The Fight against Female Genital Mutilation/Cutting among the Ejaghams of Cameroon: Kinks in the Legal Approach and Implications for Public Health Practice

Abstract

Female genital mutilation/cutting (FGM/C) is one of the most prevalent harmful cultural practices against women and girls in many African countries. We identified reasons for the failure of the legal approach to stop FGC practice in the Ejagham region Southwest of Cameroon through multi-locale ethnographic fieldwork. The reasons revolve around the belief that FGM is useful for the reduction of sexual immorality among women, removal of sexual ambiguity and improving genital esthetics, a feministic symbol and cultural identity, and the government’s socio-economic neglect of the Ejagham communities; the basis for resistance. Non-legal approaches involving community development and women empowerment have been proposed for fighting FGC.

Keywords:

• Female genital mutilation/cutting
• harmful traditional practices
• Ejagham
• human rights
• Cameroon

Introduction

According to the World Health Organization (WHO), Female Genital Mutilation/Cutting encompasses all procedures involving partial or total removal of external female genitalia or other injuries to the female genital organs for cultural, religious, or other non-medical reasons (World Health Organization, 1995). The term FGM does not refer to sex reassignment surgery or genital modification of intersexuals. Different parties to the FGM/C conversation use different expressions to describe the act of female genital mutilation (Sarah et al., 2009; World Health Organization, 2018). The term ‘‘female genital mutilation/cutting’’ is preferred by some United Nations agencies, wherein the additional term ‘‘cutting’’ is intended to reflect the importance of using non-judgmental terminology (Sarah et al., 2009). This paper will, therefore, utilize FGC simply for purposes of consistency.

FGC can have immediate and life-long health harms on the victim. The severity of health harms depends on the type of mutilation but includes immediate physical consequences such as excruciating pain, hemorrhage, localized and ascending genitourinary infection resulting from nonuse of aseptic techniques during the cutting, and death (Sarah et al., 2009). The chronic damaging effects of FGC include urinary, gynecological, psychological, and obstetrical complications (World Health Organization, 2000). Nabaneh and Muula (Satang & Adamson, 2019) emphatically indicate that the recognition of FGC as a gross violation of the human rights of girls and women is well established in numerous international legal instruments, and that nations have made efforts to use laws as a strategy to eliminate the vice. The 2018 World Bank's Compendium of International and National Legal Frameworks on FGM shows that about 60 countries have adopted laws that criminalize FGM/C globally, including 28 African countries (Satang & Adamson, 2019). Despite the impetus demonstrated by some countries to ratify international recommendations on legal reforms to include laws that criminalize FGC, the practice has continued.

The WHO estimates that more than 3 million girls are estimated to be at risk for FGC annually while more than 200 million girls and women alive today have been subjected to the practice. The available data from 30 countries shows that the practice is mainly concentrated in the Western, Eastern, and North-Eastern regions of Africa, in some countries of the Middle East and Asia, as well as among migrants from these areas (World Health Organization, 2018). In Cameroon, FGC is mainly practiced by the Ejagham tribe situated in the Southwest region. There is no official data available showing the exact population size of the Ejagham people in Cameroon. However, conservative estimates put the Ejagham population at 4,564,500 [6]. They are found in both Southwest Cameroon (1, 553,000) and the Cross River State of the Federal Republic of Nigeria (3,011,500) (Joshua Project, n.d.). The colonial partition of the nineteenth century led to the division of this tribe by the Cameroon-Nigeria frontier, but they maintain kinship ties and have similar socio-cultural institutions such as the male secret society (Ekpeh) and the female secret society, Moninkim – which includes FGC as Ejaghams’ rite of passage to adulthood for females (Pemunta, 2012). The Moninkim is considered by the Ejagham women as the pride of their culture because it confers on them a social status that includes marriageability, and thereby being respectable among their peers (Pemunta, 2012). The Ejaghams in the Southwest region of Cameroon survive on small-scale subsistence farming where men are involved in cash crop production (cocoa), while women produce food crops (Pemunta, 2012). This paper explores the reasons for the failure of the legal approach in quelling FGC among the Ejaghams adopted by the government of Cameroon.

