Socio-Anthropological Determinants of the Practice Persistence of Female Genital Mutilation in Conakry, Guinea in 2021

: Introduction: This study aimed to analyze the socio-anthropological determinants of the persistence of the practice of female genital mutilation in Conakry. Methods : A one-month qualitative study (May 1-31, 2021) involving seven categories of people (mothers and fathers, imams, Christian religious leaders, local elected officials, young girls and boys) in Conakry. Results : This study shows that 81% of participants consider FGM to be a customary and traditional practice and a legacy of their ancestors to be perpetuated. More than half of the respondents (52%) considered FGM to be a religious prescription. Others thought that FGM was intended to ward off bad diseases and reduce the odor of young girls' urine. The majority (66.7%) saw uncut women in a negative light, as free women who could not control their sexual urges. Nearly half (46%) of the participants did not know that FGM could lead to complications and 31% of them did not know that there was a law in the country prohibiting the practice of FGM. Conclusions : Religious beliefs, customs, traditions, and the stigmatization of uncircumcised women contribute to the persistence of FGM in Conakry. The fight against this scourge requires that these aspects be taken into account in all response strategies.


Introduction
Female genital mutilation (FGM) is a procedure that results in the partial or total removal of a woman's external genitalia or other injury to the female genitalia for nontherapeutic purposes [1].
FGM is almost always performed on minors and is therefore a violation of children's rights, which is why some countries formally prohibit FGM in the name of human rights [10,11].Although FGM is internationally recognized as a human rights violation and legislation to prohibit the practice has been put in place in many countries, the practice persists Female Genital Mutilation in Conakry, Guinea in 2021 to this day in 30 African countries [1,12].
In Guinea, the prevalence of FGM is one of the highest in the world.As of 2018, 95% of women aged 15-49 are estimated to have been cut.This statistic places Guinea second only to Somalia (98%) for the practice of FGC [13,14].Yet, the 2016 Guinean penal code confirms Guinea's commitment to criminalize FGM in its articles 258-261 [15].
Despite all the efforts made to fight this scourge, it must be noted that these practices still persist in communities and are a major concern.Hence the importance of a study on the socioanthropological determinants of the persistence of FGM, in order to guide new approaches in the fight against this scourge.

Setting, Design and Population of Study
This was a cross-sectional study using a qualitative method over a one-month period (May 1-31, 2021).The study included seven categories of people: mothers, fathers, imams, Christian leaders, local elected officials, girls and boys living in the selected neighborhoods in Conakry, Republic of Guinea.

Data Collection and Management
The saturation method was used to determine the sample size.Saturation was considered to have occurred when we found 4-5 consecutive people with ideas already given by their predecessors.
For participant recruitment, a neighborhood was randomly selected in each municipality.Within the neighborhood, cluster sampling was used to select families.Within the families, individuals meeting the inclusion criteria were recruited.Sociodemographic characteristics, religious beliefs and customs regarding FGM, community perceptions of uncircumcised women, people's representation of virginity, and knowledge of the complications and the law prohibiting the practice of FGM in Guinea were explored.
For data collection, we used a semi-structured individual interview lasting an average of 45 minutes was conducted in French or in a national language for respondents who did not understand French.The interviews were recorded with the respondents' consent and accompanied by note-taking.The data were collected by a team of two physicians (one female and one male) who had been trained for this purpose.The women were interviewed by the woman and the men by the man.The recorded speeches were transcribed immediately after the interviews and the information collected was analyzed according to the different themes.

Characteristics of Participants
In this study, 69% of the respondents were women and 31% were men.The mean age of the women was 36.6±11.07 years and that of the men was 40.8±13.8years (Table 1).

