Social norms are invariably cited as the other main driver, and social norms theory is widely regarded as an important theoretical tool in efforts to end FGM/C. Put very simply, social norms theory states that people behave as they do because they are conforming to the behavioural norms of their community, largely for fear of ostracisation (Mackie and Lejeune 2009; Mackie et al. 2015). To avoid treading on sensitivities around culture, development agencies now tend to speak of their desire to change social norms, rather than culture. Few scholars have critiqued social norms theory, not least for its failure to produce the desired result – the eradication of FGM/C in countries where development agencies and NGOs have long applied the theory.1This theory is also applied to many other types of behaviour, which I need not go into here. (Critical scholars include Efferson et al. 2015; Dempsey, McAlaney and Bewick 2018; Graamans 2020.) But a shift appears to be taking place, as more scholars of FGM/C explore alternative theories around social influence and social learning.

This chapter will discuss notions of culture, both in relation to FGM/C and its use in approaches aimed at ending it, notably Alternative Rites of Passage (ARP), a strategy used by NGOs in FGM/C eradication campaigns, largely in East Africa2Alternative rites have been piloted in a few countries outside East Africa, such as Sierra Leone. But they are not necessarily called ARP. (e.g. Droy et al. 2018; Graamans et al. 2019; Graamans 2020; Hughes 2018; Mepukori 2016; Muhula et al. 2021; Oloo, Wanjiru and Newell-Jones 2011; Prazak 2016, 2007; Van Bavel 2021, 2023 et al., etc.). ARP was first developed from 1996 by NGOs in Kenya in an attempt to offer girls a form of initiation into womanhood that retains cultural elements of the ‘traditional’ ritual, but without FGM/C. There is no single model of ARP. But it usually consists of an education phase for initiates, and culminates in a grand public ceremony that includes a community declaration to abandon FGM/C. NGOs sometimes invite boys to take part too, since there is increasing recognition that engaging boys and men is crucial to ending FGM/C.

Why notions? Because ideas about culture may have little to do with culture per se. ARP is often described as an attempt to preserve culture in initiation processes, while removing the FGM/C element of culture.3The Anti-FGM Board of Kenya has, with its 2018 ARP Guidelines, attempted to standardise the model of ARP that different NGOs use, but there is no ‘one size fits all’. Graamans et al. also warn: ‘Because the cultural meanings ascribed to [FGM/C] are also evolving, any intervention that is effective at present might become superfluous in the future’ (2019:8). ARP is inappropriate in communities where FGM/C is not linked to girls’ rites of passage, hence it has only been tried in communities where those links exist. (Large public ceremonies celebrating circumcision do not take place in all communities; references to them in this chapter only apply to those where they do or did.) Apart from those around male circumcision, such ceremonies largely disappeared after FGM/C was banned in Kenya and Tanzania.4I witnessed FGM/C, and the public ceremonies that traditionally followed male and female circumcision, on visits to Tanzanian Maasailand in 1981–2. This was long before Tanzania banned FGM/C in 1998. Kenya banned it in 2011. NGOs have inserted other supposedly cultural elements into the design of ARP ceremonies. Many of these sit awkwardly within a concocted and hybridised event that does not resemble a rite or ritual, yet is purported to be one (Hughes 2018). Conversations with informants in FGM/C-practising communities suggest that few people are fooled by these attempts at simulation. NGOs may claim that the public declaration element of these ceremonies is their most important function, following a model pioneered in Senegal by Tostan.5The NGO Tostan’s public declarations of community intent to stop practising FGM/C are widely admired. But the declarations are just one part of a long-term strategy, and Tostan does not claim that these alone can alter people’s behaviour. But public pledges to abandon FGM/C have not been shown to work, at least not in East Africa. Some NGOs and development agencies claim otherwise.6Van Bavel’s informants told her that the February 2019 public declaration in Loita encouraged Maasai to embrace the Loita Rite of Passage because cultural leaders were seen to make it (pers. communication). But this is not borne out by later research findings at that site (Van Bavel et al. 2023). UNFPA-UNICEF maintain that public declarations ‘may change attitudes and potentially reduce FGM’ (2021:22), but provide no evidence. They make similar claims in other annual reports, e.g. referring to public declarations in five Kenyan communities, these were said to have ‘resulted in a total of 1,654 girls declared safe from FGM’ (UNFPA-UNICEF 2020:41). In order to prove that, girls would need to be monitored for at least five years, maybe longer.

It is important to understand the historical continuities in FGM/C eradication efforts. For accounts of the ‘female circumcision crisis’ in colonial Kenya, which arose from missionary attempts to stop the Kikuyu and Meru communities practising FGM/C, see the Introduction to this volume. Most interestingly, in a 1931 article examining the reasons why the Kikuyu community opposed the ban, palaeoanthropologist Louis Leakey suggested ‘an alternative variation on the ceremony of initiation’ which in many ways resembles ARP. He even came up with a proposed curriculum, which included subjects that are now part of ARP curricula (Leakey 1931).8Leakey proposed a period of instruction for initiates, followed by a public ceremony where they would ‘receive a public and permanently visible sign of their initiation, and their arrival into the status of adulthood’. He suggested this could consist of a small cut on the arm or thigh. Leakey did not support or condemn FGM/C, but ‘deplored’ a total ban (1931:284).

