PLoS ONEplosplosonePLOS ONE1932-6203Public Library of ScienceSan Francisco, CA USA10.1371/journal.pone.0268322PONE-D-21-16363Research ArticleMedicine and health sciencesSurgical and invasive medical proceduresReproductive system proceduresCircumcisionSocial sciencesSociologySexual and gender issuesFemale genital mutilationPeople and placesPopulation groupingsEthnicitiesAfrican peopleSomalian peopleSocial sciencesAnthropologyCultural anthropologyReligionSocial sciencesSociologyReligionBiology and life sciencesAnatomyReproductive systemGenital anatomyClitorisMedicine and health sciencesAnatomyReproductive systemGenital anatomyClitorisPeople and placesPopulation groupingsReligious faithsIslamSocial sciencesSociologyCulturePeople and placesGeographical locationsAfricaSomaliaDiscourses of change: The shift from infibulation to sunna circumcision among Somali and Sudanese migrants in NorwayChanging from infibulation to sunna circumcisionhttps://orcid.org/0000-0002-6666-6978JohansenR. Elise B.ConceptualizationFormal analysisMethodologyProject administrationWriting – original draftWriting – review & editing*Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS), Nydalen, Oslo, NorwayJordalMalinEditorUniversity of Gävle Faculty of Health and Occupational Studies: Hogskolan i Gavle Akademin for halsa och arbetsliv, SWEDEN
The author have declared that no competing interests exists.
* E-mail: r.e.johansen@nkvts.no17620222022176e0268322255202122420222022R. Elise B. JohansenThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Somali and Sudanese transnational discourses on female genital cutting (FGC) center on a shift from infibulation to sunna circumcision, a change perceived to reduce health risks and accommodate religious teaching, yet this shift is far less extensive and substantial than its typical portrayal suggests. Based on data from interviews and focus group discussions with 95 migrants of Somali and Sudanese origin, in this paper, I explore these migrants’ discourses of change and how and why they seem blurred and contradictory. Most participants described the ongoing abandonment of infibulation and uptake of sunna circumcision in terms of civilization, modernization and transition toward a more correct Islam; however, their perceptions of the anatomical extents and religious and cultural meanings of sunna circumcision appeared blurred and contradictory. We suggest that these blurred and contradictory perceptions of sunna circumcision enable the study’s participants to maneuver in a context of opposing and changing social norms regarding FGC.
The author received no specific funding for this work.Data AvailabilityThe data used for the analysis in this paper consists of transcribed interviews, which for anonymity reasons cannot be shared. However, relevant quotes and the minimal data-set can be shared through request from postmottak@nkvts.no. The ethical review board NSD, now Sikt, requires that all data be anonymized, which is impossible to do with the interview transcript without it loosing its meaning. Therefore the ethical review board (NSD/SIKT) do not allow us to share transcripts, only a list of used quotes.Introduction
Several studies have identified a shift toward less severe types of female genital cutting (FGC), commonly referred to as sunna circumcision, in communities that have traditionally practiced infibulation [1–6]. This change is generally understood to reduce FGC-related health risks and to accommodate religious teaching due to a dominant perception that sunna circumcision is a minor and harmless procedure. Nevertheless, existing evidence suggests that this shift remains both less widespread and substantial than is commonly claimed [4, 7–9]. On the contrary may procedures described as sunna circumcision differ little from infibulation. Building further on this apparent contradiction, my aim in this paper is to explore how discourse of change regarding the shift from infibulation to sunna circumcision unfold among Somali and Sudanese migrants in Norway. Accordingly, the paper has two specific objectives: first, to describe how this change is perceived in terms of its anatomical extents and associated health consequences; second, to shed light on how these perceived changes are associated with changes in meaning making.
I start with a brief outline and comparison of the etic (external) and emic (internal to communities) FGC typologies as described by the World Health Organization (WHO), Somali, and Sudanese local communities. The WHO distinguishes four main types of FGC on the basis of anatomical extent and severity, with an increasing anatomical extent of tissue removal from I to III, though Type IV does not include tissue removal [10]. The emic categorization and terminology in Somalia and Sudan commonly identify two major types of FGC: infibulation, often referred to as pharaonic circumcision, and sunna circumcision, also referred to as sunni in Somali communities [11–13]. In terms of its anatomical extent, infibulation corresponds to WHO Type III. The term sunna circumcision, in contrast, is used to designate a wide variety of procedures, from a needle prick that corresponds to WHO Type IV to extensive removal and closure, similar to WHO Type III [4, 7, 14]. Based on a study among Somali migrants in Sweden, Wahlberg [14] has illustrated this difference in categorization represented in Fig 1 (S1 Fig, Fig 1):
10.1371/journal.pone.0268322.g001
Existing studies thus suggest that the emic differentiation between infibulation and sunna circumcision vary considerably. The broad definition of sunna circumcision has also been stratified into subtypes [8, 15, 16]. Table 1 outlines similarities and differences between the WHO and emic subcategories, as outlined in several studies, but mainly follows a recent study in Somaliland (the semi-independent Somali state) [7].
10.1371/journal.pone.0268322.t001
WHO classifications, juxtaposed with emic typology and terminology from Somalia and Sudan.
WHO Type I
WHO: Clitoridectomy. Defined as complete or partial removal of the (external part of) clitoris.
Emic: Sunna circumcision, small circumcision. Defined as removal of the tip of the clitoral glans.
WHO type II
WHO: Excision. Partial or total removal of the clitoral glans and the labia minora, with or without excision of the labia majora.
Emic: “Intermediate”, “sunna2”, “large sunna”. Defined as removal of tissue from the clitoris and labia minora, followed by two to three stitches to stop bleeding and ensure a partial closure of the vaginal entrance.
WHO Type III
WHO: Infibulation. Defined as narrowing the vaginal opening with the creation of a covering seal by cutting and appositioning the labia minora or labia majora, with or without excision of the clitoral prepuce and glans.
Emic: Pharaonic. Defined as removal of tissue from the clitoris and inner and outer labia followed by four to seven stitches, resulting in a miniscule vaginal opening.
WHO Type IV
WHO: All other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping or cauterization.
Emic: Sunna. Defined as pricking, nicking or pinching the genitalia (commonly the clitoris or its foreskin) to ensure bleeding, without tissue removal.
The categorization in Table 1 illustrates the ways in which infibulation and sunna circumcision are commonly differentiated in terms of both their amount and type of tissue removal and requisite stitches.
Worldwide, approximately 10% of the 200 million girls and women who have been subjected to FGC have undergone infibulation [17], yet this is the most common type of FGC in Somalia and Sudan. Of the 99% of women with FGC in Somalia, 64% report having undergone infibulation [11], and 77% of the 87% of Sudanese women who report having undergone FGC also report having undergone infibulation [18].
In Norway, the proportion of the 17,300 girls and women with FGC who have been subjected to infibulation constitutes approximately 50% [19]. This overrepresentation of infibulation is due to an immigration pattern; Somali women constitute about half of the total number of migrant girls and women assessed to have been subjected to FGC prior to immigration. Sudanese refugees and migrants constitute a considerably smaller proportion of female migrants affected by FGC, at approximately 3% [19]. However, due to the similarities in the types of salient FGC, the cultural meanings and discourses of the shift from infibulation to sunna among both population groups, Sudanese are included in this paper.
Infibulation is traditionally associated with key cultural values that hinge on ideals and practices related to women’s virginity and virtue and men’s virility and sexual pleasure [20–22]. It is also associated with femininity, beauty and cleanliness [23]. Physical closure via infibulation is considered a form of a hymen, meant to create, protect and prove virginity [23, 24]. An intact infibulation at marriage is deemed evidence of a woman’s virginity and virtue and thus her high moral standards [21, 25]. Failure to present an intact infibulation is, on the other hand, taken as evidence of premarital sexual encounters and thus immorality [5, 9, 21, 23, 26]. This is expected to lead to an immediate annulment of a marriage, causing the uttermost shame for the woman and her family. Infibulation is, however, also associated with male values, particularly virility and prowess, as men are expected to tear open the infibulated seal of skin with their penis to consummate their marriage [22]. Subsequently, infibulation, or rather the opening of an infibulation, is associated with sexual engagement and thus fertility [27]. Hence, the symbolic meaning of infibulation is intimately linked to the physical extent of the practice.
Nevertheless is infibulation also associated with a series of immediate and long-term health problems, many of which are well-known in practicing communities, including pain associated with urination, menstruation and childbirth. Painful and obstructed urination and menstruation refer to a slowed passage of blood and urine, creating pain from pressure that builds behind the vaginal seal [28]. Pain associated with sexual initiation and childbirth stems from the need to tear or cut open the infibulated seal of skin to create sufficient space for these activities [29, 30].
Additionally, the removal of all or part of the clitoral gland and foreskin that is common in infibulation is considered a measure that reduces a woman’s sexual desire and therefore helps her maintain her virginity and virtue. This is built on the perception that the clitoris is both the site of sexual desire and perceived male values or characteristics, such as aggression and dominance [30, 31]. The clitoris is even commonly believed to grow to a penis-like size during puberty if it is not cut, resulting in an abhorrent organ that can obstruct sexual intercourse [30, 32]. This complex set of meanings that are associated with infibulation has been identified in studies of both Somalia and Sudan and among their respective migrant communities [20, 21, 23, 26].
As indicated above, the term sunna is generally used to describe all types of FGC that are not defined as infibulation. The term itself has an Arabic origin and is commonly used in Islam to designate religiously condoned practices. The practice of FGC is, however, controversial in Islam [33, 34]. While most Muslim communities do not practice FGC, most religious leaders in Somalia and Sudan support or accept the practice [7, 13]. However, the hadiths mentioning FGC, which supporters of the practice perceive to provide scriptural support for FGC, do not specify the correct anatomical extent of the procedure. They only offer admonitions not to “cut too deep” or “exaggerate” [7, 13, 33, 35]. Thus, in Islam, there is no clear or uniform understanding of FGC or of how it ultimately should be conducted.
Accordingly, to explore the discourses of change from infibulation to sunna circumcision, I draw on qualitative data from two studies that investigated the changing perceptions of FGC among Somali and Sudanese migrants in Norway.
Materials and methods
Data collection included in-depth interviews (IDIs) and focus group discussions (FGDs) with 95 Somali and Sudanese women and men. This was carried out between the fall of 2017 and the fall of 2018 in two parallel studies. Fifty participants took part in the IDI, and 45 participants took part in a total of eight FGDs with three to nine participants in each. The majority were of Somali origin (n = 87) and a minority were of Sudanese origin (n = 8), corresponding closely to their proportions of the FGC-affected communities in Norway, 53% and 3%, respectively.
The first study included IDIs and FGDs with 72 Somali women and men, all of whom resided in or close to a medium-sized Norwegian town. The second study included IDIs with 23 Somali (no = 15) and Sudanese (no = 8) women who had settled in eight different towns and villages across Norway.
All FGDs and most IDIs (all in the first study and seven in the second study (n = 79) were carried out by seven research assistants matching the participants in terms of ethnicity or national background and gender (male/female). The research assistants included three Somali and one Sudanese woman and three Somali men. They used Somali, Arabic, Norwegian, English, or a mixture of these languages. FGDs were, with one exception, segregated by gender and age group, as this was expected to facilitate discussion through more shared life situations and social expectations. For example, do the sexual norms of virginity imply that unmarried persons, particularly women, would likely feel uncomfortable discussing such topics with their mother’s generation. Other experiences, such as childbirth or marital relationships, were also less likely to be shared experiences that could generate free and open discussions across age groups. One FGD however, mixed ages, with two young and three adult men. Division into age group for the FGD was based on the participants’ self-identification, with the demarcation between “youth” or “adult” generally corresponded with marital status. The IDIs and FGDs were tape recorded, transcribed verbatim, and then translated into Norwegian or English by the research assistants before they shared them with the author. The remaining interviews (n = 16) were conducted by the author, an ethnic Norwegian woman, and were conducted in Norwegian, English, Kiswahili or Somali, the last with the help of an interpreter. Most interviews lasted between one and three hours, were open and informal, and were conducted at a place chosen by the informant.
