The chapter will explain why Amref focuses on FGM/C eradication, the Kenyan and specifically Kajiado County context, and FGM/C trends, before going on to describe the CLARP approach and its development over time (2009–24). We will discuss important challenges and critiques that we faced in recent years and how we relate and responded to them in our programming, incorporating methods of measurement such as difference-in-difference, stepped-wedge clustered random control trials, and formative and longitudinal qualitative data analysis. We will end our chapter by looking at the future of CLARP and FGM/C.

The principal legislation addressing FGM/C in Kenya is the Prohibition of Female Genital Mutilation Act (2011, hereafter the anti-FGM Act), which criminalises all forms of FGM/C. The Children Act (2022), the Protection Against Domestic Violence Act (2015), and Article 4 of Kenya’s Penal Code also recognise FGM/C as a violation. Several policies, along with the establishment of the Anti-FGM Board,1140 The Anti-FGM Board was established in 2013, following the passing of the anti-FGM Act. Its primary mandate is to coordinate efforts to eradicate FGM/C in Kenya. It works with various stakeholders, including government agencies, NGOs, community leaders, and international organisations, to implement policies and strategies. demonstrate the commitment of the Kenyan government to ending the practice. In 2021 the anti-FGM Act was challenged in the High Court, but it was upheld as constitutional (see Chapter 10, Van Bavel et. al., and Chapter 12, Kamau, this volume).

In Kajiado County, which is predominantly inhabited by Maasai, FGM/C is traditionally part of a rite of passage from girlhood to womanhood. Girls affected by FGM/C in this region are mostly between ten and fifteen years old, though younger girls are sometimes subjected to the practice to avoid law enforcement or prevent them from refusing to give consent as they grow older. Stakeholders include parents and extended family members such as grandmothers, and the practice is performed at home by traditional birth attendants. In the past, ceremonies were held for girls who had undergone the cut, but these have declined since FGM/C was outlawed. The county government enacted a policy for the eradication of FGM/C in December 2019 (County Government of Kajiado 2019).2Devolution of power to forty-seven county governments is a process that began in 2013, following the passing of the 2010 Constitution. Kajiado County’s anti-FGM/C policy provides a framework for the eradication of FGM/C by sensitising the community that the practice is illegal and a violation of human rights. It was the first county to enact such legislation. https://newsroom.amref.org/news/2019/12/kajiado-county-enacts-policy-to-end-female-genital-mutilation/ [Accessed 8 July 2025]. The most common type of FGM/C in Kajiado is Type 2. FGM/C intersects with teenage pregnancy, school drop-outs, and child marriage. This is because FGM/C marks the transition to womanhood and allows young women to be sexually active and risk becoming pregnant, which subsequently leads to school drop-out and early marriage (Kok et al. 2023).

Maasai living in Kajiado have different motives for continuing to practise FGM/C. Graamans et al. (2018) identified marriageability, women’s chastity, endurance of pain, and fear of ancestral curses if FGM/C is abandoned as among the reasons often mentioned. On the other hand, ideas about health, education, progress, religious beliefs, and sexual satisfaction counter support for FGM/C. The leverage for change exists through dialogue between these opposing discourses (Graamans et al. call them discourses and counter-discourses), but also depends on the community, individual, and context.

The earliest known ARP in Kenya dates back to 1996 and was developed by the women’s development organisation Maendeleo ya Wanawake (MYWO), in collaboration with the Programme for Alternative Technology in Health (PATH), among the Tharaka people in Meru (Muteshi and Sass 2005; Van Bavel 2021). ARP as a strategy to end FGM/C was born out of a desire by communities, in dialogue with NGOs, to drop the cut while at the same time keeping certain aspects of their culture, such as preparing their daughters for womanhood through education and a celebratory ceremony. Communities feared that their girls might not find husbands if they had not been initiated. This first ARP programme was assessed by the Population Council, and although the study could not evaluate effectiveness and impact due to data limitations, it accounted for some effect on behaviour change among ‘those who decided to discontinue the practice’ (Chege, Askew and Liku 2001), though these authors noted it was highly influenced by other socio-cultural factors. Other important studies on ARP among the Maasai are Hughes (2018), Graamans et al. (2019), and Van Bavel (2021), all of which have evaluated, informed, and supported NGOs to understand and address the weaknesses of their ARP design. The main criticism by scholars of ARP centres around (lack of) community ownership, its top-down, external (fundraising) focus, and single-issue interventions that deny the complexity of FGM/C. This will be discussed further.