Voestermans and Verheggen (2013:9) argue persuasively, from a cultural psychology perspective, against labelling certain behaviour as culture:

The tendency to label behaviour in this way, they write, does not allow us to see the dynamics of a situation, and they specifically mention FGM/C (ibid.:15).

Winterbottom, Koomen and Burford (2009:47) flag up the risks of denigrating Maasai communities which practise FGM/C, warning that approaches ‘that do not address local contexts of FGC, including the complex politics and history of interventions designed to eradicate it, can in fact reify and reinscribe the practice as central to Maasai cultural identity’. Koomen (2014:256), like Hodgson (2017), is uneasy about the ‘pervasive understandings of female excision as a problem of traditional culture’ that are evident in campaigns against it, particularly in historically marginalised communities. She argues that this may have the unintended consequence of politicising the ‘contextual significance of excision’ which may result in the cut ‘[gaining] new significance as a reified symbol of insider Maasai identity’. Van Bavel et al. (2017:10) also see the cut as serving to inscribe Maasai identity onto the body, and as an act of resistance to outsider intervention. Esho, Enzlin and Van Wolputte (2013:225) note that FGM/C inscribes social identity, femininity, sexuality, and fertility onto the body.

Koomen (2014) traces continuities in resistance to colonial-era anti-FGM/C campaigns, and warns of the dangers of overlooking wider struggles by marginalised groups to defend their land, rights, and autonomy. Gruenbaum (2001:25) has written: ‘Simplistic condemnations are not only ineffectual but can also stimulate strong defensive reactions. On many occasions, the pious pronouncements of outsiders against cultural practices deemed “backward” or “barbaric” have provoked a backlash, with people staunchly defending their traditions against criticism.’ These ‘outsiders’ can include other Africans. Graamans et al. (2019:8) make similar remarks. Gruenbaum (2005:431) summarises points made by several scholars:

Prazak (2007:30, 2016:213) notes the unhelpful ‘rhetoric of blame and shame’, while Hodgson (2017:98) claims that Maasai culture is ‘demonized, presumed to be only a source for the oppression of women, not their empowerment’.

This chapter will mostly discuss practices in age-organised societies in Kenya. I prefix my analysis by saying that ARP is a laudable attempt to find an alternative to FGM/C. However, that does not render it above and beyond critique. I should make two things clear: 1. I am not saying that culture does not matter; and 2. The practice of FGM/C has changed over time, as people modified it of their own accord without external intervention.

The term ‘culture’ has by and large been abandoned by anthropologists and other scholars in recent years. However, it has simultaneously flourished in non-scholarly parlance and practice, not least in Africa. That coincides with the increasing proliferation of global indigenous and cultural rights activism. Scholars such as John and Jean Comaroff (1991:21) see culture as a ‘space of signifying practice’. However, as I have previously written, ‘this definition would be unrecognisable to millions who adhere to a “ways of life” concept of culture that is homogeneous, static, timeless, essentialist, and often defined in terms of ethnic difference – the very model that anthropology has dumped … The two concepts are visibly in tension in the space of ARP’ (Hughes 2018:275).11The Anti-FGM Board uses the ‘ways of life’ definition; see its ARP Guidelines: ‘Culture is a way of life, especially the general customs and beliefs of a people at a given time.’

It may be more useful to describe FGM/C, in non-judgmental language, not as a primarily cultural phenomenon but as a component of customary behaviour which is believed to have a transformational function, and upgrades girls and mothers to higher strata. Marriage and childbearing upgrade women further; FGM/C is regarded by its proponents as the first step in that incremental process (Esho, Enzlin and Van Wolputte 2013). Initiation ritual as a whole involves practices rooted in social reproduction and the development of personhood. Females do not belong to age-sets in age-organised societies like the Maasai, Okiek, and Samburu, but the social upgrading that flows from initiation is the closest they get to it. Communities like the Kikuyu, though not generally regarded as age-organised, also used initiation to raise the status of girls and women.12Pers. communication by email with Tatu Kamau, Dec. 2023. Historian Godfrey Muriuki also confirms that this was the case historically among Kikuyu (pers. communication).

