The association between female genital cutting and correlates of sexual and gynaecological morbidity in Edo State, Nigeria
* Professor F. E. Okonofua, Women's Health and Action Research Center, 4 Alofoje Street, Off Uwasota Street, P.O. Box 10231, Ugbowo, Benin City, Nigeria.
Objective To examine the association between female genital cutting and frequency of sexual and gynaecological symptoms among a cohort of cut versus uncut women in Edo State of Nigeria.
Design Cross sectional study.
Setting Women attending family planning and antenatal clinics at three hospitals in Edo State, South–south Nigeria.
Population 1836 healthy premenopausal women.
Methods The sample included 1836 women. Information about type of female genital cutting was based on medical exams while a structured questionnaire was used to elicit information on the women's socio-demographic characteristics, their ages of first menstruation (menarche), first intercourse, marriage and pregnancy, sexual history and experiences of symptoms of reproductive tract infections. Associations between female genital cutting and these correlates of sexual and gynaecologic morbidity were analysed using univariate and multivariate logistic regression and Cox models.
Main outcome measures Frequency of self-reported orgasm achieved during sexual intercourse and symptoms of reproductive tract infections.
Results Forty-five percent were circumcised and 71% had type 1, while 24% had type 2 female genital cutting. No significant differences between cut and uncut women were observed in the frequency of reports of sexual intercourse in the preceding week or month, the frequency of reports of early arousal during intercourse and the proportions reporting experience of orgasm during intercourse. There was also no difference between cut and uncut women in their reported ages of menarche, first intercourse or first marriage in the multivariate models controlling for the effects of socio-economic factors. In contrast, cut women were 1.25 times more likely to get pregnant at a given age than uncut women. Uncut women were significantly more likely to report that the clitoris is the most sexually sensitive part of their body (OR = 0.35, 95% CI = 0.26–0.47), while cut women were more likely to report that their breasts are their most sexually sensitive body parts (OR = 1.91; 95% CI = 1.51–2.42). Cut women were significantly more likely than uncut women to report having lower abdominal pain (OR = 1.54, 95% CI = 1.11–2.14), yellow bad-smelling vaginal discharge (OR = 2.81, 95% CI = 1.54–5.09), white vaginal discharge (OR = 1.65, 95% CI = 1.09–2.49) and genital ulcers (OR = 4.38, 95% CI = 1.13–17.00).
Conclusion Female genital cutting in this group of women did not attenuate sexual feelings. However, female genital cutting may predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infections. Therefore, female genital cutting cannot be justified by arguments that suggest that it reduces sexual activity in women and prevents adverse outcomes of sexuality.
The WHO1 has defined female genital mutilation as all procedures that involve the partial or total removal of the female external genitalia and/or injury to the female genital organs for cultural or any other non-therapeutic reasons. Although the term female genital mutilation was previously used to describe this practice, it is now more widely known as female genital cutting to remove the stigma previously associated with female genital mutilation2. In this paper therefore, the term female genital cutting will be used to engender common understanding of the related concepts.
Female genital cutting is currently being practiced in several countries in Africa, as well as in some Far Eastern and Mediterranean countries. In Nigeria, the prevalence of female genital cutting has been reported to be 25%, and ranges from 1.9% in the Northeast to 48% in the Southwest parts of the country3. Consistent with the international condemnation of the practice, there has been an increasing wave of activism geared towards eradicating female genital cutting from many states of Nigeria. Many programmes that seek to prevent or eradicate female genital cutting are based on community education that emphasises the harmful health effects of the practice. In addition, female genital cutting prevention programmes in the country have attempted to counter some of the main arguments often proffered by those in support of continuation of the practice. However, it has been suggested that female genital cutting educational programmes would be more effective if they were based on scientific evidence relating to the adverse health and social consequences of the practice4,5.
