Women's position and attitudes towards female genital mutilation in Egypt: A secondary analysis of the Egypt demographic and health surveys, 1995-2014
Van Rossem et al. BMC Public Health
Women's position and attitudes towards female genital mutilation in Egypt: A secondary analysis of the Egypt demographic and health surveys, 1995-2014
Ronan Van Rossem 0
Dominique Meekers 1
Anastasia J. Gage 1
0 Department of Sociology, Universiteit Gent , Korte Meer 3-5, 9000 Ghent , Belgium
1 Department of Global Community Health and Behavioral Sciences, Tulane University, School of Public Health and Tropical Medicine , 1440 Canal Street, New Orleans, LA 70112 , USA
Background: Female genital mutilation (FGM) is still widespread in Egyptian society. It is strongly entrenched in local tradition and culture and has a strong link to the position of women. To eradicate the practice a major attitudinal change is a required for which an improvement in the social position of women is a prerequisite. This study examines the relationship between Egyptian women's social positions and their attitudes towards FGM, and investigates whether the spread of anti-FGM attitudes is related to the observed improvements in the position of women over time. Methods: Changes in attitudes towards FGM are tracked using data from the Egypt Demographic and Health Surveys from 1995 to 2014. Multilevel logistic regressions are used to estimate 1) the effects of indicators of a woman's social position on her attitude towards FGM, and 2) whether these effects change over time. Results: Literate, better educated and employed women are more likely to oppose FGM. Initially growing opposition to FGM was related to the expansion of women's education, but lately opposition to FGM also seems to have spread to other segments of Egyptian society. Conclusions: The improvement of women's social position has certainly contributed to the spread of anti-FGM attitudes in Egyptian society. Better educated and less traditional women were at the heart of this change, and formed the basis from where anti-FGM sentiment has spread over wider segments of Egyptian society.
Female genital mutilation (FGM) is still a common
practice in many African countries. The World Health
Organization (WHO) estimates that worldwide between
100 and 140 million women have been cut , of which
about 91.5 million in Africa. They also estimate that in
Africa about three million girls are circumcised every
In Egypt, FGM remains nearly universal: over 95 % of
women between 15 and 49 years old are circumcised,
and this proportion remains fairly constant across all
cohorts [2 and own calculations]. WHO distinguishes four
types of FGM . In Egypt types I (clitoridectomy) and
II (clitoridectomy + (partial) removal of the labia minora)
are the most frequent ones . Type III (infibulations) is
fairly rare, as is type IV (other forms). The practice
usually takes place before puberty . The median age at
circumcision is 10 years of age, and almost all girls are
cut before their 13th birthday . Traditionally, the
cutting was done by Dayas, traditional midwives, but the
practice is increasingly medicalized [5, 6]. By 2005, more
than 70 % of the cuttings were performed by doctors
and only 22 % by Dayas .
For over half a century Egypt has been developing, to
little effect, policies to discourage and ban FGM. An
important reason for their failure is that FGM still enjoys
the support of a large majority of the population [7, 8].
In 2003, only 23.3 % of ever-married women favoured its
discontinuation , and 60.8 % believed that FGM is
required by their religion. Although some prominent
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Islamic leaders have recognized that Islam does not
require women to be cut  and even though the country’s
supreme Islamic authorities reiterated it was prohibited
[10, 11], many Islamic leaders still accept or even support
the practice [4, 12, 13]. In 2007 and 2008 laws were passed
that banned the practice [14, 15]. However, it remains
unclear how rigidly these laws have been enforced. Although
the 2007 law prohibited general practitioners from
performing FGM, Rasheed, Abd-Ellah and Yousef  found
that in Upper Egypt, the incidence of FGM remained very
high, and that most cuttings were still performed by
general practitioners. The social and political upheaval leading
to and following the fall of the Mubarak regime in 2011
may further have undermined the enforcement of the laws
as the Muslim Brotherhood is said to support the practice.
Although female genital mutilation or female
circumcision is still nearly universal in Egypt, there is some
evidence that the social and political climate regarding
FGM is changing. According to the 2014 Egypt
Demographic and Health Survey (EDHS) 92 % of ever married
women between the ages of 15 and 49 were circumcised
. However, the prevalence of FGM among 20–24
year old ever married women was only 87 %, compared
to about 95 % for 35 to 49 year olds. El-Gibaly et al. 
also demonstrated that the prevalence of FGM among
girls aged 10–19 was about 10 % lower than among their
mothers. Other studies confirm these results [5, 18],
suggesting a slow decline of the practice. Given the
embedment of FGM in tradition and social structure
and the widespread support for it, the eradication of
this practice – which is the objective of current
legislation – seems impossible without major changes in
popular attitudes. Theories of behaviour change stress
the importance of attitudinal change as a necessary,
although not sufficient, precursor to behavioural change
[19–24]. For people to abandon traditional behaviours,
such behaviours must be delegitimized while alternative
ones need to gain acceptance.