In both studies, we asked for background information including childhood and upbringing, experiences of pressure for or against FGC, perceived differences between country of origin and Norway, perceived relevance of FGC to the sense of identity and belonging, and perceptions of the change in FGC practices. The first study included additional questions on perceived motivation for FGC, decision-making, health risks, legal issues and ultimate relevance of FGC to marriage (S1 and S2 Files). The second study included additional inquiries about their first encounters with FGC as a practice, critical discourses about the practice, participants’ social networks and their reflections on FGC regarding their eventual daughters (S3 File).
To obtain a broader impression of such discourse, additional data were collected through ethnographic fieldwork, including in-depth interviews, key-informant interviews, informal conversations, group discussions and participant observation. Most of this data-collection was carried out in Norway, whereas a small part was collected during a one-month stay in Kenya in March 2019. This included the following activities:
In the first study, the research team (author and research assistants) arranged three community meetings for potential study participants prior to the study, involving approximately 30 people. After the completion of data collection, we (the author and two of the research assistants) arranged two FGDs with community members (one with 9 young women and one with 10 adult men). Here, I presented a preliminary analysis to determine how our findings resonated with their perspectives and to give the participants an opportunity to correct and expand our analytical perspectives.
The author also conducted in-depth interviews and informal conversations with other Somali and Sudanese women and men. This included onward migrants—Somali and Sudanese migrants who had left Norway to resettle in other countries of migration (UK and Canada)—and return migrants—Somali and Sudanese migrants who had permanently left Norway to resettle in their countries of origin including Sudan, Somalia and Kenya. Some of these interviews were conducted over the phone. The author also gained additional insight through participant observations in various settings, including FGC workshops and seminars on women’s health and FGC with Somali and Sudanese participants. Interviews with key informants included persons working in nongovernmental organizations (NGOs) (mostly of Somali origin) and government agencies dealing with FGC in transnational contexts (of British, Norwegian and Somali origin).
Findings from the ethnographic fieldwork is, with one exception (an interview of a Somali midwife in Kenya), not directly referred to in the paper, but was used as background information during the analysis to improve and check the analysis and its validity.
Some aspects of the discourses regarding the change from infibulation to sunna circumcision have been alluded to in two formerly peer-reviewed and published papers, using data from the same studies [5, 36]. Whereas the former papers presented an overview of all themes identified during data-analysis, the aim of this paper was to make an in-depth analysis of one of the major findings, that is, the discourse of change from infibulation to sunna circumcision. For the purpose of this paper, I thus re-read and reanalyzed all transcribed data from both studies to identify all data relevant for the discourse on change of type. Thereafter I systematized the data into major themes and subthemes and used them to organize this paper. Thus, this paper includes considerably broader empirical evidence on the change of type, and a more nuanced and elaborated analysis than previous papers.
Research participants
The 95 research participants included 65 women and 30 men. Participants were between 16 and 59 years of age. All research participants were first-generation immigrants, born and raised in Somalia, Sudan or a neighboring country, most commonly Kenya, Ethiopia, the United Arab Emirates or Yemen. Some had arrived in Norway in their early childhood, others during their youth, but most as adults. Their times of residence in Norway ranged from six months to thirty years.
Most young participants claimed to be students at a high school or university, whereas few of the adults provided reliable information on their current engagement in education or employment. Educational backgrounds varied extensively, from one year of Koranic School to a PhD. Overall, the Sudanese participants had higher levels of education than the Somali participants, with several of the former having a postgraduate university education.
Most female participants (n = 65) shared information about their personal FGC status (n = 57). Of these, the majority revealed they had undergone FGC (n = 50), mostly infibulation (n = 37). Five women claimed to have undergone sunna circumcision, of which four reported extensive vaginal closure. One woman was unclear about type, and not sure what type of FGC she had, and six participants claimed to have no FGC.
Ethical considerations
The studies followed the ethical considerations required by the Norwegian Centre for Research Data (NSD), which confirmed that the study was in line with the personal data act (reference no. 55641). All the potential participants were provided with a written and oral presentation of the study and the implications of their participation in their selected language (Norwegian, English, Arabic or Somali). All participants gave their informed consent orally (tape recorded) or written according to their choice. In Norway, parental approval is not required for anyone over the age of 16 years; thus, this was not needed. To ensure anonymity and reduce the risk of recognition, details about the study’s participants are left deliberately vague.
Reflexivity
As indicated, most of the interviews were conducted by a research assistant with the same ethnic and/or national background as each study participant, and the author, an ethnic Norwegian, collected some interviews and all ethnographic data. Similarities and differences in personal factors, such as ethnicity, age, education, language proficiency and (perceived) FGC status, between the interviewers and interviewees are likely to affect access, trust and thus data quality. While there were no systematic differences found between the data collected by the author and those obtained by the research assistants in this study, such differences may occur, as described in an earlier paper [37].
Although there were many similarities between the two studies that the data in this paper are drawn from, the second study did not address the conceptualization of sunna circumcision unless it was raised by its participants. Thus, most of the quotes in this paper are from the first study. Quotes and stories drawn from the second study are marked with a star (*). Quotes and stories from Somali participants marked with a star are from the interviews conducted by the author, whereas the rest are from interviews conducted by the research assistants.
Findings: Discourses and perceptions of a shift from infibulation to sunna FGC
All the participants expressed a negative attitude toward infibulation and believed this negative attitude to be the dominant social norm in their local community in Norway and a growing social norm in their countries of origin. One example of this is a statement by an adult man during a discussion on FGC abandonment in Somalia: “I think people have stopped practicing infibulation in the large cities. They use sunna circumcision instead, because it is not dangerous” (FGD). Most study participants, however, described the shift from infibulation to sunna circumcision in terms of FGC abandonment. When talking generally about FGC, participants seemed in general to refer to infibulation. When we wanted their views on sunna circumcision on the other hand, this had to be specified. This often became evident indirectly, as in the following example, where a Somali woman recalled how she had successfully discouraged the circumcision of her to nieces in Somalia, saying that: “My sister has not circumcised her two daughters.” Later in the interview, however, she specified that she had succeeded in saving them from infibulation as “Or, yes, she had them undergo sunna, Type I and II” (IDI). * This is particularly interesting as this woman had been engaged in work against FGC in Norway, and thus had more in-depth knowledge and reflection that the average migrant.
Negotiating the abandonment of infibulation
Most study participants grounded their resistance against infibulation in a concern about its negative health consequences. Furthermore, all the health consequences outlined by participants were related to extensive vaginal closure, such as painful and obstructed menstruation, urination, sexual initiation, and childbirth.
Many participants also suggested that these health complications designated infibulation contrary to religion. In contrast, no participants considered sunna circumcision to be haram, i.e. religiously forbidden. There was thus a perception of a religiously right or wrong way to conduct FGC, as formulated by a young Somali woman: “I am not saying the FGC is haram [sinful], but the way people do it is wrong. (…) They don’t do it the way it is described by religion” (IDI). This distinction between a religiously wrong or right way of FGC was also framed in terms of a contrast between tradition and culture, which are manmade and thus changeable, and the eternal values of religion, as expressed by an adult Somali woman:
“Culture is wrong. It is something humans have invented. Religion, in contrast, comes from God, and religion says that FGC [infibulation] is forbidden. This I heard when I grew up in Somalia, when the Koranic School said that FGC is not good, it is only culture” (IDI).
Participants also commonly dismissed infibulation as an outdated and dying practice, which only occurred in rural areas among uneducated and impoverished individuals. This they often contrasted with the practice of educated migrants with an urban background, described as civilized and informed, as in this claim by a middle-aged Somali man:
“Somalis in Norway are more civilized than those in the country of origin. They have got information, and some also have a higher education from before. Those who did pharaonic [FGC] lived in the countryside and did not get the opportunity to move to Norway” (IDI).
Many participants suggested that infibulation had been imported from Egypt, with some inferring this from the terminological parallel between pharaonic FGC and the Egyptian pharaohs, others through a reinterpretation of religious texts (Old testament Exodus 1:15–22, Koran (Quran): 28:1–6), such as in this elaboration by an adult Somali man:
“(…) to limit the birth of babies, he [the Egyptian king] decided to control women’s sexual desire or behavior and decided, together with the minister of health, that they should start cutting away female genitalia and stitch it together. Later, this practice was spread to other groups or states around Egypt, with which Egypt had financial, cultural or political connections. After several thousand years, it came to Somalia and became a part of our culture” (FGD).
Similar perceptions of the Egyptian origin of infibulation have been recorded elsewhere [32, 35].
Some of the Somali men used this perception of an Egyptian origin to distance themselves from the practice, framing it as an imported and foreign practice and thus not a genuine Somali tradition. For most Somali women, in contrast, the perceived pharaonic origin did not lead to a similar distancing. None of the Sudanese participants mentioned an Egyptian origin, though it has been a common perception in Sudan as well [38]. For most participants, however, the link to a pharaonic origin placed the practice in the past, and this distant historical origin was used as evidence that the practice is outdated.
The historic origins of infibulation were often contrasted with the newness of sunna circumcision, which some of the participants dated to the 1990s, as a Somali man in an FGD: “Pharaonic [FGC] is ancient, from the Egyptian pharaohs, whereas sunna came about in the early nineties”.
Generally, then, all participants were negative toward infibulation, and most believed the practice to be waning. Most participants, particularly the men, further dissociated themselves from the practice by defining it as distant in terms of time, place (rural areas) and degree of civilization (uneducated, poor, and ignorant).
Perceptions of sunna circumcision
While describing sunna circumcision, most participants used infibulation as a reference. Participants generally described it as a modern procedure, common among educated and urban cosmopolitans, religiously promoted or approved. They also claimed it to be less extensive and harmful than infibulation, though rarely provided any concrete descriptions of its anatomical extent.
Concrete depictions of the physical extent of sunna circumcision, however, varied extensively, both between and among individuals. It was described as anything from a minor pricking to allow some blood to flow to an extensive removal, commonly followed by two or three stitches. Many participants explained this variation as a distinction between an ideal and a real way to perform sunna circumcision. Ideal sunna circumcision was considered a type of FGC that is encouraged, supported or accepted in Islam and was generally described as minor in terms of its physical infringement. Most participants grounded their conception of a religiously correct form of FGC as a procedure with minimal cutting in their broader religious values of avoiding bodily harm. In contrast to ideal sunna, many participants described real sunna circumcision, i.e. as they believed it to take place in reality, as a quite extensive procedure that could include both extensive tissue removal and vaginal closure.
Nevertheless, most commonly, the participants contrasted both ideal and real sunna circumcision with infibulation by referring to vaginal closure. In contrast to the tight vaginal introitus associated with infibulation, all participants described sunna circumcision in terms of a lack of, or less extensive, closure. One example was a Somali woman in her late fifties: “Sunna has an opening, with less cutting. That’s the difference, stitched versus open” (IDI). However, this distinction was often vague and sometimes even contradictory, as indicated in the statement of a Somali woman in her forties:
“Sunni is no cutting or stiches. You can do two stitches, so it’s very little, almost no cutting. Sunni is a small procedure; there is less pain and only two stitches, so the woman will have less pain during sex, periods and childbirth” (IDI).
Many participants shared this view of sunna circumcision as involving some stitches and hence some vaginal closure. How extensive such closure was perceived to be, however, varied. One Somali woman, for example, distinguished the closure of infibulation from sunna circumcision by pointing at the two ends of a pencil, the writing end indicating the closure in infibulation and the rubber end that in sunna circumcision (*). Following her indication it would imply that in infibulation the vaginal introitus would be only 3–4 mm. in diameter, whereas the vaginal opening left in sunna circumcision could have diameter of 2,5 cm. Another Somali woman claimed that sunna circumcision entailed closure until the urethra, which she illustrated with a drawing (*). However, the most common way of describing the extent of closure in sunna circumcision was a reference to the number of stitches, commonly two or three. No participants specified how this differed from the number of stitches in infibulation. However, as indicated in Table 1, the common number of stitches in infibulation is between four and seven. Most participants did not provide any clear or shared idea of the extent of the closure that the stitches in sunna circumcision would form. The only exception was a Somali midwife I interviewed during my stay in Kenya. She was working at a health center catering to Somali women and claimed that since FGC is performed on small girls with equivalently small genitalia, two to three stitches cause significant vaginal closure. She also claimed that she had never seen a sunna circumcision without closures sufficient to hinder vaginal intercourse. She insisted that circumcision (both infibulation and sunna) has to include closure that effectively makes sexual intercourse impossible without tearing or cutting parts of the infibulated seal. This is in line with findings from a recent study from Somaliland [7].