Materials and methods

Study design and site

This study is based on multi-locale ethnographic fieldwork undertaken among the Ekwe, Keaka, and Obang- three Ejagham clans in Southwest Cameroon. An extended sexual and reproductive health fieldwork was conducted in the area between 2006 and 2018. The extended case study strategy involved a multiplicity of ethnographic methods; individual in-depth interviews, focus group and informal discussion sessions, case histories of participants, casual and participant observation of relevant cultural fields, and activities. The extended case study strategy highlighted the discrepancies between normative prescriptions and everyday practices, hence its use (Michael, 1998). This method was adopted because of the exploratory nature of the research and to have a feel of the natural environment and the socio-cultural realities – referred to as ‘ecological validity’ of the setting in both time and space (Vulliamy, 1990).

Data collection and analysis

The main data for our study were voluntarily elicited from a total of 273 respondents using both English and Pidgin English. The participants needed to be aged 18 years or above, from the Ejagham clan, and of sound mind to be enrolled into the study. Field notes and tape recording went on simultaneously. Tape-recorded interviews were transcribed as soon as possible in the field and usually within 48 h and coded using CSAC Content Codes to create Meta categories in field notes based on the content, followed by an abstract for every note (Fischer et al., 1996). Microsoft Excel 2016 was used to describe the socio-demographic characteristics of the participants. In keeping with the case study strategy, we identified themes, patterns, and processes, commonalities, and differences (Edwards & Talbot, 1994). Generally, the analysis was carried out at two levels: ‘‘individual-case analysis’’ involving the identification of patterns, consistencies, and differences in what was observed, obtained from subject interviews, focus group discussion sessions with gender, and status within the social structure as important variables. Then, ‘‘cross-case analysis’’ in which individual cases were compared, similarities and differences of opinion identified, and possible explanations were generated (Stake, 1995).

Ethical considerations

In keeping with standard social science research practice, ethical considerations guided our actions in the implementation of this study. Respondents were, on each occasion before an interview or a focus group discussion session, informed of their right to freely participate or not to participate. The participants were also informed that they had the right to withdraw from the study at any point should they develop the need to do so. Therefore, informed consent was obtained before anyone could participate in the study. Furthermore, the principle to respect the terms of negotiations with participants underpinned this research (Reynolds, 1982). Anonymity and confidentiality were maintained by the use of pseudonyms. The study received ethical approval from the Central European University and the University of Yaoundé 1, Department of Sociology.

Result

We explored the reasons for the failure of the legal approach adopted by the Cameroonian government to stop the FGC practice among the Ejagham people, using a multi-loci case study. The demographic characteristics of the study participants are presented in Table 1. The participants were aged 18 years and above and 41.4% were males while 58.6% were females. Most of the participants were either cohabiting (males = 35.4%, females = 28.1%) or married in a monogamous marriage (males = 35.4%, females = 25%), while 17.7% of the males were single compared to 33.3% of the females. None of the females (0%) and only one male (0.9%) had attained university education. However, 61.9% of the male participants and 55% of the female participants had attained primary education.

Table 1. Socio-demographic characteristics of participants.

	Participants’ sex
	Male N = 113 (41.4%)		Female N = 160 (58.6%)
	N	%	N	%
Age group
18–22	45	39.8	60	37.5
23–49	51	45.1	65	40.6
50–65	15	13.3	35	21.9
66+	2	1.8	0	0
Marital status
Single	20	17.7	50	31.3
Cohabiting	40	35.4	45	28.1
Married (monogamy)	40	35.4	40	25.0
Married (Polygamy)	7	6.2	10	6.3
Widower/widow	6	5.3	15	9.4
Education level
No formal education	23	20.4	30	18.8
Primary education	70	61.9	88	55.0
Secondary education	10	8.8	12	7.5
Vocational training	9	8.0	30	18.8
University	1	0.9	0	0

The data was carefully analyzed and four main themes emerged as the reasons why the Ejagham clan perpetuates the FGC practice and the reasons why they resist the government’s attempts to stop the practice. Therefore, the findings of this study are organized under four themes, namely: reduction of sexual immorality among women; removal of sexual ambiguity and improving genital esthetics; a feministic symbol and cultural identity; and the government’s socio-economic neglect of the Ejagham communities; the basis for resistance.