The starting point of this study is that FGM is associated
with the social position of women, i.e., their location in
recognized status and role structures, and that the practice is
culturally embedded and therefore widely supported. The
delegitimization of the practice and an attitudinal change
among large parts of society are essential steps in the
abolishment of the practice. Countries where FGM is
prevalent typically have high gender inequality. International
organizations emphasize female empowerment,
improving women’s position in society, and reducing gender
inequality as a strategy to eradicate FGM  This paper
examines the hypothesis that anti-FGM attitudes initially
emerge among the more ‘modernized’ segments of Egyptian
society, where women are believed to be more
empowered, and subsequently spread from there to the rest of
In communities that practice FGM, people often accept
it as a normal part of growing up as a woman. In
traditional societies being cut confers status on a woman
because it identifies her as a member-in-good-standing of
her community. Parents fear that non-circumcised
daughters will do less well on the marriage market than
circumcised women. Specifically, parents worry that they
will have more difficulty finding a spouse or will have
to be satisfied with a lower status one. Whether a woman
has been circumcised determines not only the moral
standing of a woman, but also her social identity and status
within the community [12, 26–30]. The practice of FGM
stresses not only the subservient position of women in
society, but also symbolizes girls’ coming of age and confirms
them as full members of the community [4, 30].
Noncircumcised women risk being treated as outcasts, as immoral
women. Not being cut leads to stigmatization and loss of
status, for both the woman and her family [27, 31, 32].
Parents experience considerable social pressure to have
their daughters cut [33, 34]. The social costs of not
having one’s daughter cut can be quite substantial: loss of
status, lower marriage opportunities for their daughters,
social exclusion, etc. Several studies have shown that
the non-circumcision of a daughter may lead to a loss
of status and stigmatization, not just for the daughter
herself, but for the entire family [13, 27, 31, 32, 35–38].
As FGM is linked to the position of women in society
[12, 25, 28, 30], substantial social pressures exist to
conform to the norm that states that FGM is a normal
aspect of every woman’s life. The practice is strongly
embedded in the society’s traditions and contributes to
the social status of both the women themselves, and
their families. The extent to which individuals and
families can withstand such pressures and go against
tradition depends on the available sources of status as well
as on their exposure to other social environments and
influences. Therefore, not all groups are equally likely
to change their attitudes toward FGM.
The strong cultural embeddedness of the practice makes
a shift in societal attitudes essential for a fundamental and
long-lasting behaviour change and the final eradication of
FGM. Most individual-level theories of behaviour change
inspired either by social cognitive or rational choice
theories recognize the role played by attitudes [19–22].
Attitudes reflect the relative values of both old and new
behaviours, and might signify the readiness to change,
although it does they may not necessarily lead to
behaviour change. The problem with cognitive models of
behavioural change is that they ignore the context in which
decisions are made and assume that when an individual is
convinced of the benefits of behavioural change he or
she is also empowered to implement this change [39, 40].
Coale’s famous Ready, Willing, Able model [23, 24],
already pointed out that one not only needs to be ready to
change, but also willing and able to do so. According to
this model all three conditions need to be met before
an actual behaviour change occurs. As FGM is deeply
entrenched in social traditions and cultural frames and
is strongly connected with family social status simply
being ready to stop the practice (as reflected by
antiFGM attitudes) usually will not be sufficient to trigger
behaviour changes, as actors may neither be willing (due
to the social costs of not cutting one’s daughters) nor able
to do so (because of lack of power in the decision process).
Nevertheless, an attitudinal shift remains essential.
Although anti-FGM law enforcement can force people to
change their behaviours, without attitudinal change, such
changes in behaviours tend to be short-lived.
Attitudes are anchored in community structures and
reflect one’s position within this community. Attitudes
relating to gender, including FGM, therefore are linked
with the position of women in the community. The
stronger their position, the more likely they will be able to
adopt a more ‘modern’ or ‘western’ view on these issues.
The empowerment of women is often linked to
processes of modernization: urbanization, increased
education, industrialization, rationalization, individualization,
emotional nuclearization, etc. [33, 38, 41–43]. Education
is the key factor here, spreading modernity across society.
Jejeebhoy  lists five ways in which education
empowers women and thus may affect their reproductive
health decisions and behaviours. First, by exposing women
to outside influences education expands women’s
knowledge beyond the common knowledge of the community
and changes their outlook and values. Second, educated
women are not only more confident, but also are in a
stronger position relative to other family members with
less education, which enhances their decision autonomy.
Third, educated women tend to be more mobile and are
thus better able to interact with actors outside the
community. Fourth, education leads to a shift in loyalty away
from the extended family and community and towards
the nuclear family, which in turn leads to emotional
nucleation. Finally and potentially most importantly
educated women tend to have more control over material
resources, largely because they tend to be more active
in the money economy. In combination with employment
in modern sectors of the economy, education provides
women with alternative routes of status attainment.