References to culture in the literature on ARP and FGM/C can be muddled and unsubstantiated. For example, there is no evidence to support this sweeping claim:

On the contrary, there is abundant evidence that ARP is not widely embraced, opposition exists, families are pressured to ‘supply’ girls, and demand tends not to come from the grassroots but from NGOs, and adults who stand to gain financially from their participation in ARP programmes (Hughes 2018; Mepukori 2016; Prazak 2007; Kamau, Chapter 12 of this volume).14An interesting new trend is emerging among urban middle-class parents who send their daughters to ARP-style camps run by churches or commercial companies. Adverts can be seen posted around Nairobi for ‘rites of passage’ camps. One company advertises ‘Becoming a modern princess. Alternative Rite of Passage Camps’. My thanks to Celia Nyamweru and Milcah Gikunyu for information. Studies and NGO reports often claim that ARP has become culturally acceptable, without providing empirical evidence. Here are other examples: ‘[ARP] is a socially acceptable means that takes girls through all the traditional and cultural processes …’ (Mbogo et al. 2019:26). And this: ‘Since the initial ceremony in Meru, the alternative rites-of-passage approach has gained community acceptance’ (Muteshi and Sass 2005:28). However, the girls who participated in those early ARPs were apparently not monitored later, and the original data is not available, hence this claim is unconvincing.15These earliest ARPs were organised by PATH (Programme for Alternative Technology in Health) and Maendeleo ya Wanawake (MYWO), a women’s development organisation. I have asked MYWO several times if the original data is archived and available to researchers, but had no reply. Chege et al., who studied these ARPs, note that ‘systematic baseline data were not collected’ (2001:6). Yet praise for these ARPs, and unsubstantiated claims of their success, is commonplace in the literature, e.g. ‘The approach has shown evidence of success among a significant portion of the targeted group of young women …’, Toubia and Sharief (2003, seen online). An Amref paper on CLARP (a community-led model of ARP, see Chapter 13) asserts: ‘CLARP has been positively received by the Maasai community’ (Muhula et al. 2021:2; Amref Health Africa 2020). But this only refers to its reception in two sub-counties of Kajiado. Finally: ‘Alternative rites facilitate community ownership and support, as they maintain key cultural practices’ (Matanda, Groce-Galis et al. 2021:55, my emphasis). In my view, they do nothing of the kind. Moreover, the rites do not facilitate community ownership and support; on the contrary, they require this.

Evidence shows that some girls undergo ARP more than once, choosing to take part again partly because the experience is exciting and rewarding (Oloo, Wanjiru and Newell-Jones 2011). Girls in Samburu are known to have attended ARPs run by different NGOs within days of each other (Mepukori 2016:61). NGOs are aware that some ARP initiates have already been cut, or are cut soon afterwards.

Kratz argues that transformation from girlhood to womanhood comes about, in Okiek traditional initiation practices, through a series of rituals that involve intense emotional engagement – not only involving the girls, but also parents, siblings, and other members of the community. Girls are ‘led through the culturally defined sequence’ of rituals, which culminate in a final ceremony. Kratz details how exactly the ‘symbolic associations of signs’ work with one another, in specific contexts, to produce socio-cultural meaning. She emphasises the roles that parents and other key actors play in these processes, which contrasts sharply with ARP, where (from observation) parents tend to be relegated to onlookers.

Kratz emphasises the importance of collectively ‘getting worked up’ for ritual efficacy. This is crucial to the ceremonial experience as well as societal transformation. Ethnographer Paul Spencer also emphasised the importance of emotional ‘build-up’, climax and ‘climb-down’ in Maasai graduation ceremonies. Although he only discussed male ceremonies, he noted how women were central to these as wives, mothers, and daughters (Spencer 1993:146–9). There is certainly plenty of emotion and excitement in ARP, but is that transformative? It surely has more to do with little girls having fun with their pals, meeting boys, and escaping the restrictions of home. I have yet to see any hard evidence that the ceremonies have any truly transformative function.

What has happened to these Okiek rituals since FGM/C was outlawed? Some Okiek continue to practise the cut clandestinely, but many reportedly respect the ban.18Pers. communication with Corinne Kratz by email in April and June 2022, and August 2023.

The women in this group described how cutting their daughters confers higher status on mothers; this is why they like it and want to keep doing it. ‘It’s a graduation ceremony for the girl and also for the parents, because they are on another level’, said Esther:

These answers suggest that one main reason why people in age-organised societies cling to FGM/C when all these other practices have ended is this: none of the other practices or behaviours (apart from warriorhood) involve social transformation and upgrading to a higher state of personhood. Although women do not belong to age-sets, other than through their husbands, they can be upgraded too, via age-related rites of passage that mirror those of boys and men. As Agnes (forty-five) said:

So, in mirroring male age-sets, girls and women are not only ritually united with their peers (male and female) but also enter into important reciprocal relationships within their lineage, clan, section, and community. Yet the organisers of ARP appear to pay no attention to this.

None of these women had heard of ARP. When I described it to them, they loudly chorused: ‘It’s just lying, it’s just cheating! That’s a waste of time. We are not for it.’

In a different part of Maasailand, Lemek in Narok County, another Maasai informant voiced a similar opinion. Eliza was in her seventies, a widow with seven children and forty grandchildren. She, too, had never heard of ARP. When I described it, she was alarmed:

It is significant that she saw this as something the government was doing, although I had not mentioned government. It remains the perception, in historically marginalised communities that have experienced generations of land and other types of loss, that all social interventions must be government-led.