Reduction of sexual immorality among women

In Cameroon, FGC is practiced in several communities with different cultures and religions. It is estimated that approximately 20% of females in the South Western (English-speaking), extreme Northern, and Eastern Provinces (French-speaking) of Cameroon have undergone the ritual. In the South-Western region, it is practiced among the Ejaghams who live in the area between Cameroon and Nigeria. They conduct this act on female children either at birth or puberty and they call it circumcision. Some respondents explained that FGC is a ceremony that symbolizes status appropriation among the Ejaghams; a process of appropriating and expropriating desirable and undesirable traits respectively. Ejaghams believe that the clitoris was responsible for sexual immorality among women and that its removal helped women to have self-control over their sexual desires. According to some respondents, Ejagham women were expected to have a dignified sexual life devoid of promiscuity, and that FGC played a pivotal role in ensuring this. The foregoing ideology was shared by many of the participants interviewed in this study. A participant responded as follows:

The circumcision that is given to girls cools down their sex anxiety. The high number of uncircumcised girls today explains the rampant prostitution and sexually transmitted infections. It should still take place so that anxiety and immorality will reduce thereby reducing diseases. (Mary, 29 years old)

The Ejagham people were not willing to have the FGC practice obliterated because they believe that it was necessary for the prevention of sexually transmitted infections (STIs). Therefore, according to this study, stopping FGC was viewed by the Ejagham people to be a ploy aimed at endangering the health and lives of their younger generations. The findings also show that Ejaghams believe that stopping the FGC practice would lead to the erosion of female morality and dignity building which may lead to a disorderly society.

Removal of sexual ambiguity and improving genital esthetics

Our participants claimed that the Ejagham clan had an old but strong belief that viewed humans to be bisexual beings. The belief states that males have a feminine organ (the penile foreskin), while females have a rudimentary male genital part (the clitoris). Therefore, according to the findings of this study also present in previous literature (Barkty, 1990), if the clitoris is not removed women’s sexual identity remained unclear and therefore would face “social public sanctions.” Additionally, several participants in this study also reiterated that the clitoris and labia make the female genitalia look ugly. The response cited below underscore this notion:

To us, we have reasoned that the clitoris is not nice. When not cut, you are both a woman and a man at the same time. Look, the vagina looks ugly in its natural appearance. This can be corrected by the circumcision which we do. You must know that women here have the right to make any part of their body look beautiful just like men. Why does the government support male circumcision but want to stop female circumcision? It is disrespectful for the government and its agents to just come here and try to stop our choices. (Bassey, 58 years old.)

Based on the above result, FGC is practiced among the Ejaghams to eliminate perceived gender ambiguity and to ensure the esthetic appeal of the female genitalia. The study found that FGC provides women with a secure sense of identity as females. Therefore, efforts to stop the practice were considered by the Ejaghams as means to discourage women from liking and embodying their femininity. The Ejaghams resisted efforts that aimed to stop the FGC practice because such attempts were seen to disrespect their choice to beautify the female genitalia. The cited respondent also suggests that the government’s efforts targeted at stopping FGC, while allowing male circumcision, could be linked to power inequalities between men and women and tantamount to disrespect.

A feministic symbol and cultural identity

According to this finding, FGC which is part of the Moninkim ceremony is practiced to distinguish Ejagham women from other women who hail from other tribes. This finding establishes FGC as a feministic symbol and a cultural identity practiced to imbue tribal pride and dignity among the Ejaghams. One of the respondents eloquently alluded to this by stating as follows:

The real Ejagham woman is the one who has been circumcised. Subjecting oneself to the ritual cutting of female circumcision is like going to the university and graduating with a degree. As an Ejagham woman, you can only be considered to have fully undergone the Moninkim if you have also been circumcised. Such women stand out as the pride of our tribe and culture. That’s what makes Ejagham women different from other women. We cannot stop this. (Nkoyo, 45 years old)

Another respondent said the following:

To go through the pains of initiation without crying showed that you could withstand the pains and troubles of everyday life. These include the pains of childbearing, of taking care of children, and of maintaining oneself in marriage, which are only possible with patience and perseverance. (Mami Ayuk, 70 years old).