One of the most important reasons often put forward to justify the practice of female genital cutting in Nigeria is the belief that it attenuates sexual feelings in women and therefore reduces the level of sexual promiscuity among women6,7. Despite the fact that this argument infringes on the rights of women to full sexual expression, it nevertheless, has been used by traditional defenders of female genital cutting to promote the practice in many communities throughout sub-Saharan Africa. If sexual promiscuity is indeed reduced, we conjecture that this could lead to a reduction in the incidence of reproductive tract morbidities especially those that relate to pregnancies and reproductive tract infections, and improve the reproductive health of women. However, to date, there is lack of substantive scientific data that describe the impact of female genital cutting on the sexual and reproductive health of women in many developing countries where the prevalence of female genital cutting is high. Such data would be useful to plan appropriate interventions and to target advocacy activities aimed at reducing the practice of female genital cutting in the country.
Studies have documented various gynaecologic and sexual health complications associated with female genital cutting8. These relate mainly to the more severe forms of female genital cutting, especially type III female genital cutting (infibulations), in which there is severe narrowing and scarring of the vaginal introitus. There are several reports in the literature that document high incidences of severe dyspareunia, penetration problems, marital disharmony, dysmenorrhoea and various psychosexual problems in association with type III female genital cutting9–11. By contrast, there has been little substantive data on the impact of the less severe forms of female genital cutting on the sexual and reproductive health of women12,13.
Available evidence suggests that types I and II female genital cutting are more common in Nigeria, and other West African countries3,14–16. In type I female genital cutting, the clitoris or parts of it are removed, while type II female genital cutting involves the complete or partial removal of the clitoris and the labial minora. It is possible that the removal of these vitally erogenous areas could potentially produce either positive or negative consequences for the sexual and reproductive health of cut women when compared with uncut women. However, little is currently known about the direction of these effects, especially for women with mild to moderate types of female genital cutting.
The present study was designed to investigate the impact of female genital cutting on the gynaecologic and sexual health of women in Edo State of Nigeria, a region with a higher prevalence of types I and II female genital cutting. The study consisted of self-reporting of gynaecologic and sexuality experiences along with a physical examination to confirm the presence or absence of female genital cutting.
The study was conducted in Edo State, one of the 36 States in Southwest Nigeria. The State has a population that was estimated in 1999 to be approximately 2.5 million people, who live predominantly in rural areas. Benin City, with a population of nearly one million people, is the only truly urban area in the state. Female genital cutting has been reported among all ethnic groups in the state, with nearly all carrying out the procedure in infancy. Although the prevalence of female genital cutting in the entire southwest region of Nigeria as reported by the DHS3 is 48.4%, no disaggregated data are available for Edo State specifically. The study was conducted among women attending antenatal clinics in Benin City and Irrua, a predominantly rural settlement about 100 km north of Benin City.
Women attending antenatal and family planning clinics in the areas were used as a convenient sample of sexually active women, from whom information about sexual and gynaecologic health was elicited. The enrolled women were those attending antenatal clinics at the University of Benin Teaching Hospital and Central Hospital in Benin City, and the Otibhor Okhae Specialist Hospital in Irrua, the main hospitals that provide secondary and tertiary obstetrics and gynaecologic services in the area.
The study employed a cross sectional study design, and involved all consecutive women attending the clinics in the hospitals between August 1998 and March 1999. Pregnant women were recruited at various stages of pregnancy, mostly between 20 and 40 weeks of pregnancy. Nearly two-thirds of the women were recruited between 30 and 40 weeks of pregnancy. The women were informed about the principles of the study, and they were enrolled after obtaining their full consent for participation in the study. They were assured of confidentiality of information obtained. The Human Ethics Committee of the University of Benin Teaching Hospital approved the study protocol.
The study instrument consisted of a questionnaire that solicited information on the women's socio-demographic backgrounds, their obstetrics and gynaecologic history, sexual practices, personal female genital cutting experiences and attitudes towards female genital cutting. Specially trained nurses and midwives, who asked questions in a value-free manner using both English and the local language as necessary, administered the questionnaire to the women. In particular, the nurses were taught to elicit questions about the women's sexuality with sensitivity and confidentiality. To engender more positive responses to the questions on sexuality, only midwives who reported that they felt comfortable with their own sexuality during the training were enlisted to administer the questionnaires.