Marriage no longer is the only way for women to obtain
status, and thus the social ‘need’ to have one’s daughters
cut is lessened. Women with higher levels of autonomy
are typically more likely to oppose FGM. For instance,
Allam et al.  found that among the most modernized
group in Egypt, i.e., university students, support for FGM
was substantially lower than in the rest of society. Only
28 % of the students supported it. Those favouring its
abolishment also had better knowledge of the dangers of
the practice and tended to claim it had no advantages.
Other studies found that mother’s education affects the
likelihood that their daughter are cut or that they intend
to have them cut [6, 45] or to oppose FGM [5, 6, 33, 46].
More emancipated women with greater autonomy tend to
be guided less by tradition and less subjected to social
control, and to also have better knowledge of the benefits
and costs of FGM. For them and their daughters, marriage
no longer is the only way to obtain status as they possess
alternative routes of status attainment.
UNDPs Gender Inequality Index shows that gender
inequality in Egypt declined slightly between 1995 and
2013. However, Egypt continues to have relatively high
gender inequality, ranking 25th (out of 130) in 1995 and
23rd (out of 152) in 2013, indicating that progress in
gender equality has been slower in Egypt than in most
other countries . El-Safty  reports that there has
recently been a conservative backlash which is leading
to a de facto curtailment of women’s rights. However,
women’s progress has not been equal across all domains.
For instance, Egyptian women have made considerable
progress in terms of education, but much less in terms of
labour force participation and employment. Female
literacy among women age 15 and older increased from
22.4 % in 1976 to 65.8 % in 2012. Gross secondary school
enrolment of women has increased from 20.4 % in 1970
to 87.8 % in 2013 . However, the percentage of women
aged 15 and older who are employed did not increase
between 1990 and 2013. Although the employment rate of
this age category fluctuates during this period, in 1990
26.7 % of women aged 15 and over were employed, and in
2013 only 22.9 % . For many women modernization is
only partial. Their education level might increase but they
remain economically dependent on their husbands or
families, limiting their autonomy. As this affects their
position in society it is likely to influence their view on the
role of women in Egyptian society.
In the modernization model the link between the change
of one’s social position, one’s attitudes and behavioural
change is quite straightforward. In reality the link may be
less clear. Not all modernization processes run
synchronously and women’s empowerment may be limited. Usually
changes in attitudes are insufficient to trigger behaviour
change, because decisions are rarely made in isolation from
one’s social environment (family, community, etc.). Even
for more individualistic decisions, such as whether to stop
smoking or drinking, whether to use a condom or to
change jobs, one needs to take into account one’s
environment, and that may influence the decision. This certainly
will be the case for FGM as this may affect a family’s social
status. Therefore, the decision process is likely to be much
more complex, involving not only the mother but also
other family members. Because the family constitutes
the primary unit of status, decisions pertaining to this
status tend to be family affairs. The extent that women
weigh in on these decisions, including decisions
concerning FGM, depends on their position within the family and
community. Often mothers have little control over the
decision whether their daughters will be cut. They may
oppose having their daughters cut, but neither be willing nor
able to influence this decision.
The spread of new attitudes through a society is
fundamentally a social process in which actors influence
each other. New attitudes originate in specific
subpopulations and then spread to the rest of society. Some of
these (groups of ) early adopters may serve as examples,
role models, opinion leaders or reference groups for other
segments of society. Innovation studies have demonstrated
that changes are more likely to be initiated by small
groups of innovators. Innovators have a
“willingness-tochange” that makes them sensitive and receptive to new
ideas and practices  and that leads them to engage in
more cosmopolitan social relationships [51, 52].
Innovators often adopt such practices after exposure to external
influences, through mass media etc. Research on the
diffusion of practices in developing nations shows that access
and exposure to these external resources is dominated by
economically advantaged and less culturally traditional
groups. Less advantaged and more traditional segments of
society are not only less exposed to sources of innovation
but are also ill positioned to take advantage of them. A
number of studies have found that highly educated and
urban women were more likely to favour the
discontinuation of FGM [44, 53], and that wealthier women and
better educated women were less likely to intend to have
their daughters cut [45, 54]. Given the higher status of
these groups they may serve as role models for other
segments of society. Several theoretical models,
including social cognitive theory , social convention
theory , and diffusion of innovation theory [51, 56],
note the importance of role models for behaviour
changes. Role models can affect knowledge, attitudes,
and behaviour through direct contact, but also through
their visibility in the community and their status .
In most cases, such role models need to be well perceived
by their audience. Marginal groups lack the status to fulfil
this role. To the extent that the more modernized
segments of Egyptian society serve as role models or
reference groups for more traditional segments, anti-FGM
attitudes are likely to spread from the former to the latter.
