Despite decades of intervention, awareness campaigns, education, and community engagement efforts, the prevalence of FGM/C remains alarmingly high. In Sudan, the practice continues to affect 86.6 per cent of women aged fifteen to forty-nine, and 31.5 per cent of girls under fourteen have also undergone it (UNICEF 2022).2UNICEF Sudan (2022). Female Genital Mutilation in Sudan. Factsheet. https://www.unicef.org/sudan/reports/female-genital-mutilation-sudan [Accessed 18 July 2025]. However, variations exist in prevalence, type, and associated customs across the different regional and ethnic groups in eighteen states. In practising communities, women often cite reasons such as cleanliness, social acceptance, improved marriage prospects, and chastity as justifications for continuing the practice (Elduma 2018).

In Sudan, the most prevalent types of FGM/C are infibulation (also known as pharaonic circumcision or WHO Type 3) and excision (also known as clitoridectomy or WHO Type 1. See the textbox on p. 00 for details of WHO classifications). These practices are particularly common in the northern and eastern regions of Sudan (ibid.). In addition, sometimes the vaginal opening is deliberately enlarged using a sharp instrument. Although this form is less commonly practised, it still poses significant health risks. There are also cases where uncircumcised women are pressured into having the procedure prior to marriage. Infibulated Sudanese women usually undergo reinfibulation after giving birth (ibid.). Regardless of the type, all forms of FGM/C are associated with severe consequences for women’s health, sexuality, and social, emotional and psychological well-being.

Extensive efforts have been made in Sudan to raise awareness about FGM/C through orientation sessions, involvement of religious leaders, and empowerment of women to resist this practice. The health risks associated with FGM/C are widely publicised. Though the practice persists, it is important to note that positive changes are emerging, which will be discussed in the following pages.

The staggering statistic of 86.6 per cent prevalence raises an important question: are the strategies currently in place truly effective, or do they only scratch the surface? It also raises questions about the suitability of long-standing methods and the cultural resonance of the messages being delivered. There are gaps in delivery and engagement that need addressing. While we understand that behaviour change is a slow process, the weak results despite substantial investments of time, effort, and resources force us to confront an uncomfortable truth: we must reconsider our approach. There is a pressing need to consider whether different, more innovative approaches are necessary to match the scale of the challenge. The fight against FGM/C requires strategies that extend beyond traditional communication and engagement methods. A willingness to reimagine interventions and critically evaluate the efficacy of existing tools is essential.

UNICEF, in partnership with various NGOs, has taken a strong stance in addressing the issue of FGM/C in Sudan for over fifty years. Although the overall prevalence remains high, this is not the full story. There have been notable shifts in the nature of the practice itself, shifts that reflect both changing perceptions and evolving social dynamics.

These changes may also be linked to growing awareness of the physical and emotional toll of early childhood circumcision. As the harms of early FGM/C become more widely recognised, communities may be opting to delay the procedure in hopes of reducing immediate health risks, such as excessive bleeding, infection, and shock, which are more prevalent in younger children.

The medicalisation of FGM/C is often presented as a way to make the procedure ‘safer’, with proponents arguing that it can be done in a more hygienic and less damaging manner. But the involvement of trained medical personnel raises ethical concerns and questions about the role of medical institutions in perpetuating harmful practices. By medicalising FGM/C, the procedure may gain a veneer of legitimacy, making it harder to challenge. The increasing role of health professionals also reflects the broader issue of institutionalised complicity in harmful cultural practices.

Community and religious beliefs: The enduring cultural and religious justifications for FGM/C remain strong in many communities, despite growing knowledge of its harms. FGM/C is often viewed as a rite of passage, a way to control female sexuality, and an important marker of social identity. In some communities, it is closely tied to religious beliefs, with the sunnah cut (Type 1) being seen as part of Islamic tradition, despite there being no religious mandate for FGM/C in Islam (Chapter 4, this volume).