Some of the participants, however, expressed concerns due to the apparent lack of any substantial difference between infibulation and real sunna circumcision, e.g., these reflections of a young Somali woman:
“I have heard that sunna is a lighter type of cut, but it is not that different from the other type. I feel that nobody follows what the prophet says. Sunna has a larger hole than pharaonic [FGC]. When I left Somalia eight years ago, pharaonic was the most common. But, you could not really see the difference, as girls were cut almost in the same way, whether it was pharaonic or sunna. That means it is all closed and you cannot see any major differences. Even the girls themselves or their parents do not know how to differentiate between the two types. I don’t say that circumcision is sinful, but the way people do it is wrong. They don’t do it the way it is prescribed by religion” (IDI).
In these elaborations, this participant suggests a lack of clarity concerning any difference between infibulation and sunna, both among parents and providers. As she was not a healthcare provider, the basis of her observations is not clear. Nevertheless, as it is common in Somalia for young girls to show each other their circumcision and discuss the size of their vaginal openings [30, 39]. Her observations could have stemmed from such experiences. Nevertheless, she seemed to conclude that severe types of FGC are religiously sinful, whether referred to as infibulation or sunna circumcision, which she distinguishes from an ideal form of sunna circumcision prescribed by religion.
The amount of tissue removal was the other major distinction made between infibulation and sunna circumcision. This was generally described rather vaguely, as in this description by a Somali woman in her early thirties: “(…) you cut (slice/cut with a scissor) some part of the clitoris. You don’t remove everything, but you cut off some part. It is a professional doing it. You cut some of the upper layer, maybe a part of clitoris, it’s so little” (IDI). She then substantiated her description by arguing against closure via infibulation, which she described as “stitching up what God has left open”. Nevertheless, while describing her own circumcision as the sunna type, her claim that she had to “remove the stitches” during childbirth suggests that her sunna circumcision also included vaginal closure.
Some women related differences concerning the extent of cutting in sunna circumcision to anatomical variations. In an FGD for adult women, one participant argued “Bodies differ. [In sunna circumcision] they cut what has grown. Skin that grows”. One of the other participants substantiated this argument, responding that “Sunna implies less circumcision [than infibulation]. There is a difference in the thickness of the skin in women’s genitals. For some women, a clitoris can grow and need to be cut. I suppose this is sunna. But, the labia are still intact.” Such suggestions of a difference in cutting based on anatomical variations among girls have not been previously reported in Sudan or Somalia, although they have been described in other settings [40, 41].
A few of the participants described ideal sunna circumcision as pricking or nicking the genitalia to draw some blood without removing any tissue, e.g., two Somali women, one in her forties and the other in her fifties, who stated, respectively: “sunna is normal, just a tiny prick to cause some bleeding” (IDI) and “No cutting, no stitching and no tying of legs” (IDI*).
Male participants were generally even less specific than women in their outline of the anatomical extent of sunna circumcision. One example is the description by a Somali man in his late twenties: “Sunna circumcision is common and normal. The girl doesn’t lose any part of her body” (IDI). An even younger man described sunna as the removal of “very little tissue” (IDI). For this reason, he considered it significantly less dangerous than pharaonic FGD, although not necessarily totally harmless.
Overall, while there were extensive variations in the depictions of the anatomical extent of sunna circumcision, there was a general agreement that the procedure was significantly less extensive than infibulation, included less or no vaginal closure and often entailed less tissue removal.
Deemed less physically infringing than infibulation, sunna circumcision was commonly depicted as harmless. Its lack of health complications was commonly explained by a larger vaginal orifice. Even those who depicted sunna circumcision as including some vaginal closure believed this closure to be less tight and hence not obstructive of women’s natural functions of urination, menstruation or sexual relations; at least, not to the same extent. This became clear when we probed for the perceived differences between the health problems caused by sunna and infibulation. A Somali woman in her forties, for example, described, during an interview, how sunna was the removal of “Just a little piece. The girls don’t get so much damage”. A Somali man in his early thirties claimed that “Sunna circumcision is less dangerous and good for the girl’s health. Sunna is easier and less dangerous. I support sunna” (IDI). A Somali man under 20 years of age similarly claimed, during an interview, “Sunni is to cut a small piece of the girl’s genitalia. It is accepted religiously. It is the type where you just cut a little, and it is less dangerous than the pharaonic [FGC]. I have not heard that sunni circumcision gives any health risks or affects her sexual drive”.
These quotes illustrate that while most Somali participants presented sunna circumcision as harmless, they simultaneously perceived the practice to typically be physically extensive. Although some participants revealed that sunna circumcision could cause some harm, this was considered rather less severe than the harm caused by infibulation and thus better. Accordingly, when participants suggested that sunna circumcision is “good for the girl’s health”, they seem once again to use infibulation as a reference, i.e. that sunna is better for their health than infibulation, and not that it is good for female health per se.
Only one participant mentioned concrete experiences with health complications caused by sunna circumcision. This was a Sudanese woman with infibulation, whose youngest sister had undergone sunna circumcision, causing her immediate and long-term health problems*. A few of the men also suggested that sunna circumcision might cause some harm, although they did not report any personal experiences. This included a man of approximately 50 years of age who, after studying the subject in preparation for his planned interview had concluded that sunna destroys an important body part for women. Another Somali man, approximately 30 years younger, concluded that while he did not consider sunna circumcision dangerous, he thought it could cause some harm.
Furthermore, there was an almost uniform view that sunna circumcision has no negative consequences for women’s sexuality. This was often specified in terms of the absence of pain during sexual initiation, which is common with infibulation. This focus on the absence of pain, however, disregards other aspects of sexual encounters, including sexual desire, pleasure and satisfaction for women. This was striking; most participants described sunna circumcision, in both its ideal and real form, to include removal of clitoral tissue, and both Somali and Sudanese migrants shared the perception that the clitoris is the physical site for women’s sexual desire and pleasure [9, 26, 30]. Hence, a depiction of sunna circumcision as lacking consequences for women’s sexuality may reflect a limited appreciation of women’s sexual desire and pleasure. It may even reflect a generally negative perception of female sexual desire and pleasure due to its perceived link to sexual immorality, as other studies have found [26, 30, 34]. This is linked to the traditional perception that a lack of FGC is associated with promiscuity, not sexual pleasure [5, 20, 21, 23]. This interpretation is affirmed by many of the stories of participants, which described the change from infibulation to sunna circumcision as a means to reduce any associated health risks while maintaining the meanings that associate FGC with sexual control and virtue. A Sudanese woman in her fifties recalled, during an interview, how her sister in Sudan had tried to convince her to have her daughter cut by referring to a medical doctor’s argument that sunna is “a small thing, just to minimize lust”*. A Somali woman in her forties was told that sunna circumcision “it helps, because when a girl has her clitoris, she will desire” (IDI). A Somali woman in her thirties, claiming to have been subjected to sunna circumcision with stitches, after which her legs were bound, laughingly expressed how she had told Somali friends that she has no FGC to see their reactions: “We friends, we touch each other, right. (…) There is a girl who touched my breasts and bum—they laugh and think I get so horny since I am not stitched”.* Another allusion to the notion that the removal of the clitoris is a way to reduce sexual energy was articulated by a few participants who likened FGC to the castration of male camels; both procedures are believed to be calming.
However, a few participants, mainly young women, expressed concerns that sunna circumcision could also have negative sexual effects on women, such as a Somali woman of approximately 20 years of age: “I don’t think there are any sexual consequences of circumcision if one is open. When it comes to sunna, it depends how much is removed” (IDI).
There thus seemed to be an apparent inconsistency in the participants’ views regarding the motivation for and effect of sunna circumcision, i.e., sunna circumcision was perceived to have no effect on women’s sexuality while simultaneously reducing women’s sexual desire.
This shifts our focus back to the ideal of virginity, which is a central aspect of infibulation. Sunna circumcision in its ideal form should not include (extensive) vaginal closure and thus may not function of constructing, protecting and proving virginity as infibulation is considered to do. Thus, below, we explore how the participants expected the transition from infibulation to ideal sunna circumcision to affect virginity ideals and ideas of marriageability.
Most participants claimed that FGC was not important for marriageability in the diaspora. This claim implied that no Somali or Sudanese man living in Europe would demand that his wife be infibulated. Furthermore, several participants suggested that many men preferred their wives not to be infibulated to avoid painful sexual initiation. Meanwhile, however, there was a common perception that unmarried women without infibulation, including women who had undergone defibulation, would be deemed promiscuous and immoral. Defibulation is a minor surgery to open the infibulation seal to expose the vaginal and urethral openings and may thus ease any health consequences caused by closure [42]. The general view of such procedures as socially unacceptable if conducted premaritally could be considered a contradiction to the uniform consensus against infibulation.
Thus, while participants grounded the change from infibulation to sunna circumcision in a concerns over health, sexual problems, and the perceived backwardness of infibulation, some of the cultural values associated with FGC, particularly virginity and virtue, seemed to obstruct the speed and extent of this change. In the following section, I thus elaborate on the meaning making that dominates the participants’ discourses of the change from infibulation to sunna circumcision.
Meaning making in the change from infibulation to sunna circumcision
Study participants generally viewed the change from infibulation to sunna circumcision as a change not only in physical extent but also in meaning. Participants commonly discussed this change along three dimensions: as a change from culture to religion, from external to internal control of female sexuality and from old-fashion to modern.
From tradition to religion
Many informants explained their own shift from supporting infibulation to supporting or accepting sunna circumcision as a part of their religious education and awakening. They had come to view infibulation as not required by Islam and even contradictory to their faith, i.e., as haram. Islamic jurisprudence issues the term haram to refer to any act forbidden by God, typically in the Quran. While infibulation is not mentioned in the Quran, the participants’ perceptions that it is haram were grounded in its severe health consequences. Regarding their religious views on sunna circumcision, many participants were aware of various hadiths and of some of the controversies in terms of their interpretations. Furthermore, while the Quran does not mention FGC, some participants thought that it does and thus deemed the practice obligatory.
Many participants framed the abandonment of infibulation as a change from tradition and culture, which are dictated by humans, and thus could be defied. In contrast, as religion was perceived as God-given, those who perceived sunna circumcision as a religious practice, thought this could not be challenged. As indicated by an adult Somali man in an FGD: “There are two types of FGC in Somalia; the one, pharaonic is cultural, and the other, sunna, is religious”. A Somali woman expressed a similar view during an interview: “Before, with infibulation, this was done to control women [sexually]. But, nowadays, with sunni, it is done for religious reasons”.
Whereas the use of the sunna term to designate a type of FGC provides the practice with a religious grounding or framing [43], the link between FGC and Islam was differently perceived by the participants. Some saw the practice as obligatory, others as beneficial and still others as merely accepted. These views were not always based on a clear or strong conviction but rather on an insecure deduction, as expressed by an adult Somali man during a FGD: “Sunna is, as the name indicates, associated with religion. At least, they say it is more in accordance with religion”.
The overall impression was thus that while most participants reinterpreted infibulation as contrary to Islamic teaching, they perceived sunna circumcision to be a replacement that was religiously encouraged, supported or at least accepted.