Representations and Beliefs
This study found that 81% of participants considered FGM to be a good practice because it is part of their customs and traditions.They said, "ko naamou men" in Pular or "won ma namounyi naara" in Sousou, which means "it is our custom.
Among them, 77% consider that FGM is a heritage from their ancestors to be perpetuated and none of them want to be the first to put an end to an ancestral tradition: "koko tawroudhen mawbhe men ko be dyokken" in Pular or Sousou "Dji folokhi moû bembé nanma moulanma moukharaba sounna narra ana moukha dinènè" which means "it is something we found among our elders and that we are obliged to follow".Nearly 3 out of 10 respondents (29%) said that it was a way to educate young girls: "FGC is a customary practice that we inherited from our ancestors.Another respondent added: "We must continue excision, otherwise prostitution will gain ground in our country as in the West, and we will not be able to educate our girls.
The study revealed that 52% of the participants considered FGC to be a religious prescription to be followed.One respondent mentioned that "the practice of FGC is part of Islam (recommended by the Prophet).One of the imams interviewed stated that "Islam says to cut in a moderate way by cutting a small part of the clitoris.
It was also noted that 7% of respondents believe that female circumcision is neither permitted nor prohibited by religion, such as the person who said, "I don't know what the Bible says.Does it say to cut girls or not?
Removes bad diseases from the girl, reduces the smell of her urine, drains bad blood from her body, prevents the clitoris from developing to look like a man's sex, prevents genital infections were other reasons given for keeping female circumcision.On this, one respondent said, "If a woman is not circumcised and she sits on a dirty place to relieve herself, she will be infected, whereas if she is circumcised, she will not.
Only 19% of the respondents, the majority of whom are intellectuals, consider FGM a bad practice because it harms the health of the girl, as in the case of this respondent who said, "FGM is not a good practice, it harms the health of the girl, it can lead to bleeding and infections such as HIV and hepatitis," and this other respondent added, "FGM is a bad practice that can cause pain during sexual intercourse, sterility and even death of the girl."But because of the mockery, stigma, and discrimination that uncircumcised women face in the community, and because of the fear of being called " soli" or " bilakoro" in the Sousou, Poular, and Maninka languages, both of which mean " uncircumcised woman.

Perceptions of Uncircumcised Women
The study found that 66.7% of respondents viewed uncircumcised women negatively and described them as "easy women, unfaithful, vagabonds, women who are not ashamed, who cannot control their sexual urges.One respondent said in Soussou: " soli guiné mou nooma a yètè soukhoudè khamè yaara, langoe guinée naara" and another said in Malinké " Ni mousso madji ala kéko dibhèleya a dikè bilakrodi," literally "an uncircumcised woman cannot hold back in front of a man.
For 44% of respondents, "uncircumcised women have not respected custom and religion (the Sunna of the Prophet).They are disobedient, impure, predisposed to prostitution, to early sexuality.They cannot be satisfied by one man.Some of the women interviewed (15%) said that "uncircumcised women do not have a beautiful sex", like this respondent who said that "the vagina of an uncircumcised woman is not beautiful to see".Others said that "they have a strong smell that is unbearable, their urine smells bad."For example, this respondent said in Soussou "soli guinè khiri nyakhu pète" which means "an uncircumcised woman smells very bad.
This study shows that 4.6% of respondents said that "an uncircumcised or poorly circumcised woman cannot have children" such as the one who said "Bheygou koto an hari suuwaaki laabhi kodhun wadhi koko men suuwitoyi mo dhibmun o yhetti reedou" in Pular, which literally means "my sister-in-law was not well circumcised, it was only when she was circumcised a second time that she conceived.
Three out of 27 male respondents (11.1%) said they "don't want to have sex with an uncircumcised woman," like this man who said in Pular, " Yo Alla dandan mi waalodudè et solii dyo," literally "May God preserve me from sleeping with an uncircumcised woman." About one in three respondents (33.3%) with a secondary education or higher felt that they had "no problem with not being circumcised" and considered these women to be "complete, ideal, normal women," as this respondent noted: "I consider her to be a woman like any other woman, because in other countries women are not circumcised, but they live normally and have children.Another person added: "She is the best woman, because she is complete, nothing has been taken away from her and she is a woman who feels sexual pleasure as she should.
According to them, it is necessary "to put an end to this practice of excision, which is responsible for many complications.

Knowledge of a Law Prohibiting FGM
We noted that 7/10 of the respondents were aware of the existence of a law in the country prohibiting the practice of FGM, such as this person who said, "I know that there is a law in the country about the practice of FGM, they often say it on the radio and television."But according to them, "the implementation of this law is difficult because of the sociocultural and religious context of the country."One interviewee stated that "many people who are involved in the fight against FGM are not doing it out of conviction but simply because they make money from NGOs." On the other hand, 31% of respondents were unaware of the existence of a law prohibiting the practice of FGM in the country.Several respondents expressed themselves as follows: "I don't know the existence of a law in the country that prohibits the practice of FGM, and even if I did, I wouldn't respect it because God's law is above the laws of men."