Health and medical discourse: The framing of FGM/C as a health issue, particularly by international health organisations, has undoubtedly influenced the way people think about the practice. Campaigns that highlight the risks of more severe forms of FGM/C may have encouraged the shift from Type 3 to Type 1, as communities seek to mitigate the risks while maintaining the practice. Similarly, the rise of medicalisation reflects the increasing integration of health discourse into the practice, as medical professionals are seen as ‘legitimate’ figures who can carry out the procedure more safely (UNICEF 2016).

The Saleema Initiative, launched in 2008 by the National Council for Child Welfare and UNICEF Sudan, focuses on protecting girls from FGM/C by promoting collective abandonment at the community level. The name ‘Saleema’ symbolises a state of being whole, healthy, and untouched – natural, unaltered, and in a God-given condition. Its primary objective is to shift societal attitudes toward FGM/C, encouraging the use of positive terminology that celebrates the natural bodies of girls and women. Since its inception, Saleema has spread across Sudan and sparked interest in neighbouring countries like Somalia and Egypt (Evans et al. 2019). The programme is grounded in social norms theory, which posits that FGM/C persists due to deeply ingrained social beliefs about what behaviour is expected in a particular community. The Saleema Initiative works to change these beliefs by creating alternative narratives that emphasise the social acceptability of uncut girls. Over time, it is hoped that this shift in perceptions will result in the abandonment of FGM/C.

In 2014, the initiative was evaluated to assess its impact on social norms, behaviours, and attitudes toward FGM/C. This focused on tracking changes over time, the degree of exposure to Saleema across different regions, and the role of Saleema’s social marketing strategies in influencing change. Key goals included measuring social norms about FGM/C, determining if higher exposure to Saleema led to improved beliefs about FGM/C abandonment, and examining the effectiveness of branding in promoting change. Through these efforts, Saleema aims to redefine social expectations and contribute to a broader cultural shift toward protecting girls from FGM/C (Evans et al. 2019).

With the overthrow of the former regime in 2019, Sudan underwent a period of significant reform, during which many laws that were seen as discriminatory or repressive were reviewed and amended. The criminalisation of FGM/C represented a direct challenge to harmful traditions and a call for social change. However, while the national law made FGM/C illegal across Sudan, it was not immediately effective in all areas. Prior to 2020, six states had already enacted legislation to curb the practice within their borders. These states included Gedaref, South Darfur, South Kordofan, and Red Sea. The implementation of these laws faces significant challenges, including difficulties in prosecuting offenders and a lack of clear data regarding prosecutions (UNICEF 2020).

The 2020 national law sought to address this patchwork of regional regulations by providing a uniform legal framework, making FGM/C illegal nationwide. In this way, it was hoped that Sudan could ensure greater consistency in its efforts to protect girls and women while also shifting public attitudes toward the practice. With the criminalisation of FGM/C, Sudan took a crucial step toward fulfilling its obligations under international human rights agreements and advancing the cause of gender equality.

As campaigns against FGM/C evolve, it is essential to address the underlying social, cultural, and institutional factors that sustain the practice, while also recognising the complexities that drive its persistence. To address this gap, this study employs a novel approach by analysing the factors believed to influence the adoption of FGM/C abandonment, guided by four key questions. First, can the abandonment of FGM/C be sustained in communities where the practice is deeply embedded? Second, what are the most influential factors in prompting behavioural change? Third, which variables are most significant in accelerating the transformation towards abandonment? And finally, how can these insights inform more effective strategies for promoting the elimination of FGM/C? Through answering these questions, this chapter aims to provide valuable insights into the promotion of FGM/C abandonment. It moves beyond surface-level health messaging to delve into the underlying motivations and social pressures that drive communities to either continue or abandon the practice.

Models and theories related to behaviour change are grounded in extensive research, rigorously validated through scientific inquiry, and built upon established frameworks of epistemology, ontology, and methodology. These theoretical foundations have long served as tools to explain and predict how individuals alter their behaviours, particularly when it comes to deeply ingrained cultural practices. However, despite their proven utility, such models have been underutilised by those currently working to address the challenges of FGM/C in affected communities. The literature on this subject reveals a clear gap: these robust theoretical models have not been adequately applied in the practical efforts aimed at combating FGM/C. This oversight represents a missed opportunity to leverage established knowledge to guide more effective interventions and strategies for behavioural transformation.