From outer to inner sexual control
The second aspect of changes in meaning relates to the perceived sexual significance of FGC. Whereas the meaning of infibulation is intimately tied to closure, constituting a physical hindrance to and evidence of a lack of sexual engagement, the reduction or absence of closure said to be characteristic of ideal sunna circumcision suggests a change in meaning. Often, participants described a transition from infibulation to sunna circumcision as a change from outer to inner sexual control. Thus, to replace the physical closure endured through infibulation, they emphasized the importance of inner control, which could be ensured through improved parenting, religious education and reduced sexual desire through sunna circumcision. One example was an explanation provided by a Somali man in his thirties:
“In our parents’ time, they thought to circumcise and stich the labia together, so that girls could not have sexual intercourse. So, they thought that this was the solution to stop girls from having sex. But, they didn’t think about giving the girls information and knowledge about how not to do it [premarital sex]. You see? They just thought about closing it [physically] to prevent sexual activity” (IDI).
References to clitoral removal as a measure to reduce women’s sexual urges, and thus their sexual self-control, were also often alluded to. One example is the recollections of a Sudanese woman in her fifties about her sister’s suggestion to at least subject her daughters to sunna circumcision:
“Your daughters are still young, so you don’t know how girls would survive the teenage period; are we going to run behind them all the time? It is just a small thing! Just to minimize their sexual desires so they won’t make troubles. Girls also start to wear jeans, and friction can stimulate them too” (IDI)*.
While statements such as this were commonly presented in terms of arguments from others, the participants rarely disclaimed their validity. In general, discourses of the change from infibulation to sunna circumcision were intertwined with a discursive change towards increased privatization and internalization of sexual control. In contrast to infibulation, which is performed, checked, and broken by others, sunna circumcision in its ideal form was perceived to be a procedure that contributes to sexual virtue by reducing sexual desire. This discursive shift seems to have begun in parallel with an increased focus on religious teaching of sexual morality.
These blurred discourses of a change from outer to inner sexual control trough a change of type of FGC, were counteracted by the limited extent to which this was perceived to have taken place in practice. That is, sunna as it was perceived to be commonly practiced in reality, often included sufficient closure so as to ensure also external control. Furthermore, was there a simultaneous discourse of increasing other forms of external control, particularly in the form of pressure to follow a modest dress code and socialization- and movement pattern. This suggests that the discourse of transition is complicated and remains primarily at a discursive and ideal level.
From old-fashioned to modern
The third major change in meaning is the discursive framing of the shift in the type of FGC as a civilizing process. Participants commonly associated infibulation with the past, with rural areas, and with a lack of education, as indicated by a Somali man in his thirties:
“People in Somalia are now beginning to leave this bad culture behind. They are enlightened. They know how it is not good for girls when they marry, for their husbands, or when they are giving birth or for their sexual life. So, people who have information and are enlightened are abandoning this. But, people in the rural areas, those who we call baadiya, they continue to practice the pharaonic type” (IDI).
Similar perceptions were expressed by another Somali man:
“If we talk about the old times, then pharaonic circumcision was common among Somalis. But, nowadays, it is different. It seems people have become more civilized now, particularly in large cities. They use sunni circumcision. I think we should continue to practice circumcision, but not the pharaonic type” (IDI).
Many participants shared similar reflections by framing the change in FGC type as a result of modernization, education, civilization, and migration. Thus the shift was described as a result of new insights gained through education, religious enlightenment, and exposure to international impulses through travel or discussions with returned or visiting migrants.
Discussion
In this paper, I have explored various aspects of the discourses of the change from infibulation to sunna circumcision by revealing how it was reflected on by Somali and Sudanese migrants in Norway. My purpose was to investigate what is at stake and what the change is about, both in terms of its physical extents and meaning makings. The perceived changes were presented as a reduction in the physical extents of FGC, mainly in terms of vaginal closure. This change was believed to reduce or escape FGC related negative health consequences. Simultaneously, I identified changes in discursive meaning making along three lines, from culture and tradition to religion, from outer to inner sexual control, and from old-fashioned to modern.
The framing of the change from infibulation to sunna circumcision as a change from tradition and culture to religion was grounded in both concerns for health and terminology. The concern for health was related to a perception of infibulation as a practice that causes severe health consequences and is thus contrary to Islamic values. In contrast, sunna circumcision was considered minor and harmless and therefore at least religiously acceptable. The difference in terminology, from pharaonic to sunna circumcision, indicates a change from an old historical and, to some extent, foreign practice to a practice condoned by Islam. There also seemed to be indirect support for sunna because it was perceived to reduce sexual desire and to thereby contribute to sexual morality in women. The linking of sunna circumcision to religion was also underpinned by experiences with religious leaders who support the practices, which have also been documented in Norway [39]
Furthermore, most participants deemed sunna circumcision harmless, with no negative consequences for women’s sexuality, regardless of whether they spoke about ideal or real sunna circumcision. On the other hand, many simultaneously expressed views that suggested a belief that the removal of clitoral tissue in sunna circumcision reduces women’s sexual desire. However, this seemed not to be of great concern. Rather, some of the statements could suggest that some participants perceived this effect as a positive contribution to secure female sexual morality in the absence of infibulation. Moreover, the common perception that real sunna includes physical closure sufficient to hinder vaginal intercourse suggests a continuation of cultural values, i.e., of the need for physical closure to ensure virginity.
The perception of the change from infibulation to sunna circumcision in Somalia and Sudan in terms of civilization was associated with ideas of urbanization, education, international migration and religious training. However, these perceptions are only minimally supported by available statistics. If infibulation was only practiced in rural areas, this would still constitute 65% of the population in Sudan and 50% of the population in Somalia. Furthermore, the most recent prevalence in Somalia of 99% offers limited room for variation between groups. In terms of the changes in the type of FGC, the common claims of abandonment of infibulation in urban areas are not confirmed. The proportion of women in Somalia who report having undergone infibulation varies minimally between rural (65%), nomadic (62%) and urban (63%) communities [11]. Education, in contrast, was associated with a lower prevalence of infibulation, but 50% of highly educated women had still undergone Type III. Thus, while there is statistical support for a reduced prevalence of FGC and for less extensive types of FGC in urban and educated families, these differences are significantly less than was commonly claimed by the research participants.
The findings reported in this paper suggest a higher acceptance or support of sunna circumcision than other studies on diaspora populations have indicated [3, 44]. This divergence is probably related to this study’s method (qualitative versus quantitative), focus (accept and meaning versus support), and place. The aspect of place relates to the site of the first study, which was conducted in a small town with a rather conservative and tightly knit Somali community. Thus, these participants may be more conservative than an average Somali migrant in Norway and certainly more conservative than the Somali migrants in Oslo who were included in the study by Abdi Gele [3]. The second study, on the other hand, was probably biased toward women eager to abandon all forms of FGC, as it included women who were specifically targeted for their advocacy against the practice and their interethnic marriages [36].
The overall impression of the discourses of the change in question are thus that they are blurred, lacking any agreement or clarity about what changes are happening and should happen in terms of the anatomical extents and meaning makings of FGC. How then, should this blurred discourse of change be understood?
To answer this, I will draw further on insights from a paper that used data from the second study to explore how migrant Sudanese and Somali women maneuver between contradictory social norms [36]. On the one hand, they had to relate to the traditional social norms of FGC, infibulation in particular, as the ultimate measures of women’s morality. On the other hand, they had to relate to the international social norms that define FGC, and infibulation in particular, as the ultimate expression of female oppression and a violation of human rights. The majority of the participants expressed a sense of ambivalence and of being torn between these sets of norms, similar to what has been found in other studies [39, 45]. Thus, on the basis of my reanalysis of the data from the two studies, I suggest that the blurred perceptions and discourses of sunna circumcision presented in this paper constitute a potential way to facilitate women’s and men’s balancing act between traditional and international sets of norms. By presenting sunna circumcision as a minor and harmless procedure, Somali and Sudanese migrants can refute the international classification of FGC as a violation of human rights. The term sunna and the perception that it is a minor procedure may also be useful for building bridges with wider Muslim communities. As most Muslims in Norway and internationally do not have a tradition of FGC and thus tend to refute its Islamic roots, referring to the practice as sunna and minimizing its physical extent can help build bridges with other Muslim communities [35, 45]. This may be particularly important for diaspora communities, as Somali and Sudanese migrants, like many other migrant groups, experience a sense of religious awakening and engagement amid diaspora. This has also been related to the desire to belong to a broader community, which can become even more important than ethnic or national identity in a diaspora [46–48]. Additionally, vis a vis international norms, a shift from traditional to religious underpinnings of the practice may receive some support, as religion has a stronger legitimacy than culture and tradition in all countries, including their national and international policies, e.g., in clauses regarding “the freedom of religion” [10]. Nevertheless, can the understanding of sunna as a general term designating a wide variety of practices, facilitate agreement with family members and other conservative forces in migrants’ country of origin. This makes it possible for a person who wants only a tiny prick and a person who supports extensive tissue removal and closure to agree, as they may both agree to sunna circumcision. I thus suggest that the blurred discourses of sunna circumcision may constitute a way for a careful negotiation of change to conciliate the highly politicized and sensitive discourses in countries of origin, Norway and in international fora.
Concluding remarks
In this paper, I have explored an ongoing international discourse on the change in FGC from infibulation to sunna circumcision that is dominant in Somali and Sudanese communities in Norway. I found that the discourse on the abandonment of infibulation was largely formulated in terms of avoiding health risks and improving religiosity, inner sexual control and civilization. In contrast, most participants depicted sunna circumcision as a modern, minor and harmless procedure in line with religious teaching. In theory, the transition from infibulation to sunna circumcision was depicted as a shift from vaginal closure to openness, associated with a change in meaning from tradition to religion, from outer to inner sexual control and from old-fashioned to modern. However, in reality, both the anatomical extents and associated cultural meanings of FGC were blurred. I thus suggest that the blurred character of such discourse, including the vague and often contradictory definitions and understandings of sunna circumcision, is well suited for negotiating changes in the challenging current landscape, where migrants must maneuver between traditional and international norms. As the term sunna circumcision offers both a sense of religious legitimacy and can be simultaneously perceived as a minor and extensive procedure, it can be acceptable to all groups, whether they adhere to traditional or international cultural norms.
Supporting information
Interview guide.
(DOCX)
Focus group guide.
(DOCX)
Interview guide.
(DOCX)
Flow chart of the study.
Adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). RCT = Randomized controlled trial.
(TIF)
I want to thank our participants for their generosity in sharing their stories and insightful reflections. I am also most grateful for the diligence, engagement and reflections put into the work by my seven research assistants: Salma A. E. Ahmed, Khadra Yasien Ahmed, Naeema Saeed Sheekh Mohammed, Amira Jama Mohammed Ibrahim, Abdirizak Mohamud, Ibrahim Sheick Mohammed Ahmed and Omar Nur Gaal. Finally, I want to thank my colleague, Mai M. Ziyada for fruitful and inspiring discussions and support.