The results above demonstrate the prestige placed on FGC, to the extent that undergoing the practice was likened to acquiring a university degree. The Ejaghams are not willing to put aside FGC, which is part of the Moninkim, because to them it is the hallmark of their culture and tribal identity. Most respondents in this study pointed out that Moninkim was the “school for the women before the advent of formal education.” This particular finding exposes the low value placed on educational attainment among the Ejaghams. Some of them stated that according to the Moninkim ideology, the pain of initiation during the FGC procedure is a symbolic representation of the pains and tribulations of everyday life, and it prepared the Ejagham girls to take on adult responsibilities, including childbearing.

The government’s socio-economic neglect of the ejagham communities; basis for resistance

The Ejagham community did not trust the Cameroonian government due to what the study respondents described as the government’s socio-economic failures. The respondents felt that colonial and post-independence Cameroonian governments have not devoted any effort to uplift the socio-economic status of the Ejagham communities. Some respondents said that the Ejagham communities have been marginalized and neglected by the government in terms of development. They constantly referred to the lack of schools, health facilities, transport and communication facilities, access to clean and safe water and sanitation, electricity supply, and other social amenities in the Ejagham region. These findings imply that the Ejaghams viewed the government as an irresponsible adversary because of its neglect, and would not cooperate with it in the efforts to stop FGC. Several participants expressed displeasure with the Cameroonian government’s failure to bring development to the Ejagham communities as seen in the two examples below:

The government has neglected this place for far too long. There is no development here; we have no schools, no hospitals, no roads, no electricity, and telecommunication towers. Most of our people here share drinking water sources with domestic and wild animals. So, we have nothing much happening here apart from our cultural activities. Why should the government bother us about quitting our ways of life if they cannot provide ordinary development? (Obed, 38 years old)

Why should we abandon female circumcision? This is like our own activity; it is like our own occupation. Our cultural practices keep us engaged as a community. The government does not care about our welfare. Why are they only concerned about our culture and traditions? Look, I have just returned from my farm with cassava and there are no customers to buy it because everybody has. If there was a road network here linking this community to markets, I would take it there or customers would come to buy it. Additionally, most of our children do not even attend school because of poverty and the lack of schools within the vicinity. The government does not care about us, they only show up when they want to push their selfish agendas. Therefore, we cannot be forced to abandon our cultural practices for the sake of pleasing a government that does not care about our welfare (Agbor, 50 years old)

According to the findings of this study, the socio-economic amenities including educational facilities, health facilities, economic facilities like roads and markets, constituted the needs of the Ejagham communities. In the same vein, the study results showed that the government needed to create trust among the Ejagham people for them to embrace any suggested cultural transformations such as the abandonment of the FGC practice.

Discussion

Evidence from previous literature shows that the Cameroonian government utilizes a legal approach to discourage the perpetuation of the FGC practice among the Ejagham people (Battle et al., 2017). The legal approach involves meting out penalties ranging from three months to life imprisonment sentences or imposed monetary fines, also adopted in other countries (Galukande et al., 2015). However, the legal approach has been resisted by the local Ejagham communities. Therefore, a basic understanding of the reasons why the Ejaghams practice FGC and/or why they resist government efforts to stop FGC is important.

Four main reasons why the legal approach adopted by the Cameroonian Government in compelling the Ejagham people to stop the FGC practice fails have been identified. They include the belief that FGC reduces sexual immorality among women, removal of sexual ambiguity and improving genital esthetics, a feministic symbol and cultural identity, and the government’s socio-economic neglect of the Ejagham communities; the basis for resistance.

The Ejaghams perpetuated FGC for purposes of reducing sexual immorality among women. The study results have shown that the Ejaghams are not willing to stop the FGC practice because they believe that it reduced women’s sexual desires thereby making them morally upright and accepted in society. The finding is consistent with previous research results elsewhere (Shah, 2015). The removal of the clitoris is believed to minimize a woman’s libido and assist her in resisting sexual activity thereby preventing her from acting promiscuously. In this way, FGC is considered to be part of the community strategies to reduce the transmission of STIs and making the woman more appealing to her future husband. For this reason, the Ejaghams would not want to stop the FGC practice. However, this notion has been viewed by other authors as a means to perpetuate social control over women, an act seen to be entrenched in gender inequalities and power dynamics that favor males (Shah, 2015). Evidence from previous literature shows that FGC is one major indicator of gender inequality and that it is linked to child marriage, forced sexual debut, and health complications across the life course (Galukande et al., 2015; Shah, 2015). Therefore, FGC violates several human rights outlined under the Universal Declaration of Human Rights, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the Convention on the Rights of the Child (Galukande et al., 2015; Goldberg & Kelly, 1993).