The questions asked about the women's sexuality included their age of first menstruation (age of menarche), age of first sexual intercourse, age of marriage and age at first childbirth. We also asked the women about their frequency of intercourse in the preceding week or month, the most sensitive parts of their body, whether they or their husbands make the first move during sexual intercourse and their experience of sexual orgasm. However, the question on the number of sexual partners the women currently had was dropped as pre-testing showed that the women, who were mostly married, felt severely embarrassed by the question. However, we reasoned that if female genital cutting affects sexuality, one way in which this could be manifested is through symptoms of sexually transmitted infections ever experienced by cut women compared with uncut women. Thus, we asked questions about the women's experiences of various symptoms of sexually transmitted infections, including vaginal discharge, lower abdominal pains, painful urination, painful intercourse and genital ulcer disease.
Following the interview, a clinical examination was done by a medical doctor to determine the presence and extent of genital cutting. The doctors, who had no knowledge of the results of the interviews conducted on the women, were trained to use the WHO (1997) criteria to allocate the type and degree of female genital cutting. Using these criteria, type I female genital cutting was defined as excision of the prepuce with or without excision of part or all of the clitoris; type II was excision of the prepuce and clitoris together with partial or total excision of the labia minora; while type III was excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation). Type IV female genital cutting was the unclassified type of female genital cutting and included any other procedures or manipulations of the genitalia such as gishiri cuts, pricking, piercing or incision of the clitoris and/or labia, stretching of the clitoris and/or labia and cauterisation and scarring of the vulva or vagina through the use of chemical substances.
As a first step in the data analysis, the prevalence of female genital cutting and the distribution of female genital cutting by clinical type were calculated based on self-reports and clinical reports. However, as clinical reports were considered the ‘gold standard’, the subsequent analysis of the data used clinical reports about female genital cutting, the type of female genital cutting and medical diagnosis of complications caused by female genital cutting. By contrast, the other outcome variables were based on self-reporting of these variables. As a second step in the analysis, the patterns of female genital cutting status and type of female genital cutting were examined by socio-demographic characteristics of the women, and Pearson's χ2 test was used to determine whether type of female genital cutting varied across different groups. The prevalence of long term complications of female genital cutting (cysts, scar formation, narrowed introitus and vulvar disfigurement) was calculated for women with types I and II female genital cutting. Women with types III and IV female genital cutting were excluded from these analyses because they included only 24 and 11 women, respectively. As cut women with type I female genital cutting may be different from those with type II, and to control for confounding factors, the relative odds of having a long term complication for women with type I relative to type II were calculated in a multivariate logistic regression model.
The prevalence of self-reports of various indices of sexuality and symptoms of sexually transmitted infections was calculated for cut and uncut women. Logistic regression models were used to calculate the odds of experiencing different sexuality and sexually transmitted infections outcomes for cut relative to uncut women, and the Wald test was used to determine whether the observed difference was significant. The crude model included one variable about whether the woman was cut. The adjusted model included this variable, as well as a number of background characteristics. Similar analyses were done to determine whether cut compared with uncut women had significantly different odds of self-reported: (1) frequency of sexual intercourse; (2) experiences of orgasm and sexual stimulation; and (3) symptoms of sexually transmitted infections. This analysis was repeated for women with type I versus type II female genital cutting, and all other women were excluded from analysis.
As a final step, univariate analyses of age at first menstruation, age at first intercourse, age at first pregnancy and age at first marriage were done for cut and uncut women using Kaplan Meier life tables to take into account censoring. Subsequently, multivariate Cox proportional hazards models were estimated to assess the different risks in age at first menstruation, age at first intercourse, age at first pregnancy and age at first marriage for cut and uncut women controlling for the effects of confounders.