ReferencesJohnsdotterS, Mestre i MestreRM. "Female genital mutilation" in Europe: Public discourse versus empirical evidence. International Journal of Law, Crime and Justice;. 2017;51.WahlbergA, JohnsdotterS, SellingKE, KällestålC, EssénB. Factors associated with the support of pricking (female genital cutting type IV) among Somali immigrants–a cross-sectional study in Sweden. Reproductive health. 2017;14(1):92. doi: 10.1186/s12978-017-0351-028789667GeleAA, JohansenREB, SundbyJ. When female circumcision comes to the West: Attitudes toward the practice among Somali Immigrants in Oslo. BMC Public Health. 2012;12(1):697.ElmusharafS, ElhadiN, AlmrothL. Reliability of self reported form of female genital mutilation and WHO classification: Cross sectional study. MBMJ. 2006;333(7559):124. doi: 10.1136/bmj.38873.649074.5516803943JohansenREB. Blurred transitions of female genital cutting in a Norwegian Somali community PloS ONE. 2019.LundeIB, SagbakkenM. Female genital cutting in Hargeisa, Somaliland: is there a move towards less severe forms?Reproductive Health Matters. 2014;22(43):169–77. doi: 10.1016/S0968-8080(14)43759-524908468Newell-JonesK.ActionAid International Somaliland (AAIS) programme on FGM/C. Final Evaluation. orchid project; 2019.CrawfordS, AliS. Situational analysis of FGM/C stakeholders and interventions in Somalia: HEART UKAid; 2014.LitorpH, FranckM, AlmrothL. Female genital mutilation among antenatal care and contraceptive advice attendees in Sweden. Acta obstetricia et gynecologica Scandinavica. 2008;87(7):716–22. doi: 10.1080/0001634080214693818607822World Health Organization. Eliminating female genital mutilation: An interagency statement–OHCHR, UNAIDS, UNDP, UNECA: UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, WHO, Geneva; 2008.Directorate of National Statistics, Federal Government of Somalia, Somalia TFRo. The Somali Health and Demographic Survey. Somalia; 2020.BedriN, SherfiH, RudwanG, ElhadiS, KabiruC, AminW. Shifts in FGM/C practice in Sudan: communities’ perspectives and drivers. BMC Women’s Health. 2019;19(1):1–8. doi: 10.1186/s12905-018-0705-y30611257Liv Tønnessen, El-Nagar S. Women’s Policy Reform in Sudan’s Islamist State: The Case of Criminalizing Female Genital Mutilation/Cutting International Feminist Journal of Politics. submitted.WahlbergA, JohnsdotterS, SellingKE, KällestålC, EssénB. Baseline data from a planned RCT on attitudes to female genital cutting after migration: when are interventions justified?BMJ open. 2017;7(8):e017506. doi: 10.1136/bmjopen-2017-01750628801440Republic of Somaliland. The zero draft national policy for the abandonment of female genital mutilation. Somaliland: Ministry of labour and social affairs; 2014?Somalia GoP. Female genital mutilation/cutting policy. In: affairsMowdaf, editor. Puntland Somalia: Government of Puntland Somalia; 2012.UNICEF. Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change. UNICEF, editor. New York2013.Central Bureau of Statistics, UNICEF Sudan. Multiple Indicator Cluster Survey 2014 of fieldwork, Key Findings. Khartoum, Sudan; 2014.ZiyadaMM, Norberg-SchulzM, JohansenREB. Estimating the magnitude of female genital mutilation/cutting in Norway: an extrapolation model. BMC Public Health. 2016;16:110. doi: 10.1186/s12889-016-2794-626837303Chavez KarlströmA, DanielssonL, DahlbergH. Medical Defibulation as a Possibility-the Experiences of Young Swedish-Somali Women. International Journal of Qualitative Studies on Health and Well-being. 2020;15(1):1848026. doi: 10.1080/17482631.2020.184802633287677JohansenREB. Undoing female genital cutting: Perceptions and experiences of infibulation, defibulation and virginity among Somali and Sudanese migrants in Norway Culture, Health & Sexuality. 2016;19(4):1–15. doi: 10.1080/13691058.2016.123983827796158JohansenREB. Virility, pleasure and female genital cutting. Perceptions and experiences of medicalized defibulation among Somali and Sudanese migrants in Norway. Reproductive Health. 2017. doi: 10.1186/s12978-017-0287-428187741BoddyJ. Wombs and alien spirits: Women, men, and the Zar cult in northern Sudan: Univ of Wisconsin Press; 1989.AbdallaR.Sisters in affliction. Circumcision and infibulation of women in Africa. London: Zed Press; 1982. 122 p.GruenbaumE.Sexuality issues in the movement to abolish female genital cutting in Sudan. Medical Anthropology Quarterly. 2006;20(1):121–38. doi: 10.1525/maq.2006.20.1.12116612996ZiyadaMM, LienIL, JohansenREB. Sexual norms and the intention to use healthcare services related to female genital cutting: A qualitative study among Somali and Sudanese women in Norway. PLOSE ONE. 2020. doi: 10.1371/journal.pone.023344032421757TalleA.The making of female fertility: anthropological perspectives on a bodily issue. Acta obstetricia et gynecologica Scandinavica. 1994;73(4):280–3. doi: 10.3109/000163494090157638160531ZiyadaMM, JohansenREB. Barriers and facilitators to the access to specialized Female Genital Cutting healthcare services: Experiences of Somali and Sudanese women in Norway. PloS one. 2021;16(9).BergRC, TaraldsenS, SaidM, SørbyeI, VangenS. The Effectiveness of Defibulation and Reconstructive Surgery Following Female Genital Mutilation/Cutting: A Systematic Review. The Journal of Sexual Medicine. 2017;14(5):e246.JohansenREB. Experiencing sex in exile—can genitals change their gender? In: HernlundY, Shell-DuncanB, editors. Transcultural bodies: female genital cutting in global context. New Brunswick: Rutgers University Press; 2007. p. 248−77.TalleA.Transforming Women Into Pure’Agnates: Aspects of Female Infibulation in Somalia. In: RudieI, BleieT, Broch-DueV, editors. Carved flesh/cast selves: gendered symbols and social practices. Oxford, UK: Berg; 1993.LoweL.Transnational conceptions: displacement, maternity, and onward migration among Somalis in Nairobi, Kenya [PhD]. Endinburgh, UK: The University of Edinburgh; 2015.28toomany. Islam and Female Genital Mutilation. UK; 2015.DuderijaA, AlakAI, HissongK. Islam and gender: major issues and debates: Routledge; 2020. doi: 10.1016/j.acvd.2020.05.01432943373AsmaniIL, AbdiMS. Delinking female genital mutilation/cutting from Islam. Frontiers in reproductive health, Population Council: UNFPA; 2008.JohansenREB, AhmedSAE. Negotiating female genital cutting in a transnational context. Qualitative Health Research. 2021;31(3):458–71. doi: 10.1177/104973232097918333427072JohansenREB, IbrahimAJM, MohammedNSS, AhmedKY, MohamudA, AhmedISM, et al. Methodological Reflections on the Engagement of Cultural Insiders: A study on female genital cutting among Somali migrants in Norway. In: JohnsdotterS, editor. Female Genital Mutilation/Cutting—The global North and South. Malmø, Sweden: Centre for Sexology and Sexual Studies, Malmø University; 2020. p. 185–215.BoddyJP. Civilizing women: British crusades in colonial Sudan: Princeton University Press; 2007.FangenK, ThunC. Unge somaliske kvinner snakker om omskjæring. Sosiologi i dag. 2007;37(3–4):107–41.FahmyA, El-MouelhyMT, RagabAR. Female genital mutilation/cutting and issues of sexuality in Egypt. Reproductive health matters. 2010;18(36):181–90. doi: 10.1016/S0968-8080(10)36535-921111362RyeS.Circumcision in urban Ethiopia: practices, discourses and contexts: Department of Social Anthropology, University of Oslo; 2002.World Health Organization. WHO guidelines on the management of health complications from female genital mutilation: policy brief. WHO guidelines on the management of health complications from female genital mutilation: policy brief2016.RouziAA. Facts and controversies on female genital mutilation and Islam. The European Journal of Contraception and Reproductive Health Care. 2013;18(1):10–4. doi: 10.3109/13625187.2012.74998223286241WahlbergA, JohnsdotterS, SellingKE, EssénB. Shifting perceptions of female genital cutting in a Swedish migration context. PloS one. 2019;14(12).TalleA.Precarious Identities: Somali Women in Exile. Finnish Journal of Ethnicity & Migration. 2008;3(2):64–73.JohnsdotterS.Somali women in western exile: Reassessing female circumcision in the light of Islamic teachings. Journal of Muslim Minority Affairs. 2003;23(2):361–73.JohnsonMC. Making Mandinga or Making Muslims?Debating Female Circumcision, Ethnicity and Islam in Guinea-Bissau and Portugal. 2007.AssaMAM. Somalis and Sudanese in Norway—Religion, ethnicity/clan and politics in the diaspora. In: MangerL, AssalMAM, editors. Diasporas within and without Africa Dynamism, heterogenity, variation. Uppsala: Nordiske Afrikainstitutet; 2006. p. 165–96.10.1371/journal.pone.0268322.r001Decision Letter 0ShenLucindaStaff Editor2022Lucinda ShenThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Submission Version0
18 Jan 2022
PONE-D-21-16363
Discourses of change from infibulation to sunna circumcision among Somali and Sudanese migrants in Norway
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Reviewer #1: Partly
Reviewer #2: Yes
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Reviewer #1: I Don't Know
Reviewer #2: N/A
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Reviewer #1: No
Reviewer #2: No
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Reviewer #2: No
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Reviewer #1: Overall
It is an interesting paper which attempts to explain the changing terminology and possible change in practices when it comes to FGM from the perspectives of the Sudanese and Somali diaspora living in Norway. The paper tries to unpick some of the terminology and perceptions of what those terms mean. This information is useful in understanding behaviour in order to make appropriate changes to public policy. However I do have some serious concerns.
I’m not sure about the validity of publishing a paper using results that have already been published in another 2 papers by the same author? Reference to paper 32 and paper 9. This needs to be better explained and dully justified. HAving read paper ref 9, the content is very similar and has already been published by PLOSONE.
The methodology is not clear with regards to other ‘informal conversations’ that are included. Neither is there a valid explanation of how the themes emerged or whether these were themes in fact created by the author. The results section needs to be better explained – as it is currently not clear which information is coming from which study of the two studies and which info is from FGDs and which are from in depth interviews. It is a very wordy paper for a scientific article – it would be more impressive if more succinct and to the point. The grammar is often not correct presumably because the author is not writing in his/her native language. I would suggest getting external support for this as I do not have the time to correct English grammar.
These are my specific points:
Intro
Quite the contrary do existing evidence suggest that the procedures performed in the name of sunna circumcision often differ only slightly from infibulation.
Is this a question?
To clarify the discourse, we will start by a brief outline
You need a full stop here.
WHO differentiates between four main types of FGC on the basis of anatomical extent and
severity, ranging from type IV with no tissue removal, to type I and II with tissue removal and Type III that also includes vaginal closure (11). Type IV includes practices such as pricking or nicking, Type I includes partial or total removal of the clitoral glans (the external and visible part of the clitoris), and/or the prepuce/ clitoral hood, Type II includes the partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia 4 majora and Type III involves the narrowing of the vaginal opening through the creation of a covering seal formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans (11).
This is a very confusing description. It may be easier to put a table in listing 1 to IV with a description of each type alongside. If you donty want to add a table I suggest you at least describe tyhem in sequence – ie I to IV rather than moving between them randomly.
This meaning complex of infibulation
This does not make sense
Method and field
Maybe you mean ‘method and setting?’ or you could just use the word methodology.
This paper draws on findings from two recent studies exploring changes in the perception of
FGC among Somali and Sudanese migrants in Norway in 2017 to 2019 (9, 32).
I’m concerned about you using the data from two studies both of which have already been published to write a further paper putting the two together. You need to explain why you are covering new ground with this paper otherwise you are simply multiplying publications based on the same data.
Both studies also included participant observation and informal conversations with other Somali and Sudanese migrants. This included other Somali and Sudanese migrants in Norway, onward migrants, that is, Somali and Sudanese migrants who had left Norway to resettle in other countries of migration (UK and Canada), as well as return migrants, that is Somali and Sudanese migrants that had left Norway permanently to resettle in their countries of origin, including Sudan, Somalia and Kenya.
Its not clear who the participants in your study are? You mention the two earlier studies and then refer to informal conversations with other migrants – are they as well as the numbers in the other two studies. If so, how many more and what kind of qualitative methodology did you use. Informal conversations would not fit as a qualitative methodology.
Furthermore we had conversations with persons working in Non-Governmental Organizations (NGO) and government organizations dealing with FGC in a transnational context in Norway and Kenya, totaling more than 70 women and men.
What qualitative methodology did you use to get information from NGOs and the government? Were they formally part of your data – were they in depth interviews? Please be explicit about how they have been included in this research and what recognised qualitative methodology you used.
Research participants
Table 1
95 research participants
Do these include the NGO and government workers? They were not of Somali origin I presume? Please be explicit about who your research participants are, which are from your previous studies and which are extra to your previously published studies.