For this study we analysed secondary data from six waves
of the Egypt Demographic and Health Survey (EDHS):
1995, 2000, 2003 2005, 2008, and 2014. The EDHS
questionnaires focus on topics such as fertility, contraceptive
use, infant and child mortality, maternal and child health,
immunization, nutrition, as well as health related
knowledge and attitudes. The surveys also included questions
about FGM. Because the Demographic and Health
Surveys is a series of standardized surveys, identical
procedures were used for both the sampling and data collection
in all EDHS waves. The EDHS surveys provide
information about large nationally representative samples of ever
married women. The only exceptions are the 2003 EDHS,
which was a smaller interim DHS in which the Frontier
Governorates were excluded from the sample, and the
2014 EDHS where two of the five Frontier Governorates
were excluded because of security concerns. As less than
2%of the Egyptian population lives in those governorates,
the impact on the representativeness of this survey is
limited, and in the multivariate analyses we statistically
controlled for region of residence. These six datasets
contain information on a total of 97,274 ever-married
women between the ages of 15 and 49 years. A three-stage
sampling design was used. In the first stage, primary
sampling units (shiakhas/towns and villages) were selected
with probability of selection proportional to size. In the
second stage, the primary sampling units were divided
into parts of roughly equal size, and depending on the size
of the primary sampling unit, between one and three parts
were systematically. The selected parts were subsequently
divided into smaller segments. Two segments were
selected from PSUs that had two or three parts; one
segment from all other PSUs. Within each selected segment,
a systematic random of households was selected using a
household listing. All ever-married women in the
household between 15 and 49 years who were present in the
household the night before were eligible to participate in
the survey. More detailed information on the sampling
and data collection is available in the EDHS reports
[2, 17, 57–60]. The procedures and questionnaires of all
DHS surveys have been reviewed and approved by the ICF
International institutional review board (IRB) and comply
with the U.S. Department of Health and Human Services
regulations for the protection of human subjects (45 CFR
46), as well as by an Egyptian IRB to assure compliance
with Egyptian rules and laws . The de-identified EDHS
data are publicly available.
Attitude towards FGM
The dependent variable in this study indicates whether
or not the respondents favour the discontinuation of FGM.
The phrasing of the question in the various EDHS surveys
varied only little, and not in a way it would affect the
response. Only respondents who explicitly stated that
they favoured the discontinuation of FGM were coded
as opposing FGM, all other respondents (in favour of
continuation, depends, other or don’t know) were coded
as not opposing the practice. This approach provides a
conservative estimate of the number of respondents
favouring the discontinuation of FGM.
Woman’s social position
The social position of the respondent was measured by
her education level (no formal education, primary,
secondary, or higher education), literacy level (illiterate, partly
literate, fully literate), her occupation, and the household’s
possession of basic assets and amenities. As a proxy for
household wealth, we included an index of basic assets
and amenities. This index is defined as an unweighted
count of up to eight items that the respondent’s household
may possess (drinking water in residence, flush toilet,
finished floor, electricity, radio, television, refrigerator
and bicycle). The index was limited to these items
because the index needed to be comparable over the six
waves.1 Because of the items included and the way the
questions were asked, this index only discriminates well
among respondents at the lower end of the wealth
As FGM is deeply entrenched in social, cultural and
religious traditions, three variables were added that
capture these traditions: whether the respondent
herself is cut, her religion, and the number of children
she has given birth to. Religious affiliation was coded as
Muslim, Christian, or other/missing. The 2000 and 2003
surveys did not include a question on religion. Hence,
information on religion is coded as missing for all
respondents for those two survey years. Finally, the current age
of the respondent, and the region and the degree of
urbanization where the respondent resides were included.
The urbanization variable distinguished between the
capital and large cities, (smaller) cities, towns and the
countryside. The 2014 EDHS only distinguished between rural
and urban places of residence. For the purpose of the
analysis, therefore, a dichotomous indicator for rural
residence (0: urban, 1: rural) is used.
Bivariate analyses using χ2 and ANOVA tests are used to
analyse trends in both focal and control variables across
the EDHS waves. These analyses test whether these
variables changed in the population of ever-married Egyptian
women. For categorical focal variables (education, labour
market participation, and literacy) we subsequently used
ANOVAs to test whether there are significant zero-order
effects of these variables on the dependent variable. For
continuous focal variable (household wealth), we tested
this using bi-serial correlations.
To test whether the effects of the woman’s social
position variables are robust, multilevel logistic regressions
were run with opposition to FGM as the dependent
variable. The first level in this analysis is formed by the
individual women, the second by the EDHS wave. In a
first model a random intercept model was estimated
including all level 1 variables. In the second model, the
EDHS wave (survey year) was added as a level 2 variable.