It may be advisable to do away with these hugely expensive ceremonies altogether, and focus on developing private, cut-free rites within the family that retain elements of genuinely traditional ritual. These would shift the focus away from the NGO to the girl, her family, and community. There is increasing evidence that families and communities are making incremental changes anyway, without external intervention, and this should be acknowledged and welcomed. There was already a trend in some communities toward FGM/C becoming ‘less public and more of a family affair’ (Chege, Askew and Liku 2001:44), and that may have increased in the years since this study. Furthermore, current thinking favours gender transformative approaches. Otherwise, by retaining all other aspects of culture apart from the cut, and keeping traditional teachings that emphasise retrogressive gender roles (such as being submissive wives), ARP can hinder positive behavioural change in relation to gender norms.

Rich ethnographies like Kratz’s account of Okiek initiation remain important, even though these practices no longer take place (at least, not in public). They describe what kinds of ritual have resonance, emotional power, and real meaning for the communities concerned. It is vital to ask why and how culture is being mimicked, and what the purpose of this mimicry is, since the efficacy of ARP has not yet been proved, and the interrelationship of its component parts, and how they work together (if indeed they do), is not fully understood either. Until the component parts of ARP are better understood, and it is shown to produce long-term results, it is unwise to say it is ‘crucial to have it replicated and evaluated in other contexts’ (Esho et al. 2017:16).

In the context of FGM/C, cultural relativism is particularly contentious. FGM/C, a rite of passage in various cultures, has drawn international condemnation for its severe physical and psychological impacts on women and girls. Proponents of cultural relativism, however, argue that condemning the practice without understanding its cultural significance risks perpetuating ethnocentrism and neo-imperialism. The FGM/C debate tests the credibility of cultural relativism, challenging the balance and tension between cultural respect and the moral imperative to protect individuals from harm.

Anthropologist Richard Shweder (2000) contends that FGM/C must be understood within its cultural context, where it is often linked to social identity, purity, and adulthood. From this viewpoint, external condemnation, particularly by Westerners, may be seen as an imposition of foreign values that disregards the practice’s cultural meaning. Similarly, Lila Abu-Lughod (2002) critiques Western feminist campaigns against FGM/C, arguing they can reflect a neo-imperialist mindset that frames non-Western women as passive victims needing Western intervention.

However, the application of cultural relativism to FGM/C is controversial. Critics argue that practices causing undeniable harm, like FGM/C, should be subject to universal ethical standards. This critique raises important questions about the limits of cultural relativism: should respect for cultural diversity extend to practices that violate human rights?
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Granted, many practising communities and individuals, where there is awareness of health risks, human rights expectations, laws, and professionals’ restrictions, or autochthonous rethinking, and the ability to mitigate the social risks of discontinuing, have chosen abandonment or transitional lesser forms. But other communities and individuals react with resentment to outside pressures, defending or reframing their traditions in positive ways. Scholars tasked with critiquing these situations have also recognised similarities with male circumcision rationales, subjecting infant male circumcision and intersex infant ‘normalisation’ surgeries to ethical review. Additional arguments swirl around the inconsistencies emerging when tolerance for Western-originating cosmetic surgeries co-exists with criticism of comparable African cutting. We ask what really constitutes ‘harm’, what are children’s rights, and do cultural and religious rights merit special recognition?

Slogans using judgmental terms like ‘zero tolerance’ or ‘eradication’, as well as the insistence on using ‘mutilation’ and ‘barbaric’, are not going to promote the discussions that might foster mutual respect or serve as precursors to social change. Instead, reform efforts should start with listening to people and fostering discussions, as the 1990s Inter-African Committee activists were shown to do in their film Female Circumcision: Beliefs and Misbeliefs (Gruenbaum 1994) and as decades of subsequent African actors have done. To promote discussion and avoid stigmatising, scholars should avoid the word ‘mutilation’ and use plurals (‘cutting practices’, ‘modifications’) whenever possible.

Should rights be the focus and all forms banned? Proponents of some practices resist the idea that FGC violates human rights, asserting competing rights based on cultural identities and religious rights. Others consider medical permissibility (for comfort or appearance) and choice as sufficient reasons not to ban female genital cosmetic surgery (FGCS), if consent is assured. The communities who believe God demands their male or female genital modifications (e.g. prepuce removal for most Jewish and Muslim boys and genital khatna for Dawoodi Bohra girls) are also resistant to bans. An adult woman’s right to choose whether to restitch an infibulation after childbirth or seek deinfibulation is another example. And the rights movement for Bondo initiations in Sierra Leone (‘All Women are Free to Choose’) seeks to alleviate stigma and assert the right to follow identity traditions. For these, contentious scholarly research and journalism seeks understanding across perspectives and shifts ethics debates away from ethnocentric or ‘colonial’ judgments that tend to be applied to African- or South Asian-heritage peoples but not to others who practise FGCS or male cutting.

Embedded in religious expectations, ethnic identities, gender identities, and loyalties to grandmothers, the practices change and evolve, sometimes swiftly, sometimes slowly, or meet with resistance. Understanding what triggers different responses is not easy, but history offers examples of aggressive opposition encountering resistance (e.g. the Rufa’a Revolution against the 1946 ban in Sudan, Gruenbaum 2001). There needs to be a process for rethinking.