As mentioned in the Introduction to this book, ARP is a strategy, developed by NGOs, that aims to transform or transition girls to women by replicating many of the cultural rituals that once accompanied ‘traditional’ initiation, but without the physical cut. Amref Health Africa implemented a series of programmes in Kenya and Tanzania, making adaptations to address any inherent weaknesses in each stage of ARP. CLARP entails mentorship, sex education and life skills training, and the graduation of girls without undergoing FGM/C. The process is furthermore aimed at delaying girls from marrying at an early age, protecting girls from the risks of getting pregnant before they reach eighteen, prolonging their education, and escaping FGM/C. This type of ARP was thus redefined and called a Community-Led Alternative Rite of Passage (CLARP).

The process is meticulously co-created by programmers and communities in order ‘to empower affected sub-groups within practising communities that wanted to resist FGM/C’ (Graamans et al. 2019).3Seen online, no page numbers. CLARP includes the following formula:

These first steps take at least twelve months to embed in the community.

CLARP attempts to solve the tripartite challenges of FGM/C, i.e. child marriage, teenage pregnancy, and school drop-out, while retaining other valuable and seemingly harmless aspects of Maasai culture. CLARP has been touted as a tool to reframe the role of culture in targeted communities and is often described as a systematic and longer process defined by communication, based on rational choice, external influences, and community validation (Reinholds 2021).

Next, we will explain Amref’s journey to generate the current CLARP formula, showing different lessons learned and points of adjustment over the years (Figure 13.2).

Certain roles and power structures within the community needed to be acknowledged in order to effectively tackle FGM/C. While the influence of morans (warriors), mothers, and grandmothers was quickly recognised, it was understood that if CLARP did not adequately address the concerns and values of parents, elders, and circumcisers, it risked being perceived as an inadequate substitute for traditional practices. For instance, in many communities mothers gain considerable respect and social standing when their daughters undergo the traditional cut (see Hughes, Chapter 14). This cultural dynamic can lead to a reluctance by mothers to fully embrace CLARP, as it may be perceived as diminishing their status within the community. Likewise, the importance of the gifts traditionally given to fathers during the cutting ceremonies is frequently missing in ARPs conducted by other organisations. In CLARP it is recognised that these gifts symbolise respect and honour, and may be an entry point to engage fathers. Furthermore, circumcisers – who are often respected figures in their communities due to their role in the traditional initiation process – can also pose a challenge to the acceptance of ARP. Their opposition stems from the fear that CLARP (and ARP in general) could undermine their status and the cultural significance of their role in transitioning girls to womanhood.

It was acknowledged that, in order to foster genuine acceptance, it is essential to create inclusive discussions that recognise and respect the cultural significance of these roles while promoting the benefits of ending FGM/C. There was also a pressing need for inter-gender dialogues. By addressing the concerns and opinions of both genders, these dialogues aimed to break down the blame game between men and women as to who the main drivers of FGM/C are. Men kept saying it was a women’s affair. On the other hand, men felt excluded from the discussions and decisions surrounding CLARP, leading to a perception that their concerns were not being adequately addressed. FGM/C primarily affects girls, which means that CLARP had tended to be girl-centred. While addressing the needs of girls is undoubtedly important, this focus often came at the expense of the boy child, raising concerns about inclusivity. This imbalance fostered a sense of distrust, making it difficult for CLARP to gain widespread acceptance, ultimately jeopardising its sustainability.

In order to ensure a shared understanding between the two genders and bring men on board, regular inter-gender conversations were integrated into the process. It emerged that women were seen to be in the forefront because they implement men’s decisions as household heads. At another level, men were provided with crucial information about the health, social, and emotional implications of FGM/C, equipping them with the knowledge to become advocates and active partners in the fight against it. Acknowledging the shared responsibilities, (male) elders and morans also accepted a role in CLARP graduation ceremonies in blessing the girls.

Working closely with communities on FGM/C through CLARP, Amref had access to information and was able to gain insights into the implementation and enforcement of the law, which was especially a challenge in remote areas such as rural Kajiado. However, its strong collaboration with local county governments, influencing them to invest in and enforce the laws on FGM/C, and the NGO’s explicit zero-tolerance approach towards FGM/C, also caused mistrust (Graamans et al. 2019). This triggered resisting communities to make adaptations and conceal the practice, including by cutting girls at a lower age, cutting girls at the same time as boys, and cutting at night or cross-border, which has made it even more difficult to protect girls. This again proves how important it is to build up a trusting relationship and continuous dialogue with and in the community to make change happen.

This real-time tracking system gathers insights into the girls’ quality of life, career trajectories, family situations, and the threats they may have faced that are related to FGM/C. In this way, the NGO has strengthened the support given to girls and women. Ideally, girls who undergo CLARP remain free from FGM/C, which means that, in many traditional communities, they are not fully recognised as women. Instead, they are seen as girls who are still in a transitional phase. This situation can lead to significant psychological challenges as the girls navigate feelings of acceptance and belonging. Often, these girls struggle with the pressure to conform to cultural expectations, feeling out of place or isolated from their peers who have undergone circumcision. In some cases, this social pressure becomes so intense that the girls may ultimately give in and undergo FGM/C, despite their earlier participation in CLARP. According to Tracking the Girls’ reports, 4,000 girls have been registered on the system, and 1,750 girls have been followed up. Of these 1,750 girls, 11 per cent have reported a case (seventy-five cases of FGM/C, fifty-five teenage pregnancies, forty-three school drop-outs, and thirteen child marriages). But the majority are still in school and have not reported any harm or threat of harm.