For each level 1 variable, we subsequently checked whether
its effect varied significantly across the EDHS survey waves.
For six variables a significant random slope was observed:
region, circumcision status, age, rural residence, education
and labour market position. Separate analyses were run
with an interaction term between each of these variables
and the EDHS survey wave. The results for interaction
terms that included the woman’s social position variables
(education and labour market position) are reported in
Figs. 3 & 4.
Table 1 shows the descriptive statistics for the pooled
data. Opposition to FGM still remains a minority
opinion. For the six EDHS waves combined only 22.5 % of
the respondents favoured the discontinuation of FGM. A
large proportion of Egyptian women are still in a fairly
weak social position. A large minority of the women in
the six EDHS waves had no formal education (34.9 %),
while 39.0 % had secondary education, and a further 10.3 %
higher education. Many women report to be illiterate
(40.4 %), while a small majority (52.6 %) claim to be
fully literate. This suggests a clear division in society
regarding the education of women. As shown in Table 1
the overwhelming majority (81.1 %) of women in the
pooled dataset are not working. Of those who were
working 39.4 % held a professional, technical or
managerial function, while another 23.1 % were working in
clerical or service occupations, and 21.1 % in
agriculture. Most respondents (51.9 %) live in households were
(almost) all basic amenities were present, only 12.9 % of
them lived in a household where only few of the basic
amenities were present. On the average, a respondent
possessed 6.02 out of 8 basic amenities and assets.
That FGM is well embedded in Egyptian society and
culture is demonstrated by the finding that almost all
women in the surveys reported to be circumcised; only
4.5 % said they were not. On average, women had given
birth to 3.14 children (SD = 2.24); 9.3 % of the women
had not (yet) given birth, and 13.7 % had more than 5
children. As a consequence of the lack of information on
religion in the 2000 and 2003 surveys, 25.5 % of the
respondents were coded as missing (although the overwhelming
majority of them is Muslim), 70.1 % reported to be Muslim,
and 3.5 % Christian.
The majority of the respondents lived in the countryside
(58.8 %). Most respondents lived either in rural Lower
Egypt (33.3) or rural Upper Egypt (25.1 %). Only 17.4 %
Table 1 Descriptive statistics for control variables
Table 1 Descriptive statistics for control variables (Continued)
De facto place of residence
Lower Egypt - Urban
Lower Egypt - Rural
Upper Egypt - Urban
Upper Egypt - Rural
Total number of children ever born
Labor market participation
Basic amenities index
Highest educational level
No formal education
Legend: F: absolute frequency, f: relative frequency
lived in the Urban Governorates and 1.0 % in the Frontier
Governorates. The average age of the respondents was
33.1 years. Only 3.9 % were younger than 20 and 27.7 %
were between ages 40 and 49.
Trends in attitudes towards FGM
As shown in Fig. 1, opposition to FGM among
evermarried women in Egypt has risen steadily from the
mid-1990s onward (χ2(5) = 2767.2, p < 0.001). In 1995 only
12.7 % of ever-married women favoured the
discontinuation of FGM; by 2014 this had more than doubled to
31.3 %. Figure 1 also shows that the increase in opposition
to FGM occurred mainly from 2003 onward. Between
2003 and 2005 a larger increase in the proportion of
women opposing FGM was observed than between 1995
and 2003. The increase slowed somewhat down in later
years, especially between 2008 and 2014.
Trends in the social position of women
Figure 2 illustrates the trends in ever-married women’s
position between 1995 and 2014, as measured by their
level of education, literacy, labour market participation
and the household’s basic amenities index. The results
Fig. 1 Trend in opposition to FGM among ever-married Egyptian women, 1995–2014
show that women’s educational levels have risen sharply
between 1995 and 2014 (χ2(15) = 5483.5, p < 0.001) . The
percentage of women who had no formal education
decreased from 43.7 % in 1995 to 24.0 % in 2014 (not
shown), while the percentage of women with secondary
or higher education increased from 31.5 % to 65.7 %.
Literacy has also increased significantly (χ2(10) = 4718.2,
p < 0.001), with the percentage who are fully literate
increasing from 36.3 % in 1995 to 68.4 % in 2014.
Although the labour force participation of the ever
married women in the EDHS varies significantly across
the various EDHS waves (χ2(40) = 2479.6, p < 0.001), no
clear trends can be distinguished. The proportion
evermarried women who are employed remains a small
minority fluctuating between 22.7 % in 2003 and 16.1 % in
2014. Most ever-married women in Egypt over the period
studied are not working, and the data do not show any
increase in female labour force participation over this
period. The number of basic amenities possessed by the
households also increased significantly between 1995 and
2003, then to remain fairly stable to 2008, and to decline
again somewhat between 2008 and 2014 (F(5, 97,268) =
519.8, p < 0.001). Fig. 2 shows that the proportion with
most or all basic amenities (scores ≥ 6) rose from 58.3 %
in 1995 to 80.3 % in 2003 and to 85.7 % in 2014. The
increase in proportion respondents who had most or all
basic assets or amenities slowed down considerable over
the past decade.