Discussion
Although all social strata of the country were included in this study, the results may not fully reflect the opinions of the population in the interior of the country, where cultural constraints may be more pronounced due to stronger customs and traditions, fewer intellectuals, and less frequent exposure to the media, among other things.Nonetheless, the findings provide some insight into the sociocultural factors behind the persistence of FGM in Guinea.
This study shows that the representations and beliefs about FGM of the majority of respondents are in favor of continuing the practice.The ancestral and religious nature of the practice of FGM makes it difficult to abandon.The perception of FGM as a way to educate young girls, to fight Female Genital Mutilation in Conakry, Guinea in 2021 prostitution, or as a way to reduce women's bad odor or to prevent the clitoris from growing like the penis contributes to the perpetuation of FGM in the country.In the absence of appropriate strategies that take these aspects into account, the practice may still have a long life ahead of it.The justification of the practice of FGM by religion and the sometimes ambiguous position of religious people by saying that the practice of FGM is neither prohibited nor authorized or that it is authorized but only a small part of it should be suppressed does not facilitate the fight against this scourge.Our finding is similar to that of the Canadian Society of Obstetrics and Gynecology (CSOG) regarding the role of cultural and religious factors in the perpetuation of FGM [16].
Some studies [13,17,18] have also found that communities and families practice FGM because it is a tradition, a cultural heritage, an ingrained social norm that weighs heavily on those who would renounce it because it is a symbol of a collective cultural identity.
According to Daya [19], several reasons are put forward to justify the practice of excision, notably the fact that excision is considered a means of repressing a woman's sexual desires, of exercising control over her sexuality and fertility, and of guaranteeing her chastity and fidelity to a single man.According to Perron et al [20], parents subject their daughters to female genital mutilation not to punish or violate them, but to protect them and offer them "the best possible chance of a future that ensures their social acceptability and economic security".The religious requirement was reported by Hamdia [21] as the main reason why Iraqi Muslim religious leaders support FGM.Also in relation to religion, Mseddi et al [22] report that FGM is practiced by Muslims, Christians, animists and atheists.Bakayoko et al [23] explain the persistence of the practice of FGM by the desire to respect customs, traditions and rites, the fear of mystical attack in case of non-compliance with tradition and Islamic recommendations.
In this context, marked by the negative influence of cultural and religious constraints, there has been a positive evolution of mentalities, with the intellectual stratum qualifying the practice of FGM as harmful to the present and future health of young girls and believing that all measures must be taken to put an end to this practice.
According to Da Silva et al [24], FGM is practiced for reasons of aesthetics, hygiene, purity, promotion of fertility, protection of virginity, control of fidelity, especially in polygamous societies, increase of male sexual pleasure and access to marriage.
The stigmatization, discrimination and marginalization to which uncut women are subjected, according to several respondents, make it difficult to accept their uncut status and justify the continuation of this traditional practice even among women opposed to FGM.The fear of being called a soli, a bilakoro, an easy woman who cannot control her sexual impulses, an impure woman, as well as the establishment of a link between FGC and a woman's fertility and the rejection of uncut women by some husbands also represent an obstacle in the fight against this form of violence against women.For some authors [17,25], the fear of being ridiculed, stigmatized and marginalized, and of being described as a bad Muslim or an easy woman have also been reported as factors that push families to continue practicing FGM.According to Perron et al [20], some men prefer circumcised women because they believe that circumcision increases male sexual pleasure.Studies [25] report that some men who unknowingly marry an uncircumcised woman and realize it later prefer to divorce her or send her back to her family to undergo the practice before being accepted by her husband.Our study shows that the level of education seems to have a positive influence on the perception and image of uncircumcised women.The higher the level of education, the more positive the perception.All those with a higher level of education believe that uncircumcised women are complete, ideal and normal.Schooling thus appears to be an effective means of combating the stigmatization of uncircumcised women, which may contribute to the abandonment of the practice of FGM.

Conclusions
Despite multiple awareness and education efforts on the subject in Guinea, this study found that the majority of participants (81%) still considered FGM a good practice.This is motivated by the fact that they consider FGM to be part of their customs and traditions.This study also shows that religious beliefs, customs, traditions, stigmatization, and discrimination against uncut women contribute to the persistence of FGM in Conakry.The challenges in the fight against this scourge remain important and concern schooling, information, sensitization of the population, including religious leaders, on the harmful consequences of FGM, and law enforcement.In addition, we recommend that a nationwide study be conducted to better understand the socio-anthropological factors of FGM in Guinea.

List of Abbreviations
FGM, Female genital mutilation; FGC, Female Genital Cutting; NGOs, Non-governmental organization; CSOG, Canadian Society of Obstetrics and Gynecology; WHO, World Health Organization.

Ethical Approval and Consent to Participate
The study carries no risk of adverse effects as it is noninterventional.Nevertheless, before the launch of this study, its protocol was presented for validation and approval by a scientific jury of the Chair of Gynecology and Obstetrics of the Faculty of Health Sciences and Techniques of the Gamal Abdel Nasser University of Conakry.Before undertaking the field activities, authorization was obtained from the commune and neighborhood leaders.Informed oral consent was obtained from each participant before data collection.To preserve confidentiality, the data collected was anonymous

Table 1 .
Distribution of respondents according to socio-demographic characteristics.