The CLARP model, while valuable, is not without its imperfections and continuing struggles. It provides a strong foundation, but there is room for improvements and refinements, allowing for the integration of insights from various disciplines, programmes, and areas of expertise. By incorporating lessons learned from other fields and adapting to evolving social and cultural dynamics, the CLARP model can become more robust and effective in addressing the needs of the communities it serves. The ultimate goal is to continually evolve and strengthen the approach to ensure its relevance in ending FGM/C.

An important criticism and eye-opener for reflectiveness on CLARP came with Mepukori’s qualitative study (2016) that aimed to evaluate the effectiveness of CLARP in a Samburu intervention site, where the NGO had worked since 2011. This study alarmed the organisation and resulted in a rather defensive management response, showing it was not used to receiving criticism from academics. It became an essential turning point for growth. Among Mepukori’s conclusions was this important point: ‘To the extent that ARP interventions are only successful when the majority rallies against female circumcision, there remains insufficient community buy-in for the intervention to succeed in the Samburu community’ (ibid.:64). Mepukori stressed social norms theory (e.g. Mackie and LeJeune 2009) and the challenges faced in order to reach the tipping point.10149 In social norms theory, Mackie and LeJeune (2009) describe the tipping-point concept as a critical threshold in changing practices like FGM/C. The tipping point is reached when enough people in a community decide to abandon FGM/C, creating a shift in norms where not cutting becomes acceptable, reducing the social pressure to conform to the old practice. For more information on social norms theory, see the Introduction to this book. The scaling-up of CLARP has proved to be a challenge for many reasons, including limited resources (funds, time, capacity) and sustainability, as change takes time and it is not easy to leave a CLARP intervention area. Sustainability is therefore a valid point of critique and worry when implementing CLARPs, as contextual changes such as the COVID-19 pandemic and climate change, which threaten the livelihoods of the Maasai people, can cause setbacks in communities that are progressing toward eliminating FGM/C (Esho et al. 2022).

Another important point of criticism that Mepukori raised was on the monitoring and evaluation of CLARP, which had not been consistent, therefore running the risk of ‘open[ing] up an already vulnerable intervention to a host of unintended consequences including severe backlash and the possibility of driving female circumcision underground’ (Mepukori 2016:64). It was a criticism that Amref took very seriously, and from that point it invested heavily in monitoring through developing and tracking a theory of change model. It also developed the monitoring tool Tracking the Girls (as described above).

It might be the lack of support networks and the isolation of their community that has caused Maasai girls to continue to succumb to FGM/C. Or is it related to the fact, often argued by scholars, that CLARPs (and ARPs in general) lack the cultural depth and authenticity of the traditional rites they are intended to replace? Even when communities are involved in the design of community-led ARPs, deciding which elements of initiation should stay and which should be abandoned, Graamans et al. (2019:6) write that ‘girls who participate in CLARPs do not feel like women, neither are they considered as such by the community’. It is a problem commonly heard among young people in Africa who struggle to attain recognised social adulthood (Johnson 2018), also conceptualised as waithood (Honwana 2012). Johnson argues that traditional rites provide adults with the ability to actively support youth (especially girls) in shaping their futures and acknowledging the tensions of the current era (marriage preparation versus urging marital delay), while symbolising continuity with past generations. What is needed for Maasai girls to perceive themselves and be perceived as women is something they will need to negotiate themselves. The question is whether the prolongation of their youth, combined with education and empowerment, will strengthen girls’ voices and agency with regard to FGM/C.

Like Graamans et al. (2018), the review of existing evidence that Matanda et al. (2023) conducted concluded that the complexity of FGM/C requires a holistic approach. Matanda et al. (ibid.:13) mention that certain elements of ‘health education, community dialogues with parents and religious leaders, the use of media and social marketing efforts, and formal education for women and girls’ show sufficient evidence and therefore can be seen as appropriate. It is acknowledged, also by practitioners, that education can provide an alternative path for youth, although girls’ ambitions might become unrealistic, as Graamans et al. (2018) argue: ‘inflated promises about what education brings may lead to disappointment. And this sequential disappointment can lead to a setback in progress being made in the work against FGM/C or the adoption of ARP.’11Seen online, no page numbers. Additionally, it would be good to mainstream sexual reproductive health and rights and FGM/C (where relevant to the context) education in the school curriculum, but this seems to have had little political support and currently Kenya (along with many other African countries) is moving towards more conservative ideas on sexual education for primary school students.