Thus, youth are defined as unmarried and young (under 30 years of age), whereas adults are defined as (ever been) married and age (above 24 years of age) (see table 1)
Your definition of youth and adults is confusing. You should be using the terms for what they are ie. ‘Never married’ and ‘married/or ever married’. Also, presumably you mean married or partnership as some may live together but never chose to get married?
Time of residence in Norway ranged from six months to thirty years, with an average of about 13.
You should be precise – not use terms like ’about.’ Please replace with the exact average.
Among the adults a little over half were employed
Please be exact.
Details about the study participants are deliberately vague or slightly altered
You cannot alter facts about the participants. This is a scientific journal and therefore details must be true and precise otherwise it makes your research invalid. Please find another way to protect the anonymity of your participants.
Reflexivity
I think you mean study limitations? Reflexivity is not a term that is used in scientific publications as far as I am aware.
Discourses and perceptions of change from infibulation to sunna type of
FGC
Most female study participants had undergone FGC, and most of them infibulation
Please be more precise. Exactly what perceptage had undergone FGC and what percentage had infibulation.
…we will work to carefully disentangle the two, and in in the following
outline each aspect of chance separately.
This sentence does not make sence.
Most commonly, study participants believed infibulation to have been imported from Egypt
Is it fair to say most commonly male study participants? If so, please add this.
Furthermore, was the transition from infibulation to sunna circumcision generally described in terms of FGC abandonment, suggesting that most participants did not consider sunna circumcision as a form of FGC
Please correct the English – it doesn’t make sense at the moment.
A midwife working at health center catering for Somali women in Nairobi taking part in an informal conversation, claimed that since FGC is done on small girls with equivalently small genitalia, two to three stitches would cause significant vaginal closure. Furthermore, she insisted that sunna circumcision nevertheless had to create a sufficiently small vaginal opening to satisfy the main purpose of FGC among Somalis, which is to create, protect and prove virginity. Thus, sunna circumcision had to include sufficient closure as to make sexual intercourse impossible without tearing or cutting parts of the infibulated seal.
If this is a quote from your informal interviews you have to reference it as so (eg Personal communications, date etc..) If you don’t reference it properly then you must explain this is not from the qualitative research but rather just an opinion of midwife working with Sudanese/Somalli women in Nairobi.
Sarah substantiated this description
Who is Sarah? Is this a mistake - including a name?
Discussion
we also found that the largest group expressed a sense of ambivalence, of being torn between traditional values and social expectations from family and network in country of origin adhering to traditional norms, and the international norms dominating their surroundings in country of migration
I am not aware that this aspect of international norms is addressed at all in this paper. Are you referring to the other paper published based on the second study? If so it seems strange to discuss it to such a large extent in the opening paragraph of your discussion. I would suggest you bring this idea in later, once you have discussed the findings of this current paper.
“I feel that a lot. Many times, I feel that they are cautious about their opinions in that
matter, for example some can say that circumcision is not existing, and they are against
it, but I feel that they are attached to their family’ traditions and believe that there is
something that has to be removed. For me, I know that there is a small thing to be
removed, but I don’t know the technique. But I feel that other people believe so too, but
they deny that. I see it in their faces that there is something, but they can’t admit, and
they say that they are against.
You cannot include a quote in your discussion. This should be added to your results section. I suggest you move it across and you can always refer to it in the discussion section.
My data also suggest that even those actively supporting sunna circumcision
would refrain from doing so due to the Norwegian ban on all types of FGC (55)
You mean ‘our data’ as you alone did not produce this I assume. Or replace by the name of the authors … et al.
However, while the aim of this paper is not to assess risk of FGC, the extent to which we have risk in mind, our focus is on how the ongoing change in meaning making accompanying a transition from infibulation to sunna circumcision may, our focus is more global.
Please correct the grammar
Though the data are collected in Norway, the explored discourse is ongoing globally, and we would not limit our concern to whether or not there is a risk of girls being cut while living in Norway, or whether Norwegian law is broken. We are also concerned about the risk of those 15% of Somalis with Norwegian citizenship that leave to settle in another country of migration or return to their country of origin (56). And beyond so-called holiday cutting, that our data suggest is rare, we are concerned about the about quarter of Somali children and teens in Europe that are sent to country of origin for so-called cultural rehabilitation (57). In such cases, where children commonly stay for a longer time (one to three years) under the custody of relatives in country of origin, there are anecdotal and documented cases where the locally responsible relatives arrange for FGC, with or without the girl’s parents’ knowledge or consents (32, 58, 59).
You are diverging quite a lot from the research discussed in your paper and the evidence it provides when discussing the risk of FGM to diaspora when they return to their country of origin. It is OK to make reference to how your findings might be relevant to policies as you do in the conclusion but you should not digress to an extensive elaboration of your opinions on this in the discussion.
Would have been interesting to look at how the discourse might be different amongst the participants who grew up in Norway or who had lived in Norway for a long time compared to those who had recently arrived. Do you have data on this – if so could you add?
Conclusion
Religiosity
I don’t think this is a word.
...was there several factors suggesting a less dramatic change than at first appearance.
Correct the grammar
Reviewer #2: The paper is important and interesting but could benefit from English proof reading. The data support conclusions but this could improve if the language was improved and clarifications made. The author have to my knowledge not been provided with the underlying data for the study.
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Submitted filename: Plos One reviewer comments.docx
10.1371/journal.pone.0268322.r002Author response to Decision Letter 0Submission Version1
4 Mar 2022
Response to reviewers point by point - PONE-D-21-16363
Comments from the editor
a. Editors’ comment: If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.
Response to editor: There is no changes in financial disclosure.
b. Editors’ comment: Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.
Response to editor: A figure has been added (Figure 1, page 4), and uploaded accordingly.
c. Editors’ comment: Provide additional details regarding participant consent. - specified (i) whether consent was informed and (ii) type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians.
Response to editor: This information is now provide in the manuscript, in the method section, page 12, line 219-224.
d. Editors’ comment: We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. "Three of the 25 quotes in this paper is presented in a former paper" Please clarify whether this publication was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.
Response to editor: This is now clarified both in the cover letter to the editor* and the manuscript, page 10, line 188-197.
The following information is provided in the cover letter: Concerning the paper being based on data of which some is also used in other papers. Three out of the total of 32 quotes in the attached paper have been used in an earlier paper peer-reviewed and published by PlosOne (Johansen REB. Blurred transitions of female genital cutting in a Norwegian Somali community, 2019). However, this new paper does not constitute a dual publication for the following reasons: In contrast to the aforementioned paper that provides an overview of all the major themes found in the study, this paper goes in-depth into one of these themes to ensure a better empirical foundation and more nuances and further elaborations. For the current paper, the author re-read and re-analyzed all original data from both studies with to identify all data relevant for the discourse of change from infibulation to sunna circumcision, and a reanalysis of these data. Thus the new paper thus includes substantially more empirical data, with 29 additional quotes as well as additional empirical information in other forms. This to provide stronger empirical basis for the analysis and to provide more rich and nuanced data and analysis. Furthermore have the final analysis been expanded, including a further analysis of why the discourse of change seems to be both contradictory and blurred. Thus the discussion and conclusion does not only provide empirical data on what is happening, but also a further analysis of why this is taking place.
e. Editors’ comment: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.
Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.
Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.
We will update your Data Availability statement to reflect the information you provide in your cover letter.
Response to editor: Information on data-availability is now included in the cover letter. All relevant data is included in the manuscript.
f. Editors’ comment: Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.
Response to editor: This is now done in method section, subsection on ethical considerations, page 11 lines 218 to page 12, 226.
Reviewer #1: Overall
1. Reviewer’s question/comment: It is an interesting paper which attempts to explain the changing terminology and possible change in practices when it comes to FGM from the perspectives of the Sudanese and Somali diaspora living in Norway. The paper tries to unpick some of the terminology and perceptions of what those terms mean. This information is useful in understanding behavior in order to make appropriate changes to public policy. However I do have some serious concerns.
I’m not sure about the validity of publishing a paper using results that have already been published in another 2 papers by the same author? Reference to paper 32 and paper 9. This needs to be better explained and dully justified. Having read paper ref 9, the content is very similar and has already been published by PLOSONE.
Response: I have now added an improved description on the difference between this and former papers from the same data-set on page 10, lines 188-197.
2. Reviewer’s question/comment: The methodology is not clear concerning other ‘informal conversations’ that are included. Neither is there a valid explanation of how the themes emerged or whether these were themes in fact created by the author.
Response: I have now added a paragraph on the analyzing process, see page 10, lines 193-195. How the additional data (beyond the 95 study participants) was collected is outlined more detailed from page 9, line 162 to page 10, line 184. How these additional data are used are described on page 10, line 185-187.
3. Reviewer’s question/comment: The results section needs to be better explained – as it is currently not clear which information is coming from which study of the two studies and which info is from FGDs and which are from in depth interviews.
Response: Regarding the quotes, in addition to gender and approximate age, II have now marked whether the statement came in an interview (IDI) or a focus group discussions (FGD). Quotes and stories from the second study are further marked with a *. Quotes and stories from the first study are unmarked. And, in the cases where a quote marked with a star is of a Somali person, this indicates that it comes from an interview conducted by the author. This is now explained in the method section, page 12, lines 236-242.
4. Reviewer’s question/comment: It is a very wordy paper for a scientific article – it would be more impressive if more succinct and to the point.
Response: I have tried to shorten and sharpen the language, and cut or reduce some side-tracks (e.g. on clothing and social control, and my the concern of FGC after migration) to compensate for the extra words added by responding the reviewers requests for additional information, reducing the number of words substantially (from 11 438 to 10 282 words), now including acknowledgement.
These are my specific points:
Introduction
5. Reviewer’s question/comment: Quite the contrary do existing evidence suggest that the procedures performed in the name of sunna circumcision often differ only slightly from infibulation. Is this a question?
Response: Not a question, a statement. Grammar corrected to avoid misunderstanding. See page 3, line 37-38.
6. Reviewer’s question/comment: To clarify the discourse, we will start by a brief outline. You need a full stop here.
Response: Done. Sentence is slightly revised, page 3, line 45-46.
7. Reviewer’s question/comment: WHO differentiates between four main types of FGC on the basis of anatomical extent and severity, ranging from type IV with no tissue removal, to type I and II with tissue removal and Type III that also includes vaginal closure (11). Type IV includes practices such as pricking or nicking, Type I includes partial or total removal of the clitoral glans (the external and visible part of the clitoris), and/or the prepuce/ clitoral hood, Type II includes the partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia 4 majora and Type III involves the narrowing of the vaginal opening through the creation of a covering seal formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans (11).
This is a very confusing description. It may be easier to put a table in listing 1 to IV with a description of each type alongside. If you donty want to add a table I suggest you at least describe tyhem in sequence – ie I to IV rather than moving between them randomly.
Response: I have now added a figure (Figure 1 page 4) and a table to clarify this (Table 1, page 4 and 5). The figure demonstrates what was formerly formulated in words in terms of the gradual increase in anatomical extent from type IV, followed by type I, II and III (Figure 1). This to clarify the common confusion made between numbers and severity, as the WHO typology describes increasingly severe procedures from I to III, whereas type IV is the least severe. In addition, I have added a table describing more detailed the similarities and differences between WHO classification and the emic classifications among Somalis and Sudanese at home and abroad in numerous order on the basis of the numbers in the WHO typology (Table 1).
8. Reviewer’s question/comment: “This meaning complex of infibulation” -This does not make sense
Response: This text is altered for clarity, page 7, line 109-111.
9. Reviewer’s question/comment: Method and field. Maybe you mean ‘method and setting?’ or you could just use the word methodology.
Response: Changed now to “Materials and methods” in accordance with the PlosOne Guidelines. Page 7, line 124.
10. Reviewers’ question/comment: This paper draws on findings from two recent studies exploring changes in the perception of FGC among Somali and Sudanese migrants in Norway in 2017 to 2019 (9, 32). I’m concerned about you using the data from two studies both of which have already been published to write a further paper putting the two together. You need to explain why you are covering new ground with this paper otherwise you are simply multiplying publications based on the same data.