Discussion allows new thinking and can result in cultural norms shifting or rigidifying. And social marketing generates discussion, sometimes inspiration and excitement about images of uncircumcised ‘Saleema’, but hopefully always discussion and questions that help people decide their futures. Clear ‘anti-FGM’ laws – pushed by global reformers and embraced by some African feminists as a tool to help convince people to change their traditions – can be helpful at times. But laws are sometimes used by non-cutting majorities to stigmatise and criminalise ethnic or religious minorities. Ironically, the laws and WHO policy generally defend the rights of dominant groups to acquiesce to marketed cosmetic genital enhancements, such as amputating healthy labia (without full understanding of their life-long value) and other cosmetic surgeries, pursue genital piercings for pleasure, or push circumcisions of male babies and men in non-circumcising groups with dubious claims of health benefits.

Reform agendas like Tostan’s (www.tostan.org), or those of Amref Health Africa (amref.org) in Kenya, have sometimes produced broader programmes. The Alternative Rites of Passage strategy used for decades in Kenya (Conradi et al. and Hughes, this volume) also tries to meet social needs for girls’ solidarity groups, cultural learning, and life transitions, while achieving organisers’ intentions to prevent cutting. But as the chapters here show, the results of good ideas are not necessarily what is anticipated, nor are they easily replicable across the landscape of cultural variation. The organisers of anti-FGM/C programmes need to remember that having a good life, and the things that make that possible, are central, and ending female genital cutting practices may not be top of the list when families face conditions of poverty, inadequate food and water, lack of healthcare or schools or economic opportunities, or war.

Two decades ago, a Sudanese colleague, Lena El-Sheikh, and I spent a week doing ethnographic research in a community in western Sudan to determine whether an NGO’s year-long anti-FGM/C programme, completed two years earlier, had been successful. The programme’s monthly lectures by visiting awareness-raising speakers resulted in about 120 boys and men signing a ‘pledge’ to stop cutting their daughters and to ‘allow their sons to marry uncircumcised women’. Our sponsors sent us to learn more about ‘health issues of women and girls’, hoping that the pledge had been honoured and would have spontaneously spread to neighbouring intermarrying communities.

Our mission must have been obvious, because people dutifully denied they did any FGC and the local midwife we sought to interview made herself scarce. But our conversations paid off, and in the course of the week we learned FGC was still practised. The midwife initially denied ever having done circumcisions of any type but eventually welcomed us into her home along with a group of friends and neighbours, once she realised we were there to learn, not report her. She described her version of sunnah – that sounded more like Type 3 than Type 1 – as involving a few stitches. She gestured at the open window and the open countryside beyond, ‘I can’t just leave the girls open, like the road to [the city of] Omdurman!’ It turned out most of the women knew nothing about the pledge the men had signed, though they fully understood the NGO’s opposition to ‘FGM’. Later, one of the men laughingly confided that if Lena and I had been men, they would have beaten us up, because they felt so angry at the NGO. They had expected that by cooperating with the anti-FGM/C campaign, the NGO would build them a new classroom at the school or add another room to the clinic. But, when the funding for the campaign ran out, the NGO just didn’t come back. In an arid environment with no regular electricity, dependent on an ancient pump for their well, an inadequate school and clinic, but with hopes and dreams of a good life, they had a long agenda of needs, and they had expected the NGO would reward their pledge. It was a transaction that failed, from both points of view.

Today, an estimated fifteen million Sudanese civilians are displaced by a senseless civil war that has killed perhaps 150,000 in just two years. The war erupted in 2023 between the Sudan Armed Forces and the Rapid Support Forces militia group, between the two generals who had led the 2021 military coup against the civilian and military Transitional Council working to stabilise Sudan after an inspiring and costly pro-democracy revolution in 2019. The struggle against Beshir, the long-time president/dictator responsible for the Darfur genocide two decades ago and a long reign of oppression, had succeeded, gender equality policies were being pursued, and even a comprehensive law against ‘FGM’ was introduced. But the generals fought over military control of the gold industry and other economic interests, and sacrificed peace. The circumstances of civilian suffering of the Sudanese today are appalling, with massive destruction of homes, livelihoods, hospitals and schools, millions fleeing from bombings, home-takeovers, rape, pillage, hunger, and senseless destruction. The Sudanese agenda surely puts peace, restorative justice, safe shelter, and a return to something approaching normal life (schools, markets, neighbourhoods, and so on) at the top.

Nevertheless, families continue to seek safer venues and providers to do the cutting they feel compelled to do. This demand drives medicalisation, as the choice of a healthcare practitioner – whether trained midwife, nurse, or physician – offers ‘harm reduction’ advantages over the cutting done by TBAs. Many posters and pamphlets of the past graphically and emotionally depicted the horrors of health consequences, blood, and fear, with the image of the ‘evil midwife’, her razor blade, needle and thread at the ready, looming over a frightened girl. Those images, and what Johnsdotter calls ‘the Standard Tale’ of forced, drastic cutting with crude instruments, have been used by reformers to convince families to stop cutting immediately. I have sympathy for this message, but not its form, as there are many who recall their own experience with traumatic, dangerous, unconsented procedures and seek to prevent such painful experiences for girls in the future. But the fear evoked seems to have failed to inspire abandonment, and instead drives families to seek medicalisation.