One of the key benefits of DTPB is its ability to clarify and deepen the relationships between the factors that influence intention. This refinement enables researchers and practitioners to pinpoint the specific beliefs that are most relevant to particular behaviours, making the model versatile and applicable across a wide range of contexts. Furthermore, the DTPB offers practical insights for designing and implementing strategies that promote the adoption and practice of desired behaviours (Taylor and Todd 1995).

Drawing from the model’s key principles, seven factors were identified that are particularly relevant to the abandonment of harmful practices like FGM/C. These are the facilitating conditions provided by intervention programmes that facilitate the adoption of a specific behaviour (Ajzen 1991); subjective norms within communities; perceived ease of adopting alternative behaviours; perceived usefulness of those behaviours; the influence of peers; the impact of superiors or authority figures; and the individual’s intention to change. Each of these factors plays a pivotal role in reshaping mindsets and fostering the abandonment of practices such as FGM/C. Through the lens of these elements, it becomes clear how social, environmental, and psychological forces converge to drive change within communities.

To test the relevance and validity of these factors in the Sudanese context, the DTPB model was applied to a sample of 600 cases from the Khartoum locality. Quantitative data for this study were obtained through a structured questionnaire featuring closed-ended questions, while qualitative data were gathered using semi-structured interviews. This mixed-methods approach facilitated the triangulation of findings, offering a more comprehensive and nuanced understanding of the complex social and cultural dynamics influencing the abandonment of FGM/C. The questionnaire was distributed to 600 participants, ensuring a diverse representation of individuals across different genders and age groups, ranging from twenty to eighty years. To ensure optimum representation, illiterate respondents received assistance from trained survey interviewers to help them complete the questionnaire. The interviewers took care to avoid influencing the respondents’ answers, ensuring that the collected data remained unbiased and genuine. Including illiterate individuals is particularly important, as they often represent key family members, such as grandfathers and grandmothers, who play a significant role in decision-making around practices like FGM/C. In Sudan, the perspectives of illiterate individuals, particularly within certain age groups, have considerable influence over family decisions, making their input crucial for gaining a comprehensive understanding of cultural practices. From the 600 distributed questionnaires, 517 were fully completed, yielding a notably high response rate of 86 per cent.

The questionnaire was carefully designed with eight sections to capture key variables for developing the FGM/C abandonment model, based on the DTPB framework. It addressed factors such as awareness campaigns, perceived ease and benefits of abandonment, subjective norms, peer and community influence, intentions, and actual behaviours related to FGM/C cessation. Responses were collected using a six-point Likert scale, enabling detailed analysis.

The findings from this study provide valuable insights into the psychological and social drivers that can foster meaningful change within communities. By understanding and addressing these drivers, we can better tailor our interventions to target the specific beliefs, social pressures, and perceived barriers that perpetuate the practice of FGM/C.

Figure 7.1 illustrates the variables hypothesised to predict the intention to adopt FGM/C abandonment. These variables – drawn from the DTPB – serve as the foundation for developing the structural equation model employed in this study. The specific components of the variables were carefully selected from the array of DTPB of Taylor and Todd (1995) to align with the case study presented here, ensuring that the model accurately reflects the unique cultural and social dynamics surrounding the issue under investigation.

From the array of factors of the DTPB figure, seven key constructs were selected based on their assumed influence on the adoption of the new behaviour of abandoning FGM/C. These factors were facilitating conditions, subjective norms, perceived ease of use, perceived usefulness, peer influence, superior influence, and behavioural intention to abandon FGM/C. Each of these variables was integrated into the development of a structural equation model designed to assess the relative influence of each variable on the actual behaviour of abandoning FGM/C. The developed model allows for a comprehensive analysis of how these elements interact to shape the decision-making process within affected communities, providing valuable insights into the drivers of behaviour change. The ultimate goal of this model is to determine the magnitude of each factor’s impact on the adoption of FGM/C abandonment. By doing so, it will offer a clear roadmap for practitioners, policy makers, and organisations working towards FGM/C eradication.