The FGC practice among the Ejaghams was found, in this study, to also be premised on the elimination of sexual ambiguity and improvement of female genital esthetics. While there is evidence from previous study results discussing a variety of cultural beliefs about the clitoris, no particular study has found this result. For example, findings from other African settings show that the clitoris is believed to have the ability to kill babies upon delivery; make a man impotent, sick, or even die if his penis comes in contact with it (Galukande et al., 2015). The Ejagham clan also have their reasons for removing the clitoris through FGC and are not willing to stop the practice due to the same reasons. The Ejaghams believe that the clitoris conferred masculinity on a woman and that it makes the vulva (outer vagina) look ugly. The removal of the clitoris through FGC, therefore, distinguishes women from men and makes the vulva desirable to look at by men. This finding links back to women's domination by men, also found by other studies elsewhere (Lambek, 2005; Douglas, 1980). This also confirms the fact that rituals concerning the body enact a form of social relations and in giving these relations visible expression, they enable people to know their society (Lambek, 2005).

FGC is practiced as part of the Moninkim ceremony which is a feministic symbol and cultural identity for the Ejagham ethnic group. This tradition is considered to be the earliest school for the Ejagham clan by which elderly women prepare girls for marriage, also reported by studies conducted elsewhere (Waigwa et al., 2018; Ozah, 2015; Antabe et al., 2019). The Ejaghams view any attempts by the government to stop the FGC practices as an assault on the freedom of enjoying their culture and traditions. They place a high value on the practice because they believe that it is their birthright passed on to them by their forefathers. FGC is considered to be a means to preserve ethnic and gender identity, femininity, female purity, and family honor. The study results show that the Ejaghams esteem FGC to be a means of maintaining women’s cleanliness and health; and assurance of women’s marriageability. Through the Moninkim, FGC is used as a rite of passage to womanhood with strong ancestral and sociocultural roots such that Ejagham women who have not undergone the ritual are socially scorned and considered not suitable for marriage.

The Ejagham communities in Cameroon rely on subsistence farming; in which men mainly perform cash crop production (cocoa), while women occupy themselves with food crop production (Pemunta, 2012). Our study found that the Ejaghams were not willing to cooperate with the Cameroonian government on stopping the FGC practice, despite legal penalties, because of the failure by the government to provide socio-economic services. According to the findings of this study, there were no health facilities, no schools, no transport and communication infrastructure, and no clean and safe water and sanitation. For this reason, the Ejaghams felt neglected and had low trust for the government. The Ejaghams demand equal access to developmental resources if they have to be allies to the government’s effort to stop FGC; the government should bring development by way of building schools, hospitals, roads, and provide clean and safe drinking water. Our study findings are supported by previous literature that shows evidence of the efficacy of the provision of education, community empowerment, and socio-economic development as tools to bring cultural transformation in ending harmful cultural practices like FGC (Galukande et al., 2015).

Public health policy and practice implications

While it is true that FGC is a medical, legal, and also human rights issue, we argue that it is more of a socio-cultural practice embraced by a society that consciously conducts it regardless of the attending consequences. Therefore, efforts by any change agents to stop FGC should consider the social bedrock upon which the practice is anchored. Based on the findings of this study, FGC would not be easily eradicated by repressive and legal quick-fixes because of the reasons discussed. We suggest that a combination of socio-economic development; including the provision of basic health services, education facilities, road infrastructure as well as female empowerment through education, can lead women to abandon FGC (Chai et al., 2017). Active community engagement and empowerment by ensuring that interventions are informed by the lived experiences, needs, and views of those affected by FGC will ultimately yield positive results, an approach also suggested by other authors (Chai et al., 2017). This implies that the Cameroonian government and its change agents should adopt a bottom-up approach based on listening to the community members, in the place of the usual top-down legal approach that has dominated the fight against FGC in the Ejagham region.