Effects of women’s social position on attitudes towards FGM
All four indicators of a woman’s social position are
significantly (at p < 0.001) associated with women’s belief
Fig. 2 Trends in the education level, literacy, work status and basic amenities of eve-married Egyptian women, 1995–2014
that FGM should be discontinued. However, the
relationships of education level (Ε2 = 12.1 %) and literacy
(Ε2 = 8.7 %) with FGM opposition are substantially
stronger than those of labour market participation (Ε2 =
3.5 %) and household wealth (Ε2 = 3.4 %). The belief that
FGM should be discontinued increases significantly (p <
0.001) with each level of education. While only 8.9 % of
the women with no formal education favoured the
discontinuation of FGM, 13.2 % of the women with only
primary education did so, and 29.7 % of those with secondary
education. Among women with higher education, a
majority (55.7 %) favoured the discontinuation of FGM. A
similar relationship is observed with literacy. Only 8.8 %
of the illiterate respondents favoured the discontinuation
of FGM, compared to 14.8 % of those who are partially
literate, and 34.2 % of those who are fully literate (not
The relationship between labour market status and
attitude towards FGM is considerably weaker. The lowest
support for the discontinuation of FGM exists among
women in agriculture, either self-employed (5.6 %), or
employees (5.3 %), while the strongest support for the
discontinuation was found among service workers (34.8 %),
clerical workers (37.7 %), and among women in
professional, technical or managerial occupations (45.4 %). Of the
non-working women 20.8 % favoured the discontinuation
of FGM. The effect of household wealth on attitudes
towards FGM was found to be curvilinear, with both
the lowest (score = 0) and the highest scores (score ≥ 6)
being most likely to favour the discontinuation of FGM
Table 2 shows the results of the multilevel logistic
regression analyses for whether women favour the
discontinuation of FGM or not. In the first model only the
individual level variables were included and a random
intercept was assumed. Opposition to FGM is most
common in the urban and frontier governorates, and
significantly less in the rest of Egypt, and especially in
the rural areas. Contrary to expectations, after controls
for the other variables in the model the likelihood to
oppose FGM increases with age. The odds ratio for
favouring the discontinuation of FGM comparing a 40 year old
respondent with a 20 year old one who score the same
on all other variables is 1.58 (95 % CI: 1.30–1.93).
That tradition is an important factor affecting attitudes
towards FGM is demonstrated by the fact that all three
tradition variables have strong effects on the likelihood
that women favour the discontinuation of FGM. Whether
a woman is circumcised or not is very important: the odds
to favour the discontinuation for non-circumcised women
is 8.58 times (95 % CI: 6.39–11.54) that of circumcised
women. Religion proves to be another important factor.
As most respondents with a missing value for religious
affiliation (mostly those interviewed in 2000 and 2003) are
Muslim it is not surprising that this group does not differ
significantly from the Muslims. Christians, however, are
much more likely than Muslims to oppose FGM (OR =
5.07, 95 % CI: 4.04–6.36). Women with more children,
ceteris paribus, are also less likely to oppose FGM. For
instance, the odds of opposing FGM for a woman with 5
children are only 0.53 times (95 % CI: 0.49–0.057) that of
a woman without children.
The effects of women’s social position variables are
consistent with those described in the bivariate section,
even after controlling for the other variables in the model.
The higher the education level of a woman, the more
likely she is to oppose FGM. For instance, for respondents
with higher education the odds to oppose FGM are 3.12
times greater (95 % CI: 2.18–4.48) than among those
without any formal education. Similarly, literate women also
are more likely than illiterate women to oppose FGM.
Women employed in professional, technical or managerial
occupations or in clerical or service jobs are also more
likely to oppose FGM than non–working women, while
those working in agriculture are less likely to oppose
FGM. Women living in wealthier households, as indicated
by the basic amenities index, are also more likely to
oppose FGM. The odds of opposing FGM for a woman who
scores the maximum (=8) on the basic amenities index
are 1.33 times higher (95 % CI: 1.10–1.61) than for a
woman scoring the minimum (=0). These results confirm
that the effects of women’s social position indicators are
robust when controlling not only for the individual level
control variables, but for the other indicators of a woman’s
social position as well.
The second model adds the EDHS wave explicitly to
the equation. This allows us to test for overall changes
in the attitudes towards FGM, irrespective of the
characteristics of the women. The results indicate that after
controlling for other actors no significant overall changes
are observed between 1995 and 2003. This implies that
increases in the opposition to FGM during this period are
largely due to changes in the composition of the
population (improvements in education, etc.). However, from
2005 onward a significant change in the overall attitude
towards the continuation of FGM occurs: compared to
1995, women in the 2005 EDHS have an OR of 2.00 (95 %
CI: 1.93–2.06) for favouring the discontinuation of FGM,
in 2008 an OR of 2.59 (95 % CI: 2.50–2.69), and an OR of
2.75 (95 % CI: 2.58–2.92) in 2014.