Two midwives I met during my ethnographic work in Sudan were particularly helpful to my understanding (Gruenbaum 1991, 2020). The first, Sister Battool, was a highly experienced professional nurse midwife I interviewed in the city of Wad Medani in the 1980s and 1990s. She considered FGC unnecessary but was frequently asked to do it by clients worried about marriageability. She tried to talk them out of it, telling parents to let the daughter and her future husband decide later, when they were adults. If they persisted, she agreed to do the lesser non-infibulating cut only. The other midwife was Besaina, a farmer in the Gezira who, as a widow with young children, had had a year of formal training so that she could serve as midwife for her community. Midwifery school did not teach circumcision, which she learned from others. But when she carried out the severe pharaonic circumcisions, she applied hygienic practices she had mastered, and offered skilled cutting, suturing, and follow-up visits for the circumcisions and births she attended. I followed her career at intervals for four decades (from 1977 to 2016) as she moved through a series of changes. Initially she was proud of her extreme cutting and tight infibulations that left a smooth vulva with a tiny matchstick-size opening. Later, her experiences, her son’s comments after marriage, and her own religious learning and pilgrimage to Mecca led her to change from ‘pharaonic’ to sunnah. It took many years to fully implement that intention, since her community demanded pharaonic, but the national discourse and local teachers’ advocacy for the lesser form resulted in a community-wide shift to sunnah, around 1994, then to complete abandonment of even sunnah by about 2010, when Besaina took the oath the Sudanese Ministry of Health expected. This oath, which involved pledging to not do FGM/C, was first introduced in the early 2000s for midwives graduating from training facilities; later, it was asked of others already in practice. Some midwives continue to understand it to mean only giving up pharaonic cutting (Type 3) in favour of a lesser form (Bedri et al. 2019). My research participant Besaina understood it clearly as stopping all forms. And when she took the oath, her community was mostly ready, they had a supportive medical assistant to chase out two midwives from a neighbouring community who tried to do secret procedures, and the decision stuck.

Midwives have not always been included as allies in change, since they are often thought to be motivated to continue cutting in order to collect fees. But if ministries of health were to compensate midwives and offer them greater supervision, instead of leaving them to earn fees for their services, perhaps midwives could more effectively work in abandonment efforts. This could be a fruitful area of research: asking midwives and other healthcare practitioners about their patients’ attitude change over time, and about their roles in persuading clients against infibulation and educating for abandonment. Researchers could also examine whether midwives et al. are, on the other hand, normalising and reinforcing intermediate forms of the practice. It is important to find out how practitioners are influenced and how they may or may not be persuaded to change over time. The effectiveness and limitations of oath-taking, and whether midwives think it applies only to particular types, deserve deeper analysis in future research.

In peacetime contexts, local NGOs with women’s or development agendas found that international revenue streams flowed their way more readily once they added violence against women (VAW), gender-based violence (GBV), or ‘FGM’ eradication to their programmes. ‘The new “traffic in women”’, a Sudanese academic friend quipped, when he described this competition for funding. But it would be wrong to assume that organisations pursue this goal only when pushed by international actors to do so. Many NGOs with this agenda are far from cynical, exercising agency as ardent proponents of ending FGM/C. In Sudan, reformers know the potential for serious health consequences from the pharaonic circumcisions (WHO Type 3) that continue to be the most common form, and which were practised by untrained and ill-equipped dayat al-habil (TBAs called ‘midwives of the rope’).

Many Sudanese women know from their own experience that pharaonic cutting and infibulation are harmful to their health and comfort, even though they may have accepted it as necessary to meet other goals, like marriageability, avoiding shame, or meeting a religious expectation. A persuasive interview came from a woman I had known for many years, since her childhood, in a Gezira Province community. It wasn’t until middle age that she told me she experienced repeated hospitalisation and surgeries as a child, because her severe infibulation did not heal well. Growing up, she knew she would not want to cut her future daughters, but she dreaded the likely confrontation with her mother. She smiled: ‘Thank God all my children were boys!’ Such women are sincere in their desire for change – whether reduction in severity or abandonment. Survey data (Alassad, Chapter 7, this volume) demonstrate that such attitudes are widespread. But to implement change in their lives, they need a supportive social environment.

