. Changing the arguments for abandonment too quickly risked creating a perception of donor-driven agendas and eroding community trust.

Unexpected findings also emerged regarding the roles of men and educators. Contrary to expectations, many men showed flexibility in their attitudes toward FGM/C, suggesting they could become allies in efforts to end the practice. On the other hand, educators, whom SOFHA had viewed as potential allies, were more resistant to change. This challenged long-held assumptions and led SOFHA to reconsider its engagement strategies with these groups, influencing future programming and advocacy.