Response: This is now clarified both in the cover letter to the editor* and the manuscript, page 10, line 188-197. In the letter to the editor the following information is provided: Concerning the paper being based on studies that also are used in other publications. Three out of the current 32 quotes in the paper have been used in an earlier peer-reviewed and published paper in PlosOne (Johansen REB. Blurred transitions of female genital cutting in a Norwegian Somali community. 2019). However, this new paper does not constitute a dual publication for the following reasons: The two former paper presented an overview of the themes found, whereas the current paper provides an in-depth analysis of one of these themes. For the current paper, original data from the two studies were re-read and re-analyzed with a focus on identifying and analyzing all data relevant for the discourse of change from infibulation to sunna circumcision. The new paper thus includes substantially more empirical data, including 29 quotes not formerly published, as well new informant stories. The purpose was to provide a stronger empirical basis for the analysis and to provide more rich and nuanced analysis. Furthermore, I have expanded the final analysis with a stronger emphasis on the ways in which and the reasons why both discourse and practice appears blurred, i.e. to facilitate peoples maneuvering of change in a context of change, where they have to relate to both traditional expectations from countrymen, not least in country of origin where infibulation is still a norm, and the wider Norwegian and international society that judge FGC practices as human rights violation.
11. Reviewers’ question/comment: Both studies also included participant observation and informal conversations with other Somali and Sudanese migrants. This included other Somali and Sudanese migrants in Norway, onward migrants, that is, Somali and Sudanese migrants who had left Norway to resettle in other countries of migration (UK and Canada), as well as return migrants, that is Somali and Sudanese migrants that had left Norway permanently to resettle in their countries of origin, including Sudan, Somalia and Kenya.
Its not clear who the participants in your study are? You mention the two earlier studies and then refer to informal conversations with other migrants – are they as well as the numbers in the other two studies. If so, how many more and what kind of qualitative methodology did you use. Informal conversations would not fit as a qualitative methodology.
Response: In this article I have used data from the two mentioned studies, which included formal interviews and focus group discussions with 95 Somali and Sudanese migrants. In addition I conducted “ethnographic fieldwork”, including interviews and participant observation in various settings. With one exemption, were none of the participants and data from the ethnographic fieldwork used directly in the paper or calculated as one of the 95 participants. Rather, these data were used to test the validity of the findings (member-checking), and provide contextual information to better inform the analysis. The one exception is the statement from a midwife interviewed during a stay in Kenya (now described in the method section (page 9, line 165-166), as suggested by editor in PlosOne. She is nevertheless not counted among the 95 study participants. This has now made clearer in the article (page 10 line 185-187).
12. Reviewers’ question/comment: “Furthermore we had conversations with persons working in Non-Governmental Organizations (NGO) and government organizations dealing with FGC in a transnational context in Norway and Kenya, totaling more than 70 women and men. What qualitative methodology did you use to get information from NGOs and the government? Were they formally part of your data – were they in depth interviews? Please be explicit about how they have been included in this research and what recognized qualitative methodology you used.
Response: Se response to question above for clarification, and manuscript (page 10, line 185-187).
13. Reviewers’ question/comment: Research participants, Table 1, 95 research participants. Do these include the NGO and government workers? They were not of Somali origin I presume? Please be explicit about who your research participants are, which are from your previous studies and which are extra to your previously published studies.
Response: Interviews conducted as a part of my ethnographic fieldwork come in addition to the 95 study participants, including the NGO, though they were of Somali origin. Government workers are neither included in the 95 participants, and none of these were of Somali origin. No additional information was collected for the purpose of this new paper. However, the table with the overview of the informants have now been removed, and the information provided in the text (see page 8, line 146-148).
14. Reviewers’ question/comment: “Thus, youth are defined as unmarried and young (under 30 years of age), whereas adults are defined as (ever been) married and age (above 24 years of age) (see table 1). Your definition of youth and adults is confusing. You should be using the terms for what they are ie. ‘Never married’ and ‘married/or ever married’. Also, presumably you mean married or partnership as some may live together but never chose to get married?
Response: I decided to remove the differentiation between youth and adults in the categorization of informants, but described how it was used to organize focus groups discussions and why, and how it was defined on page 8, line 140-148.
Some additional answers regarding marriage and co-habitation status. None of the participants claimed to be co-habiting without being married, probably because this would be strongly frowned upon as immoral within Somali and Sudanese network. On the other hand were some of the participants married, but not cohabitating, as the spousse lived in other towns or countries. These participants are probably registered as single in official systems in Norway. However, as this information did not seem to be relevant for the study findings, and would take space to discuss, I have not included it in this paper.
15. Reviewers’ question/comment: Time of residence in Norway ranged from six months to thirty years, with an average of about 13. You should be precise – not use terms like ’about.’ Please replace with the exact average.
Response: As this is not a quantitative paper, and some participants did not provide information of their length of stay, I have removed the reference to an average – page 11, line 203-205.
16. Reviewers’ question/comment: Among the adults a little over half were employed. Please be exact.
Response: As this is a qualitative study, the data are not representative, nor did all participants provide such information, I do not find it useful to be so specific about actual numbers. However, I have now specified in the text that while we did not ask specifically about current employment or study status, most provided this. Page 11, lines 206-211.
17. Reviewers’ question/comment: Details about the study participants are deliberately vague or slightly altered. You cannot alter facts about the participants. This is a scientific journal and therefore details must be true and precise otherwise it makes your research invalid. Please find another way to protect the anonymity of your participants.
Response: I have now clarified in the text that in actually the data are not altered, only vague. And potential identifying data, such as age, number of children, marital status, or time of residence in Norway is not provided. See page 12, line 224-226.
18. Reviewers’ question/comment: Reflexivity. I think you mean study limitations? Reflexivity is not a term that is used in scientific publications as far as I am aware.
Response: In qualitative studies it has become increasingly common over the last 20 years to add a section on reflexivity. This is a response to an increased awareness of the role of the researcher in data-collection, and a perception of qualitative data as construed in collaboration between the researcher and the study participant, in which their similarities and differences in personal qualities, belonging, ethnicity and position, is likely to have an effect on access, trust and maybe also study findings (1, 2). It is even more important to include in studies of sensitive topics affecting a minority group. I have thus left the subtitle “reflexivity”. Thus in qualitative studies the position of researcher and data-collector is often elaborated in a section commonly entitled “reflexivity”, in contrasts to the more common reference to “study limitations” in quantitative studies. See for example:
1. Ziyada MM, Lien IL, Johansen REB. Sexual norms and the intention to use healthcare services related to female genital cutting: A qualitative study among Somali and Sudanese women in Norway. PLOSE ONE. 2020.
2. Dodgson JE. Reflexivity in qualitative research. Journal of Human Lactation. 2019;35(2):220-2.
Also, the professional English language reviewers did not question the headline.
19. Reviewers’ question/comment: Discourses and perceptions of change from infibulation to sunna type of- FGC. Most female study participants had undergone FGC, and most of them infibulation Please be more precise. Exactly what percentage had undergone FGC and what percentage had infibulation.
Response: As this is not a quantitative paper with representative sample, I do not consider it suitable to provide prevalence in percentages. Neither did we ask directly about FGC status, thus this was not always provided. However, I have however now given actual number of girls and women who claimed to have undergone infibulation, as well as those claiming sunna and no FGC., and those who gave no clear indication of type experienced. See page 11, line 212-216.
20. Reviewers’ question/comment: “…we will work to carefully disentangle the two, and in in the following outline each aspect of chance separately.2 This sentence does not make sence.
Response: Whole paragraph have been reworked for clarity.
21. Reviewers’ question/comment: “…Most commonly, study participants believed infibulation to have been imported from Egypt Is it fair to say most commonly male study participants? If so, please add this.
Response: The higher prevalence of this view, or more importantly how this made participants think about the practice of FGC as a foreign cultural element was more common among the men, and has now been highlighted in the article. Page 15, line 298-304.
22. Reviewers’ question/comment: “…Furthermore, was the transition from infibulation to sunna circumcision generally described in terms of FGC abandonment, suggesting that most participants did not consider sunna circumcision as a form of FGC Please correct the English – it doesn’t make sense at the moment.
Response: The sentence has been reworked for clarity, page 13, line 251-260.
23. Reviewers’ question/comment: “…A midwife working at health center catering for Somali women in Nairobi taking part in an informal conversation, claimed that since FGC is done on small girls with equivalently small genitalia, two to three stitches would cause significant vaginal closure. Furthermore, she insisted that sunna circumcision nevertheless had to create a sufficiently small vaginal opening to satisfy the main purpose of FGC among Somalis, which is to create, protect and prove virginity. Thus, sunna circumcision had to include sufficient closure as to make sexual intercourse impossible without tearing or cutting parts of the infibulated seal.
If this is a quote from your informal interviews you have to reference it as so (eg Personal communications, date etc..) If you don’t reference it properly then you must explain this is not from the qualitative research but rather just an opinion of midwife working with Sudanese/Somali women in Nairobi.
Response: This is from one of the informal interviews, yes. I have added the information on how and when this data was acquired as suggested by PlosOne, see page 9 line 165 to 167, page 10, line 185-187, and page 17, line 350-351
24. Reviewers’ question/comment: “…Sarah substantiated this description Who is Sarah? Is this a mistake - including a name?
Response: Pseudonym has now been removed and replaced with description of her as a study participant.
25. Reviewers’ question/comment: “…Discussion we also found that the largest group expressed a sense of ambivalence, of being torn between traditional values and social expectations from family and network in country of origin adhering to traditional norms, and the international norms dominating their surroundings in country of migration
I am not aware that this aspect of international norms is addressed at all in this paper. Are you referring to the other paper published based on the second study? If so it seems strange to discuss it to such a large extent in the opening paragraph of your discussion. I would suggest you bring this idea in later, once you have discussed the findings of this current paper.
Response: The suggestion is now followed, and the discussion section reworked. See page 26, line 588 onwards.
26. Reviewers’ question/comment: “… “I feel that a lot. Many times, I feel that they are cautious about their opinions in that matter, for example some can say that circumcision is not existing, and they are against it, but I feel that they are attached to their family’ traditions and believe that there is something that has to be removed. For me, I know that there is a small thing to be removed, but I don’t know the technique. But I feel that other people believe so too, but they deny that. I see it in their faces that there is something, but they can’t admit, and they say that they are against.
You cannot include a quote in your discussion. This should be added to your results section. I suggest you move it across and you can always refer to it in the discussion section.
Response: Quote is now removed from the paper as it did not fit into the finding section without expanding that extensively.
27. Reviewers’ question/comment: “…My data also suggest that even those actively supporting sunna circumcision would refrain from doing so due to the Norwegian ban on all types of FGC (55) You mean ‘our data’ as you alone did not produce this I assume. Or replace by the name of the authors … et al.
Response: Done. Replaced with “our findings” to indicate how most data was collected by a team of research assistants. For more elaboration on research on this see page 8, lines 136-140 and page 9 lines 167-173.
28. Reviewers’ question/comment: “…However, while the aim of this paper is not to assess risk of FGC, the extent to which we have risk in mind, our focus is on how the ongoing change in meaning making accompanying a transition from infibulation to sunna circumcision may, our focus is more global. Please correct the grammar
Response: This sentence and discussion is now removed to shorten and sharpen the text as requested.
29. Reviewers’ question/comment: “…Though the data are collected in Norway, the explored discourse is ongoing globally, and we would not limit our concern to whether or not there is a risk of girls being cut while living in Norway, or whether Norwegian law is broken. We are also concerned about the risk of those 15% of Somalis with Norwegian citizenship that leave to settle in another country of migration or return to their country of origin (56). And beyond so-called holiday cutting, that our data suggest is rare, we are concerned about the about quarter of Somali children and teens in Europe that are sent to country of origin for so-called cultural rehabilitation (57). In such cases, where children commonly stay for a longer time (one to three years) under the custody of relatives in country of origin, there are anecdotal and documented cases where the locally responsible relatives arrange for FGC, with or without the girl’s parents’ knowledge or consents (32, 58, 59).