Furthermore, there is a long-heard argument that the effectiveness of CLARP can only be shown through baseline versus endline comparisons, a view that Amref has fully embraced. In addition to such evaluations (Mbogo et al. 2022), other methodologies like the stepped-wedge cluster randomised controlled trial (Esho et al. 2023), and the difference-in-difference method (Muhula et al. 2021), have been used to strengthen evidence through quantitative research. Quantitative evidence (more than the different qualitative studies that have already been conducted) of CLARP’s effectiveness could really boost the political, advocacy, and funding agenda (ibid.).

The Muhula et al. (2021) study was the first in Africa to apply a quasi-experimental approach to examine the impact of the CLARP intervention. The study used the difference-in-difference approach12151 The difference-in-difference approach is a widely-used method in impact evaluation, especially in the development sector, to estimate the causal effects of interventions or policies. It is particularly useful in situations where randomised controlled trials are not feasible, but pre- and post-intervention data are available for both treated and comparison groups. to quantify the average impact of the CLARP intervention, focusing on Kajiado as the intervention county, with Mandera, Marsabit, and Wajir as control counties. To empirically investigate and respond to whether CLARP has had any impacts on the social and educational outcomes of the beneficiaries, the study employed the Kenya Demographic and Health Survey (KDHS) data from 2003, 2008–9, and 2014. KDHS data are not only statistically representative but also detailed, with various useful variables on demographic, health, and socio-economic indicators. The study demonstrated that CLARP had contributed to the decline in FGM/C prevalence, child marriage, and teenage pregnancies among girls in Kajiado by 24.2 per cent, 4.9 per cent, and 6.3 per cent respectively. The study also showed that the intervention had contributed to an increase in girls’ schooling by two-and-a-half years, thereby keeping girls in school longer and reducing their chances of being circumcised. This paper elicited much discussion among scholars in the FGM/C space, criticising the use of secondary KDHS data, rather than the authors’ own collected data. This, together with the questions raised around the use of difference-in-difference as a quasi-experimental design, points to the lack of understanding of how econometric models can be exploited to address the evaluation challenges in health programmes. The difference-in-difference approach calculates the average treatment effects by differencing the average outcomes before and after programme implementation across control (without intervention) and treated (with interventions) groups. In the context of the CLARP programme, the difference-in-difference approach measures the average impacts of the CLARP roll-out on social and educational outcomes in Kajiado County, where Amref introduced the CLARP model. The results were then compared with Mandera, Marsabit, and Wajir – counties with no CLARP model (control groups) – before and after the model was rolled out in 2009.

The KDHS are nationally representative household surveys that provide data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition, and have been implemented in over ninety countries. It should be noted that the KDHS asks limited questions about FGM/C. However, we consider it to be the most reliable data to support impact evaluation of programmes such as CLARP with the confirmation of the availability of necessary variables of interest in the database.

However, admittedly, measuring the attribution of the CLARP and CLARP-related interventions indeed has limitations, especially because FGM/C is a long-term and complex change process in which it is extremely difficult to isolate the attribution of one intervention to reduced FGM/C prevalence. Should that stop us from trying to measure its effectiveness? We should not be shy to look for ways to measure behaviour change around FGM/C, although it might be difficult to achieve academic rigour. If we are supported and can continue the dialogue with scholars, we might get more insight into which systems and aspects need to be further developed and addressed to improve effectiveness measurements. It takes interdisciplinary collaboration, allowing the perspectives of local actors, stakeholders, and structures to give us the necessary insights. But what is also key is consistent and good quality documentation.

Another limitation that NGOs face is fundraising. While striving to improve models of intervention, our transparency about lessons learned can impede the flow of funding that is essential to continue the work. This dichotomy between learning and accountability/fundraising causes dilemmas. As an organisation, we need to raise funds to continue supporting and protecting more girls and reach the sustainable development goal to end FGM/C.

From a programmatic perspective, there remains a great motivation to work and learn from the practice and CLARP implementations in different contexts. The challenges lie in the collection of consistent quantitative data, in order to convince politicians and duty bearers of the need to act and enforce existing laws.

Measuring behaviour change (and ascertaining how and to what extent interventions are a factor) requires a carefully planned framework, which should account for cultural sensitivities, involve local stakeholders, and employ diverse methodologies to ensure accurate and meaningful results. We hope that by emphasising the long-term monitoring of girls, their needs and priorities remain the focus of our work. To keep a sharp eye on CLARP and its results, it is essential to allow an open and respectful dialogue between implementers and scholars, aiming to overcome the limitations that all actors face in deepening the understanding of FGM/C and the behaviour change that CLARP aims to achieve.