A final series of models included the interaction terms
between labour market position and education on the
one hand and the EDHS survey wave on the other. These
models allow us to check how the effects of these women’s
position indicators vary over time. For literacy and the
basic assets and amenities index no significant random
slopes were observed, and therefore no interaction with
EDHS wave was tested. The results are presented in
Table 2 Multilevel logistic regression results for opposition to
the continuation of FGM in Egypt
b (95 % CI) (1) (2)
Constant −0.139 −0.754***
Table 2 Multilevel logistic regression results for opposition to
the continuation of FGM in Egypt (Continued)
(ref; No formal education)
Region (ref: Urban Governorates)
Lower-Egypt - Urban
Lower-Egypt - Rural
Upper-Egypt - Urban
Upper-Egypt - Rural
Religion (ref: Muslim)
Number of children born
Labor market position
(ref: Not working)
Professional, technical or
Skilled manual labor
Literacy (ref: Illiterate)
EDHS wave (ref: 1995)
Figs. 3 and 4. In these figures the baseline is formed by
the reference category of the woman’s position
indicator, i.e., not working for labour market position and no
formal education for education, in the 1995 EDHS.
Figure 3 shows the effects of labour market position
across the EDHS waves. All interaction terms are
significant at p < 0.050 except those for being
selfemployed in agriculture, being an agricultural worker
in 2000 and 2014, having a clerical job in 2003 or a
service job in 2005. This implies that for these specific
years the effects of these categories do not differ from
their effects in 1995. The results show a clear
convergence between the various labour market position
categories over time. The categories that had the largest
positive effects in 1995, i.e., respondents in professional,
technical or managerial occupations and those in clerical
Fig. 3 Graphic representation of the interaction effects of labour market position with EDHS wave
occupations, tended to have negative interaction terms in
the subsequent EDHS waves. By contrast, those with the
most negative main effects, i.e., respondents working in
sales or in agriculture, tended to have positive
interaction terms in the subsequent EDHS waves. The two
extremes therefore are moving toward each other with
regard to their attitudes towards FGM, at least up to
2008. For instance, where the odds-ratio for favouring
the discontinuation of FGM between respondents in
professional, technical or managerial occupations and
agricultural workers in 1995 was OR = 4.89 (95 % CI:
3.22–7.43; p < 0.001), by 2008 this OR had become
non-significant (OR = 1.25; 95 % CI: 0.90–1.73), but by
2014 it had increased again to OR = 2.79 (95 % CI: 2.21–
3.54, p < 0.001). A convergence can also be observed for
the effects of education (see Fig. 4). As before, all
interaction terms are significant (p < 0.001) except for
primary education in 2003. All the interaction effects indicate
that the effects of the various education levels (compared
to the respondents without formal education) on
opposition to FGM decreased over time. For instance, in 1995
the odds of opposing FGM was 9.57 times higher for
respondents with higher education than for those without
formal education (95 % CI: 7.01–13.07). By 2014 this odds
ratio had declined to 2.01 (95 % CI: 1.57–2.59).
Discussion and conclusions
The results discussed above support earlier findings that
female opposition to FGM is most pronounced among
well-educated women [5, 6, 9, 33, 43, 45, 46, 53]. The
proportion of ever-married Egyptian women who favour
the discontinuation of FGM increases with their level of
Fig. 4 Graphic representation of the interaction effects of education with EDHS wave
education as well as with employment in the more
modern sectors. It is the better educated and less traditional
groups that form the vanguard of the anti-FGM
movement in Egypt. Resistance to attempts to eradicate and
control FGM stems from its embeddedness in traditions
and community structures, and its link to the status of
women and their families.
Female empowerment strategies often prove effective
because they also focus on improving women’s
education and literacy. As Jejeebhoy  already mentioned,
education improves a woman’s position through multiple
mechanisms. It not only enhances the economic and
social autonomy of women, thus providing alternative
paths to status, but it also improves their psychological
and cultural outlook. Education not only provides
additional knowledge, but also carries what is labelled as
‘modernity’. This involves new social, economic and
political institutions, but also a new way of thinking.
Modernity entails rationalization and reflexivity, the idea that
society is makeable and that people control their own
fate [62, 63]. This modern reflexivity allows people to
challenge traditional views and practices, and helps them
look beyond what they are accustomed to. The changes
in knowledge and attitudes about FGM should be seen
not as isolated elements but as manifestations of wider
cultural changes affecting more domains of life. These
cultural changes challenge traditional views of gender
roles and relations, which not only refer to the position
of women in society, but also to the role and importance
of the extended family and community.