The key focus is on the role of facilitating conditions – resources within awareness programmes that educate communities about the health risks of FGM/C. This includes factors such as the programme’s accessibility, clarity, comprehensibility, and the effectiveness of the messages conveyed. These programmes are considered ‘cognitive instrumental influencers’, helping individuals comprehend the importance of abandoning FGM/C.

The study hypothesises that facilitating conditions influence subjective norms, perceived ease of use, and perceived usefulness, which in turn affect the intention to abandon FGM/C. Key hypotheses include:

• Facilitating conditions positively impact subjective norms (H1).

• These conditions influence the perceived usefulness (H2) and ease of use (H3) of abandoning FGM/C. Perceived ease of use positively affects the perceived usefulness (H6).

• Perceived usefulness influences the intention to abandon FGM/C (H7).

• Facilitating conditions also directly affect perceived usefulness and ease of use (H4, H5).

• The study also investigates peers’ influence (H9) and superiors’ influence (H8) on behavioural intention to abandon FGM/C. It posits that peers’ socialisation and authoritative figures (e.g. community leaders) play a critical role in shaping individuals’ decisions, either reinforcing or challenging FGM/C practices.

• Additionally, subjective norms – societal expectations – are highlighted as major factors influencing behaviour (H2), particularly in culturally sensitive areas like FGM/C. The research suggests that interventions targeting these social pressures can be effective in promoting behavioural change.

• Finally, the study explores the relationship between behavioural intention and actual behaviour (H11), hypothesising that strong behavioural intentions lead to actual abandonment of FGM/C. Overall, the research aims to provide a comprehensive framework for understanding and influencing the complex behaviours surrounding FGM/C, with a focus on integrating social influence and perceived benefits into intervention strategies.

Lastly, in terms of income levels, the majority of respondents (43.0 per cent) identified as low income, with 31.7 per cent classified within the middle-income bracket and 25.3 per cent categorised as high-income earners. These demographic measures collectively promote ethical research practices and significantly enhance the credibility of the study’s findings.

The analysis of the model instrument was conducted through a comprehensive two-step process. Initially, the measurement model was evaluated, followed by a detailed examination of the hypotheses using a structural model. This assessment focused on key aspects of variables’ reliability, convergent validity, and discriminant validity for the various variables involved.

The average responses from participants provided a nuanced understanding of their perceptions and behaviours regarding FGM/C. The data revealed a moderate level of abandonment, reflecting a delicate balance between acceptance and resistance. This suggested that, while some individuals appeared open to the idea of discontinuing the practice, others remained more hesitant, influenced perhaps by deep-seated cultural or social factors. Similarly, when participants were asked about their behavioural intentions toward abandonment, the results were telling. There was a slight, but noticeable, inclination toward supporting abandonment, hinting at a shift in mindset, even if the transformation was not yet widespread. The survey also explored how participants perceived the ease and usefulness of abandoning FGM/C, with responses indicating that, for many, the process could be perceived as challenging yet ultimately beneficial.

Further insights were gained by considering the role of social norms and peer pressure. It was evident that these factors played a significant role in shaping attitudes, with many respondents acknowledging the weight of community influence on their views and actions regarding FGM/C. The discussion around the facilitating conditions for programmes aimed at eliminating the practice revealed a wide spectrum of opinions. While some participants expressed concerns that these programmes were difficult to understand, unavailable, or lacking in permanence, others offered a more cautious endorsement, acknowledging some support for these initiatives. However, the majority of respondents shared a negative view regarding the quality and effectiveness of these programmes, particularly in terms of how well they communicated their messages. Many felt that the programmes fell short, leaving room for significant improvement in both content and delivery.