You are diverging quite a lot from the research discussed in your paper and the evidence it provides when discussing the risk of FGM to diaspora when they return to their country of origin. It is OK to make reference to how your findings might be relevant to policies as you do in the conclusion but you should not digress to an extensive elaboration of your opinions on this in the discussion.
Response: This view is now taken into consideration and the text removed for the purpose of shortening and sharpening the manuscript.
30. Reviewers’ question/comment: “…Would have been interesting to look at how the discourse might be different amongst the participants who grew up in Norway or who had lived in Norway for a long time compared to those who had recently arrived. Do you have data on this – if so could you add?
Response: Time of residence (in terms of actual years or approximate or real age at arrival) was provided by most, but not all participants. However, there was no systematic differences in perceptions and views in terms of length of stay. Some participants had been engaged in activities against FGC already in country of origin, whereas some had not thought about the practice even after 10 – 15 years in Norway. Hence, contrary to what has been suggested in quantitative studies, this study does not indicate systematic differences between length of stay and insight and opinion is thus not discussed in the paper.
31. Reviewers’ question/comment: “…Conclusion Religiosity I don’t think this is a word.
Response: The term exist and is used according to google, google translate and English dictionaries. Furthermore was the word not questioned by the professional proof readers.
32. Reviewers’ question/comment: “…...was there several factors suggesting a less dramatic change than at first appearance. Correct the grammar
Response: Done. See page 3, line 36-37.
Reviewer #2:
I. Reviewers’ question/comment: “…The paper is important and interesting but could benefit from English proof reading. The data support conclusions but this could improve if the language was improved and clarifications made.
Response: The paper has been sent for English proof reading. As this is expensive, I did this only after receiving and responding to the reviews.
II. Reviewers’ question/comment: “…The author have to my knowledge not been provided with the underlying data for the study.
Response: I am not sure what is meant by this comment, but yes, the author have conducted a number of the interviews personally, and received transcripts of all the other interviews and focus group discussions, hence provided with all underlying data for the paper. This is now clarified in the method section, see page 8, line 148-153.
III. Reviewers’ question/comment: Very important and interesting paper with informative content and interesting points brought to light. However, the paper would benefit from undergoing English proof reading, sometimes the meaning gets lost due to incorrect (I assume) use of words.
Response: Proofreading is conducted after reception of the reviews and my subsequent revision of manuscript.
IV. Reviewers’ question/comment: Also, you sometimes write ‘we’ and sometimes ‘me’.
Response: I have written this paper alone, whereas most of the data was collected by research assistants. I have double checked the manuscript to ensure that I, me and we are used correctly.
Introduction:
V. Reviewers’ question/comment: You have two aims, it would be clearer if you place these together, perhaps turn them into a broader aim and two objectives.
Response: This is now done, page 3, line 39-44.
The result section is clear and informative.
Discussion:
VI. Reviewers’ question/comment: The discussion is a bit messy and could benefit from clarification, could do with subheadings. I suggest you try to separate the points a bit, perhaps discuss sexuality by itself, and then tradition/religion, and then ‘modern/backwards’. I think this will provide some clarification. Also look over how you use ‘real’ and ‘ideal’ and ‘discourse’ and ‘reality’, and how these connect to each other.
Interesting discussion on religion here.
Response: Have reworked the discussion section with these commentaries in mind, though not adding subheadings, the text is not reorganized as suggested. See page 26, line 587 onwards.
Conclusion:
VII. Reviewers’ question/comment: I like your conclusion as your points, but not sure if the point about sexual control to move from outer (infibulation) to inner (sunna) works – except for in the discourse (if the ‘real’ sunna is closure anyway). Perhaps one point that could be highlighted more is that without the changes in meaning of female sexuality (ie that it still needs to be controlled), a change to lesser forms of FGC (or abandonment) is unlikely to take place, at least in more than the discourse. This does come across, but could be clearer.
Response: Both the findings, the discussion and conclusion have been revised to clarify the suggested points that change from infibulation to sunna circumcision is mainly a discursive change. However, I do not think that it is impossible to change to a less extensive sunna without changing the meaning of female sexuality, as I have now stronger highlighted that sexual control is also increasingly thought to be possible through other outer means than cutting, including clothing and increased social control. However, due to space I have only been able to allude to this. Rather I have strengthened the discussion and conclusion on how the blurred aspects of the discourse facilitates maneuvering in the current context of change.
Specific comments:
VIII. Reviewers’ question/comment: Page 3, first half: Please provide a reference to the sentence: Nevertheless, existing evidence suggest that the change of type is both less widespread and substantial than commonly claimed.
Response: References are now added, page 3, line 37.
IX. Reviewers’ question/comment: Look over this sentence, Furthermore, the change of anatomical extent of FGC is associated with changes in the meaning making, in which religion seems to play a major role, while concerns over female sexuality, a major component of infibulation, still is a major cultural and religious value. Can it be divided and clarified?
Response: The whole paragraph is now change, page 27, line 588 onwards. See alse page 29, line 641-644.
Page 4:
X. Reviewers’ question/comment: Thus, the contrast between infibulation and sunna circumcision can, in some cases, be limited to a slight difference in the extent of vaginal closure. Perhaps specify that you mean the discursive contrast here.
Response: The whole text is reworked to be more specific and illustrated in a figure (Figure 1, page 4) and a table (Table 1, page 4-5). I have also reworked the text to highlight that the difference can be slight both discursively and in practice.
Page 7: Methods and field
XI. Reviewers’ question/comment: Do you mean that you draw on data from two studies that also resulted in two other publications? Or do you only draw on the result/findings from these two published studies? Please clarify here.
Response: I draw on data from two studies that also resulted in two other papers. This is now made clearer in the text, page 10, line 188-197.
XII. Reviewers’ question/comment: Also, did you include the conversations with NGO officials in your analysis? Or did these merely interpret your analysis? This could also need clarification.
Response: Findings from discussions with NGO officials contributed to my overall understanding of the discourse. This is now clarified in the method section.(page 10, lines 185-187).
XIII. Reviewers’ question/comment: Also, could you include some of the questions (or perhaps topic guide) used for the interviews? Were they all the same or did they differ?
Response: I have now included a paragraph on the topics explored in the interviews and focus group discussions in the two studies, see page 9, line 154-161.
Page 8:
XIV. Reviewers’ question/comment: What does it add to the study to divide the groups into ‘youth’ and ‘adults’? I find it a bit confusing, also because some can go into both groups and because it is different in men. I understand that this can be an interesting point for analysis and discussion, but do not see the purposefulness in the division on this level. Also, what about those women aged 23 in the table? Even if there were no such women. Please look over the table and make it clearer.
Response: I have now removed the differentiation between youth and adults, expect for its role in the composition of the focus groups and why and how it was defined, see page 8, line 140-147. As the result section is not divided by age group, I have also removed the table on this, but added this info in the text, page 8, line 146-148.
Page 9:
XV. Reviewers’ question/comment: Regarding education, perhaps avoid using the word ‘ significantly’ as this implies a quantitative terminology and measurement.
Response: I have removed the term significant to avoid misunderstandings, page 11, line 211.
Ethical considerations:
XVI. Reviewers’ question/comment: Do you mean that you changed some of the characteristics when providing the quotes? Or in the table? Please specify.
Response: This is now specified, in the sense that that the I did not alter any information about the individual participants in this final manuscript, just providing limited or vague data (such as approximate age, without providing information about marital status, educational level or time of residence for each participant), page 11, line 224-226.
Page 10:
XVII. Reviewers’ question/comment: Reflexivity: in the first paragraph, I think you can reflect a little bit more about how being an insider/outsider might have influenced the responses, or at least why/how you can to the conclusion that this did not affect your data. The second paragraph of the reflexivity chapter I do not feel belong here but earlier in the methods chapter.
Response: I have added a reflections on this and its lack of any visible difference in this study, and kept the reference to a more elaborately discussed of this in another paper that was based on the first study, page 1, lines 228-235 + 338-242. Second paragraph is now reworked and the information moved further up front.
XVIII. Reviewers’ question/comment: Please specify where you start indicating your findings.
Response: This is now done, page 12, line 243.
XIX. Reviewers’ question/comment: Page 11: the wording ‘The flow of the discourse’ is used a bit lightly here and it is not clear what this means. I suggest a different, more specific, wording here. Also, how do this quote indicate that this means a change towards abandonment as opposed to change from one FGC to another? Could you provide some more evidence to support this suggestion?
Response: This text have now been strongly altered for clarification of these questions and one example added on page 13, line 251-260.
XX. Reviewers’ question/comment: Page 14: It would be great if you had a quote to support the 40-year old women who considered her extensive ‘sunna’ to be minor and harmless.
Response: As this information had to be deducted from different statements throughout the interview and thus be difficult to illustrate by one or two quotes, I have omitted this story from the manuscript, but added more broad discussions and additional data on the participants’ conceptualization of harm caused by sunna in the section on sunna, page 15 line 313 onwards.
XXI. Reviewers’ question/comment: Page 15: Interesting quote by this woman. It would be good, however, to get a little bit more information about why she knows how the ‘sunna’ looks in many women – is this something the majority of women know (how it is in others) because they talk to each other or does she have special insight (being a doctor/midwife or something)?
Response: I have now added a couple of sentences of this, page 18, line 370-374.
XXII. Reviewers’ question/comment: Also, can you give a bit more detail on how ‘sunna’ is proscribed by religion? Perhaps in the background?
Response: Some additional information on this is now provide in the introduction on page 7, lines 112-120.
XXIII. Reviewers’ question/comment: Page 29: What is the difference between the papers building up to the study, to this study? What can you draw on from that paper, and what comes (in result) of the present paper? Did you have different conclusions in that paper than in this one?
Response: Yes, the other papers building on the data presented an overview of the different themes that were recurrent and dominant in the findings, whereas this paper focus in-depth on one of these themes. This is now clearer expressed on page 10, line 188-197. Furthermore is the conclusion different, in that it focuses more on the blurredness of the discourse as a way to maneuver in times of contradictory social norms and change.
Submitted filename: Responce to reviewers-3.docx
10.1371/journal.pone.0268322.r003Decision Letter 1JordalMalinGuest Editor2022Malin JordalThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Submission Version1
28 Apr 2022
Discourses of change: The shift from infibulation to sunna circumcision among Somali and Sudanese migrants in Norway
PONE-D-21-16363R1
Dear Dr. Johansen,
We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.
Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.
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Guest Editor
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Additional Editor Comments (optional):
Congratulation with a clear and well-written paper which highlights the complexities involved in the transition from infibulation to sunna circumcision in Somali and Sudanese populations in diaspora. The paper contributes to a nuanced discussion on the subject of FGC and change.
I discovered a few small unclarities and/or spelling mistakes, indicated below. Please address these before submitting your final version.
Line 180: it should be ‘additional’ here.
Line 212: write ‘n’ instead of ‘no’ in the bracket.
Line 238-239: this line is a little bit unclear.
Line 313: should the first word be ‘when’ (not ‘while’)?
Line 314: this reference to ‘well-described practice’ reads a bit awkward here, I cannot see that the following indicates that it is not ‘well-defined’. Is faraonic ‘well-defined’ and sunna not? The following sentence reads well though, perhaps just remove the first part of the sentence?
Line 241-242: this is very interesting, but a little bit clear. Can you specify what the woman meant by the writing end and the rubber end of a pen and how this related to the two types (infibulation and sunna)? Perhaps indicating approximately centimeters?
Line 372: remove the word ‘thus’?
Line 448: spelling mistake, it should be ‘it’.
Line 669-671: there seems to be a grammatical error in this sentence.
Reviewers' comments:
10.1371/journal.pone.0268322.r004Acceptance letterJordalMalinGuest Editor2022Malin JordalThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
26 May 2022
PONE-D-21-16363R1
DISCOURSES OF CHANGE: THE SHIFT FROM INFIBULATION TO SUNNA CIRCUMCISION AMONG SOMALI AND SUDANESE MIGRANTS IN NORWAY
Dear Dr. Johansen:
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