Our evidence shows that in Egypt the empowerment
of women only is a partial success. During the past few
decades a tremendous increase in the education levels of
women occurred, but female labour force participation
remained dismal. Egypt continues to have a high degree
of gender inequality and generally speaking the social
position of women remains weak.
Nevertheless, the opposition to FGM among
evermarried women increased substantially over the period
studied, 1995–2014. Improvements in education and the
diffusion of new attitudes may be sufficient for a wider
attitudinal change. The data suggest that the initial
increase in opposition to FGM occurred mainly because of
the growth of those segments of society most likely to
oppose FGM, particularly due to the increase in the
number of educated women. However, from 2003
onward, opposition to FGM started to spread from the
better educated and less traditional segments of society to
almost all segments of Egyptian society. This implies
that the effects of important predictors, such as
education and labour force participation, decreased over time,
as the lower educated groups start to catch up with the
better educated ones, and the differences among the
various socio-economic groups declined.
However, this large scale attitudinal shift may be
insufficient to bring FGM to a halt, as the women are usually
not in a position to make decisions about FGM.
Decisions about whether or not to have a daughter cut are
not made by the mother in isolation, but by the larger
family. The family is likely to take into account the views
of the community as FGM reflects on the status of both
the family and the girl herself. Individual mothers have
too little power in these networks to block the decision
made, but as a group women do play a crucial role as
guardians of tradition. Being cut is seen as one’s ticket to
becoming a member in good standing of the women’s
community . Nevertheless, individual attitudinal changes
are an import link in the process of the eradication of
FGM. To end FGM, it may not be sufficient that
individual women oppose FGM; it may be necessary that
entire families and communities adopt anti-FGM views.
Although the media can play a role in disseminating
antiFGM messages, the diffusion of anti-FGM attitudes still
largely occurs through social networks, although not
necessarily through direct contacts. Opposition to FGM
has to grow one person at a time until a critical mass is
reached within a family, a community, or the country
[51, 55, 65]. Behaviour change will become more likely
when people are not only ready to change, but willing
and able as well. Such interpretation is consistent with
social convention theory. Social conventions require
social support. To change social conventions, role models
(such as individuals or families in good social standing)
may introduce new behaviours .
Anti-FGM legislation can also contribute to an
attitudinal change toward FGM and may help eradicate the
practice. The increased opposition to FGM in ever larger
parts of Egyptian society open prospects for the legal
measures against it. In the past legal measures were
ineffective because they had little legitimacy among the
population and therefore were rarely enforced. Now that public
opinion is changing against FGM existing legislation may
become more effective, although one should not expect
the practice to stop all at once. The practice of FGM
cannot be eradicated until it has become delegitimized
in much of Egyptian society. Currently FGM still enjoys
too much support of the population, especially outside
the major cities, for the legislation to be a success. The
importance of the anti-FGM-legislation may be less in
its immediate effect in banning the practice, than in its
longer term contribution to its delegitimation. Although
the legislative action in 2007 and 2008 seemed a step
in the right direction, the social and political upheaval
from 2011 onward may have halted opposition to
FGM. There are several reports that the Muslim
Brotherhood and the Mosni government did not merely
silently condone the practice but actually promoted it
This study has a number of limitations. First, this study
makes use of the EDHS which contains only ever-married
women. Because younger single women may be more
likely to oppose FGM, the DHS data may underestimate
the increase in anti-FGM attitudes . As the sample does
not contain any never-married women it most likely is
not fully representative for the younger, better educated
women who may be in the vanguard of the anti-FGM
movement. Second, this study only looks at the attitudes
of women towards FGM (whether they favour its
discontinuation), but does not look at whether they actually have
their daughters cut. The literature shows that there are
substantial discrepancies between attitudes, intentions and
actual behaviour. Many of the women who oppose FGM
may still have their daughters cut as they face substantial
social pressure to do so. Thus, while the changes in
attitudes may be a first step towards the eradication of FGM,
the eradication of FGM may still be a long way off. Social
norm change will be required and there may need to be a
critical mass of women who are educated, uncut, and
employed in independent income-generating activities.
1The standard DHS wealth index is calculated for each
survey wave separately and is not suitable for comparisons
1 over time.
CI: Confidence interval; DHSs: Demographic and Health Surveys; EDHS: Egypt
Demographic and Health Survey; FGM: Female Genital Mutilation;
IRB: Institutional Review Board; OR: Odds-ratio; SD: Standard deviation;
UNDP: United Nations Development Programme; WHO: World Health
The authors declare they have no competing interests.
RVR, DM and AG conceived of the idea. RVR performed the analyses and
wrote the initial draft of the paper. All three authors restructured and
rewrote the manuscript, and read and approved the final manuscript.
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