Taken together, these responses painted a picture of a society at a crossroads, where the path toward abandoning FGM/C is neither clear-cut nor universally embraced, but where there is also an undercurrent of possibility for change. The data served as a powerful reminder of the deep-rooted cultural dynamics at play and the need for thoughtful, contextually-aware strategies to foster progress.

For instance, a coefficient with a significant positive value indicates the strong influence of a specific factor on the target behaviour, whereas a negative coefficient reveals a suppressive or deterrent effect. These coefficients are crucial in determining which variables have the greatest impact on behaviour change. By examining the magnitude of these coefficients, researchers can effectively prioritise interventions that are most likely to bring about significant change.

In addition to coefficients, the model’s loadings offer a clear indication of the importance of each indicator within a latent construct. This information is invaluable for practitioners, guiding them in focusing on the most relevant variables that can drive change. Furthermore, a comprehensive understanding of these relationships aids the efficient allocation of resources, ensuring that interventions are targeted where they are most likely to have the greatest impact. This approach helps optimise intervention costs, maximising effectiveness while minimising wasted resources.

Before developing the model, a comprehensive assessment of its overall fit was conducted, focusing on several fit indices that evaluate how well the model matches the observed data (Table 7.1). These indices are essential for gauging the model’s robustness and its capacity to accurately capture the relationships between the constructs. The analysis showed a strong fit, suggesting that the model offers a reliable framework for understanding the underlying dynamics.

After carefully analysing the model’s components and ensuring their reliability, an SEM was developed. This model reflects the relationships between the key variables in the study, offering valuable insights into how they influence one another. Figure 7.2 presents the model that best represents the data, visually showing how the different factors are interconnected. These findings are crucial for uncovering the key behavioural drivers behind the decision to abandon FGM/C, giving us a clearer picture of the factors at play.

Moreover, the analysis supports the idea that facilitating conditions of eradication programmes can indirectly enhance the perceived usefulness of abandoning FGM/C by influencing subjective norms. However, the direct effects of these programmes on perceived usefulness were found to be stronger, emphasising the need for programmes to address both direct and indirect pathways in promoting behaviour change.

The influence of supportive conditions on perceived ease of adopting FGM/C abandonment was also examined. The study found that changing social norms significantly enhances perceptions of ease, suggesting that addressing societal beliefs is crucial in facilitating the adoption of new behaviours. The strong impact of subjective norms on behavioural intentions further emphasises how cultural pressures and expectations shape individual choices. The strong influence of subjective norms on individuals’ intentions to abandon FGM/C aligns with the data in UNICEF’s 2024 FGM/C update report. This underscores the critical role that societal and communal expectations play in shaping behaviour. Specifically, the support and pressure from peers and authority figures emerged as significant motivators, highlighting the importance of social dynamics in driving change.

The perceived usefulness of abandoning FGM/C also proved to be a strong predictor of individuals’ intentions. This suggests that when people recognise the benefits of refraining from FGM/C, they are more likely to commit to this new behaviour. Conversely, the study found that the facilitating conditions provided by eradication programmes had an insignificant effect on individuals’ perceptions of ease regarding FGM/C abandonment. This indicates that other factors may be more influential in determining how easy individuals feel it is to adopt this behaviour.

In addition, the research proposes a model to assess factors influencing FGM/C abandonment, offering insights for more effective interventions. It also provides a roadmap for organisations, focusing on incorporating social norms into eradication programmes. Policies should prioritise altering societal beliefs and engage both peers and influential community members, as their impact on behaviour is stronger than that of superiors. Programme effectiveness should also address practical concerns, such as legal frameworks and financial support.

Strategically, awareness campaigns should target subjective norms and be tailored to both rural and urban populations. Support systems should be established to help individuals resist societal pressure, while regular monitoring and evaluation will ensure the continuous improvement of programmes. A four-phase implementation plan is proposed:

This roadmap is also relevant for global organisations like UNICEF and UNFPA, which can provide resources and advocacy to support national efforts in the global eradication of FGM/C.