Fortunately, national scholars and academic institutions, ministries, and other local actors involved in the design of anti-FGM programmes are exerting a positive influence on agenda-setting in some countries. In Sudan, for example, the Gender and Reproductive Health and Rights Resource and Advocacy Center (GRACe) has initiatives in research, conferences, education, and outreach to end FGC. Led by Sudanese gender experts like Professor Nafisa Bedri at the dynamic Ahfad University for Women,29Ahfad is an independent Sudanese university with about 26,000 graduates from Sudan and other regional countries, offering studies in many professional and service areas, including a medical school and School of Public Health, with a commitment to experiential education and community service. The founding family, descendants of early girls’ education advocate Shaykh Babikr Bedri, had quietly stopped doing FGC by the 1950s or earlier, and by 1979 the university-affiliated Babikr Bedri Scientific Association for Women’s Studies was founded for educational outreach to end FGC. As of early 2025, with civil war continuing, the university is struggling from exile to provide online education until there is peace. and benefiting from international funding and in partnership with the Ministry of Social Welfare and Ministry of Health, a Sudanese-led agenda to address FGM/C is moving forward.

Sudanese academics and programme providers have long recognised the limitations of the international MICS and DHS prevalence data, which do not differentiate between the various types of severity and can only show very slow changes in prevalence of some form of FGM/C in successive cohorts of fifteen- to forty-nine-year-olds. GRACe scholars (Bedri et al. 2019) carried out research to identify indicators (‘drivers’) of readiness for change and the steps of change, short of abandonment, that could be utilised for better theories and programmes. Bedri et al. (ibid.) found that shifts in popular thinking and practice were widespread, and there were moves toward a preference for Type 1. Furthermore, limited laws in individual states (during the period prior to enactment of the national law) appear to have negatively affected healthcare professionals’ ability to be candid with researchers, as they claimed not to participate in cutting despite community members saying they performed Type 1. The data discrepancy is understandable, as professionals do not want trouble. Nevertheless, the findings suggest that Type 1 is becoming more widely practised in Sudan, and that it is being done by healthcare providers. Where there is a medicalisation option, it can be hypothesised, people are shifting to Type 1. Indeed, these authors argue that the medicalisation option has encouraged communities ready for change to see a shift in type, rather than abandonment, as an acceptable option. (Data are not provided on the question of whether that regularises Type 1 long term.)

Laws have limitations as strategies of change. Historically, Sudan’s national law only banned pharaonic (from 1946–2020) and was not enforced for decades. Feminists worked for a ban of all forms in the Child Rights Act of 2011, but it was blocked politically by the then president Beshir. A few states enacted weak laws that had little effect. In 2022, after the overthrow of Beshir, a new law banning all forms was adopted as Article 141 of the Criminal Act. But by 2023, that was derailed by war. Instead, research suggests that the most significant drivers of change are the awareness-raising about health risks from individual healthcare providers and in hospitals as well as educational sessions in mosques (where the religious association of sunnah Type 1 FGM/C is a likely factor in the preservation of some forms of cutting) and the oath required of trained midwives. But the brakes holding back change – or perhaps driving in another direction – were still the ‘strong cultural commitment to the practice of FGM/C, social networks and reference groups … forcing continuation of Type III, and the practice of community social ostracism’ that threatens midwives ‘who refuse to do FGM/C’ (Bedri et al. 2019:172).

This research shows no conflict of mission between outsiders and insiders, but rather a genuine goal among Sudanese activists, healthcare providers, scholars, and community members alike to figure out how to make things better for women and girls. If we are convinced that medicalisation lengthens the road to abandonment, then it is banned or discouraged. Families who see it as saving a girl from infections or the other horrors the awareness-raising campaigns have publicised do not see why they cannot make this choice, a dramatic change away from ‘pharaonic’ toward ‘sunnah’, and why they cannot have good healthcare in order to do it. The healthcare providers, faced with families that insist on cutting and who may endanger girls with TBAs, and pressured by social opinion, appear to make the choice to medicalise quietly. It is not surprising that medicalisation continues in many countries, nor that Type 1 is gaining ground in Sudan.

Persistent medicalisation is an inevitable reality that coexists with striving for abandonment. The medicalisation ban also affected the government-employed maternal and child health aides I interviewed in Sierra Leone in 2008, who revealed that they indirectly, and secretly, assisted Bondo rituals by giving tetanus shots or providing sterile tools to the circumcisers to reduce the risks. Nevertheless, Sudanese reform activists continue to oppose medicalisation and seek a law to ban all forms of FGM/C – even though laws alone do not result in change and can create obstacles for obtaining accurate research data. The earlier law (1946–2022) banned only ‘pharaonic’ and permitted sunnah, which resulted in many midwives relabelling their Type 3 cutting as sunnah, as for example the midwife in western Sudan who did ‘sunnah with a few stitches’ so the girls would not be too open. Eschewing the lack of clarity for their persuasion efforts, activists argue that they need the law to clearly ban all forms, no matter how minor or how hygienically performed.