The provision of community empowerment through education and socio-economic development may only be able to yield results in stopping harmful cultural practices in the long-term, but is one of the sure ways to have long-lasting social change and build indelible trust between communities and their governments (Galukande et al., 2015; Shah, 2015; Babalola et al., 2006; Boyle & Corl, 2010). The implication of the legal maneuvers to have the Ejaghams quit the FGC practice, a tradition they have practiced for several centuries, is that they should do so immediately. This explains why such approaches have failed in the Ejagham region. We, therefore, suggest deliberate but civil approaches that aim at creating an alternative modern way of life, thereby encouraging the abandonment of harmful traditional beliefs like FGC. In the case of the Ejagham region, we suggest that the Cameroonian government should prioritize the creation of trust by building educational, health, transport, and communication infrastructure. We further propose an all-inclusive, multi-pronged approach to anti-FGC policy approaches that aim to alleviate abject poverty through fair distribution of social services, thereby winning the Ejaghams’ trust and cooperation. The Ejagham people, like other citizens, would like to see their government engaging them on various developmental matters. This will make them amenable to change, including quitting harmful traditional practices like FGC. We insist that there are no quick fixes to long-held, socially entrenched cultural practices. Therefore, the Cameroonian government should commit to long-term civil and multi-sectoral engagements with the Ejagham people.

However, investing in broad, long-term approaches, as Glymour (Maria et al., 2014) suggests, may not be motivating to politicians whose focus is usually on quick fixes intending to appease voters. That notwithstanding, the study participants strongly demanded the Ejaghams’ equal access to national resources and investments in social services to improve their socio-economic situations, as much as they have to quit FGC. This is in line with Kawachi et al. (Ichiro et al., 2014) who convincingly argue that socio-economic status (SES) is an important trigger to a plethora of health and social events. Therefore, the Cameroonian government may not succeed in quelling FGC without addressing poverty among the Ejaghams. The FGC practicing communities must be handled holistically by addressing their developmental needs, and have all the stakeholders involved in developing a policy roadmap. This ensures that the issue of FGC is included on the national agenda and that all stakeholders are not shy to have a conversation about it. But as argued by Buse et al. (Buse & Mays, 2012) “it is one thing for an issue to get onto the agenda, yet another for it ultimately to be acted upon.” Therefore, leaders (political and community) must commit to fighting FGC.

FGC is a “highly sensitive and culturally embedded practice,” (Sarah et al., 2009) therefore, strategies must be based on community values and customs. The practitioners of FGC also known as “traditional female excisors” (De Silva, 1989), must be allied to the process of change. This is because they have earned a social reputation that not only accrues respect and prestige to them but also payments. Therefore, it would be prudent to offer them alternative sources of income. One suggestion is to retrain them as village health workers or birth attendants so that they retain their prestigious social positions but rechanneling their energies to more beneficial health activities (Sarah et al., 2009). Parents of children must also be involved. The motivation for parents to have their girls undergo FGC is for social conformity. Because marriage is highly esteemed in these communities, parents worry that their daughters would be regarded as unmarriageable if they do not undergo FGC. Therefore, they should be brought on board, with the help of couples who are not circumcised as role models, to build a narrative that uncircumcised women are marriageable. The above stakeholders should constitute the center of any policy aimed at changing society’s view of FGC. However, several other stakeholders are cardinal to this discourse and their selection will depend on the context of the implementing state; traditional and religious leaders, civic leaders, political leaders, law enforcement agencies, civil society organizations, and many more others must be harnessed into the band to ensure inclusivity and reduce the likelihood of resistance against the FGC fight.

Conclusion

We identified four main reasons why the legal approach adopted by the Cameroonian Government in compelling the Ejagham people to stop the FGC practice fails. The four main reasons for the Ejaghams’ continued practice of FGC and their refusal to stop it are reduction of sexual immorality among women, removal of sexual ambiguity and improving genital esthetics; a feministic symbol and cultural identity, and the government’s socio-economic neglect of the Ejagham communities; the basis for resistance. Finally, we propose that non-legal actions involving a multi-pronged community development approach that is gender-sensitive, all-inclusive, and address women’s other needs in terms of empowerment through the provision of sexual and reproductive health services, affordable health care facilities, education, clean water, and sanitation are necessary prerequisites to the successful implementation of un-FGC interventions.

Conflict of interest statement

The authors declare that they have no competing interests.