Estimating the magnitude of female genital mutilation/cutting in Norway: an extrapolation model

Ziyada et al. BMC Public Health (2016) 16:110 DOI 10.1186/s12889-016-2794-6 RESEARCH ARTICLE Open Access Estimating the magnitude of female genital mutilation/cutting in Norway: an extrapolation model Mai M. Ziyada1, Marthe Norberg-Schulz2 and R. Elise B. Johansen1* Abstract Background: With emphasis on policy implications, the main objective of this study was to estimate the numbers of two main groups affected by FGM/C in Norway: 1) those already subjected to FGM/C and therefore potentially in need for health care and 2) those at risk of FGM/C and consequently the target of preventive and protective measures. Special attention has been paid to type III as it is associated with more severe complications. Methods: Register data from Statistics Norway (SSB) was combined with population-based survey data on FGM/C in the women/girls’ countries of origin. Results: As of January 1st 2013, there were 44,467 first and second-generation female immigrants residing in Norway whose country of origin is one of the 29 countries where FGM/C is well documented. About 40 pct. of these women and girls are estimated to have already been subjected to FGM/C prior to immigration to Norway. Type III is estimated in around 50 pct. of those already subjected to FGM/C. Further, a total of 15,500 girls are identified as potentially at risk, out of which an approximate number of girls ranging between 3000 and 7900 are estimated to be at risk of FGM/C. Conclusion: Reliable estimates on FGM/C are important for evidence-based policies. The study findings indicate that about 17,300 women and girls in Norway can be in need of health care, in particular the 9100 who are estimated to have type III. Preventive and protective measures are also needed to protect girls at risk (3000 to 7900) from being subjected to FGM/C. Nevertheless, as there are no appropriate tools at the moment that can single these girls out of all who are potentially at risk, all girls in the potentially at risk group (15,500) should be targeted with preventive measures. Keywords: Female genital mutilation/cutting, Female circumcision, Prevalence, Risk, Diaspora, Norway Background The World Health Organization (WHO) defines Female Genital Mutilation/Cutting (FGM/C) as ‘all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’ [1]. FGM/C is associated with series of immediate and long-term physical and psychological health consequences [2–7]. It is estimated that 133,000,000 girls and women in 29 countries have undergone FGM/C, and that 3,600,000 girls are at risk annually [8]. Immigration from these * Correspondence: 1 Norwegian Centre for Violence and Traumatic Stress Studies, P.b. 181 Nydalen, 0409 Oslo, Norway Full list of author information is available at the end of the article countries to other parts of the world has made FGM/C a global concern. As a response, many governments in host countries have established preventive, protective and prosecutive measures alongside health care provision to tackle the issue [9–21]. The target group for preventive and protective measures is girls at risk, while health care provision targets girls and women already subjected to the procedure. Efficient planning and allocation of resources for the different sets of measures require precise estimates of total numbers of women and girls in each of the two target groups. Currently, the most accurate estimates on the prevalence of FGM/C and those at risk are derived from population-based survey data such as Demographic Health Survey (DHS) and Multiple Indicator Cluster © 2016 Ziyada et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ziyada et al. BMC Public Health (2016) 16:110 Survey (MICS) in 29 countries where FGM/C is traditionally practiced [22]. To employ similar methods in diaspora, where FGM/C is only common among immigrant minorities, would be methodologically, ethically and financially difficult. Therefore, alternative models and data-sources have been explored. The most commonly used alternative model in Europe extrapolates prevalence data from countries of origin to the corresponding resident female immigrant population [23]. Other models include surveys among health professionals [23–25] and non-representative samples of FGM/C practicing communities [23, 26, 27]. Even though the results from these surveys cannot be generalized, it still provides important insight into how FGM/C is evolving in the diaspora. In Norway, a previous risk estimate was published in 2008 by the Norwegian Institute for Social Research (ISF) [28]. The estimate was a small part of a larger study that focused on incidence of FGM/C and included only women and girls between 0 and 19 years of age from six African countries [28]. To give a more comprehensive estimate on the number of women and girls in Norway living with FGM/C and girls at risk of FGM/C we included in this study both first and second generation immigrants from the 29 FGM/C prevalent countries. An earlier and less refined version of this study was published by DAMVAD and NKVTS in 2014 [29]. The earlier version did not take into account differences in prevalence when estimating the number of girls at risk for FGM/C; neither did it include data on typology. The present paper controls for both these factors, as well as employing updated national prevalence data. Methods We adopted the extrapolation model to estimate the number of girls and women living in Norway by January 1st 2013 who were at risk of FGM/C and those who most likely already have been subjected to FGM/C. We combined data on FGM/C from the 29 FGM/C prevalent countries with register data on first- and second-generation female immigrants from these countries. Methodological approaches In 2012, a consortium of researchers were commissioned by the European Institute for Gender Equality (EIGE) to map the current situation on FGM/C in the European Union (EU) and Croatia [30]. The study identified lack of harmonized approach to generate reliable data on the magnitude of FGM/C as one of the main challenges facing the development of effective policies on FGM/C in the EU [23, 30]. The study also found that even when the extrapolation model was adopted, the variation in definitions and data sources have generated incomparable data [23, 30]. Page 2 of 12 To enhance the comparability of our findings with oth (...truncated)