While the growth of the FGCS industry has been a surprise for many of us, it is difficult to criticise consenting adult decisions about legal body alterations. But what about the growth of the market for underage teenage girls seeking female genital cosmetic surgery (e.g. labiaplasty), estimated to be about 20 per cent of FGCS clients in the US (Kalampalikis and Michala 2023)? Even with parental consent or by acceptance of a younger age, like sixteen, for consent, sceptics see this unnecessary trend as influenced not by medical needs but by social pressure, pornographic images, and advertising that influence the view that ‘outies’ are in need of changing to ‘innies’. This is surely just as ‘cultural’ as other FGC, but because it is relatively new, found in middle-class families, and not based on heritage practices nor clustered in a particular race or religion, it is given a pass. What does this tell us about the inconsistency of the arguments?

Second, where there are efforts to change heritage-based genital modification practices – whether for ethical reasons, improvements to health outcomes, religious rethinking, or acculturative or other social change processes as people’s contexts change (from war, migration, education, urbanisation, national communication, new generations, or for whatever reasons) – we should investigate whether making a change to one aspect of genital cutting leads to other changes in gender and sexuality. Does changing to Type 1 invariably get ‘stuck’ there? Do healthcare providers trying to reduce harm in one period of time have a positive role to play in influencing future abandonment? Here, I think of a conversation I heard among young mothers in the Sudanese community where Besaina served as midwife. After the community had made the shift from Type 3 to Type 1 for most families, one young mother was heard, in conversation with her friends, to ask, ‘If we can do without pharaonic, do we really need to do any cutting?’ I believe such conversations can be significant in allowing people to contemplate change. Within ten years, Besaina the midwife had taken the oath never to perform any type, an outside circumciser who had come to do secret cutting was threatened by the medical assistant and chased away, and the community had settled on abandonment. The last girls to have been cut, then teenagers, did not blame their mothers for having them cut, but they resolved never to do it to their future daughters.

Third, how do contexts impact the outcome of projects? It often seems like anti-FGM programmes are looking for a ‘key’ to change, something that will always work – persuasive educational campaigns about health risks or group pledges to generate social pressure, or new laws to deter practitioners or parents. But even good ideas can get stale when repeated. As one Kenyan feminist once told me during the long years when international organisations were stressing human rights as the key argument to replace the ‘health risks’ message: ‘We are tired of hearing about human rights. Why don’t they vary the message?’

Fourth, communication is such an important aspect of social life that the role of social marketing, social media, imagery, language, and artistic productions should all be studied for their roles in reinforcing or challenging thinking. The old posters and slogans of anti-FGM/C campaigns of recent decades can look very ‘colonial’ today, and the need for African artistic leadership in assessing public health education on this topic is compelling. I applaud Samira Amin Ahmed of UNICEF Sudan for her idea, in 2006, to convene a group of artists, poets, religious leaders, health providers, and educators to critique the existing messaging of anti-FGM/C work, suggest new ideas for messaging, and develop a new positive term for uncircumcised girls, Saleema (meaning whole, healthy, in Arabic), around which Sudanese feminists developed a social marketing communication strategy for ending FGM/C (see Alassad, Chapter 7, this volume).

Fifth, we must not neglect dignity, respect, and privacy as values for research foci. Developing clarity about the ethical work and health contexts that could maximize individual and family well-being, informed consent rights, harm reduction, legal rights, and other humanitarian considerations is beneficial. In Global North situations of migration, where laws and standards focus on practices of a racialised or religious minority, the zeal of suppression has led to mandatory reporting requirements for teachers and medical staff, sometimes even unconsented medical examinations, and oppressive surveillance of travelling families (Johnsdotter 2020; Mogilnicka et al., Chapter 8, this volume). This stigmatisation is harmful in itself and merits research attention.

The chapters of this book offer optimism that multiple challenges to the previous set of policy responses to genital modification practices are arising and ideas for workable futures are emerging. The contributors challenge the existing anti-FGM/C discourse by reigniting long-standing wisdom about the need for listening and discussing, for shifting perspectives, and recognising underlying dynamics of change – drivers, readiness for change, social norms challenges, or suppressants – that statistics alone cannot show. Scholarship is finding new footing by questioning simplistic slogans like ‘zero tolerance’ in favour of deeper understanding of lived realities.

The WHO position in the genital modification discourse continues to merit critical scrutiny, because it is inconsistent and questionable to promote infant and adolescent male circumcision based on not completely convincing research on possible benefits, even though it challenges the ‘right to bodily integrity’ that forms the basis of condemning all forms of cutting of females. Similarly, allowing medicalised contexts for genital cutting by cosmetic surgeons and for unnecessary male circumcisions, while denying such care to girls and women who have decided to undergo cultural or religious genital cutting, could be understood as discriminatory, but for the prediction that medicalised contexts prolong the process of change – but do they? Are we able to show evidence? The prevention of harm reduction that medicalisation might afford for those unready to end all forms troubles me. It is my hope that all unnecessary cutting, whether considered damaging or cosmetic, can eventually be dropped voluntarily, that compassion be exercised toward those who have experienced or desired cutting, and that we acknowledge the ultimate motivation to protect children and promote physical, social, and spiritual well-being as much as is possible within the limits of human belief systems. Scholars of all points of view on the ultimate goals should recognise the dignity and rights of individuals and communities to move toward their own social change goals in varying ways along many paths.
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