A total of 1861 women were recruited to the study from the hospitals. The participation rate was 99.5%, with 0.5% (10) of the women refusing to participate either in the questionnaire interview or in the medical examination. Thus, 1851 questionnaires and medical examinations were completed. However, in 15 women, the questionnaires were incomplete and some did not contain the results of the medical examination, and were therefore excluded. A total of 1836 questionnaires were included in the final data set.
As shown in Table 1, 45.0% of the women had female genital cutting assessed by medical examination and 43.5% as evidenced from self-reporting. There was good correlation between self-reporting and medical examination in determining the presence or absence of genital cutting (sensitivity = 93.6%; specificity = 91.0%; positive predictive value = 91.6%; and negative predictive value = 93.1%). By contrast, as shown in Table 1, the women were not able to accurately report female genital cutting by type. As we considered the medical examination to be the ‘gold standard’, we based subsequent analysis of the data on the results of medical examination rather than self-reporting. Types I and II female genital cutting were the most common types (32.1% and 11.0%, respectively), while types III and IV female genital cutting were rare in the sample. The prevalence of female genital cutting varied significantly by the woman's age at survey, religion, ethnic grouping, education, husband's education, marital status, number of co-wives, age at first pregnancy, whether the woman was married at first pregnancy and the number of times she had been pregnant at the time of the survey (results not shown). There was no difference between cut and uncut women in the duration of pregnancy at the time of recruitment as well as the proportions of non-pregnant women recruited from family planning clinics.
Table 1. The prevalence and type of female genital cutting by medical exam and women's self-report (N= 1836).
|No answer or do not know|| || ||17.1||314|
|Type of cut|
|No answer or do not know|| || ||34.4||632|
During the medical examinations, the presence of physical abnormalities at the site of female genital cutting was documented. As presented in Table 2, the abnormalities identified in cut women included clitoridal cysts, scar formation, narrowed introitus and vulvar disfigurement. By contrast, none of these abnormalities were found in uncut women. We thereafter, compared the prevalence of these abnormalities in cut women with types I and II female genital cutting using multivariate analysis. The results of the model (Table 2) showed that women with type I female genital cutting were significantly less likely to have scar formation, narrowed introitus and vulvar disfigurement, while there was no significant difference in the likelihood of having clitoridal cysts between the two types of female genital cutting.
Table 2. Odds ratios (OR) for comparison of medical diagnosis of long term complications for cut women with type I relative to type II.
|Sample size||590||202|| || || || |
Questions were asked to determine the frequency of sexual intercourse and sexual pleasure in cut versus uncut women in the sample. The results of this analysis are presented in Table 3. In the adjusted models, there was no significant difference between cut and uncut women in the odds of self-reports of sexual intercourse in the preceding week or in the preceding month or in the proportion reporting that they are easily ‘turned on’ during sexual intercourse or that their partners more often make the first move during sexual intercourse. By contrast, cut women were 31% more likely than uncut women to report that they often make the first move during sexual intercourse.
Table 3. Odds ratios (OR) for comparison of women's reports about sexual practices and sexual pleasure between cut and uncut women (cut = 1, uncut = 0) (N= 1836).
|Had sex in last week (yes = 1, no = 0)||56.0||47.0||1.44||1.19–1.73||0.95||0.75–1.20|
|Had sex in last month (yes = 1, no = 0)||80.9||71.4||1.70||1.36–2.12||1.03||0.76–1.40|
|Would you say that you are easily turned on (yes = 1, no or sometimes = 0)||32.5||35.0||0.89||0.73–1.08||0.89||0.69–1.14|
|How often does your partner make the first move (always or sometimes = 1, never = 0)||95.9||87.3||3.39||2.29–5.01||1.45||0.73–2.88|
|How often do you make the first move (always or sometimes = 1, never = 0)||58.3||52.7||1.25||1.04–1.51||1.31||1.01–1.70|
|Do you reach orgasm during sex? (always or usually = 1, rarely or never = 0)||66.1||59.4||1.34||1.10–1.62||0.92||0.70–1.19|
|Most sensitive bodily part|
|Clitoris (yes = 1, other = 0)||10.5||27.4||0.31||0.24– 0.41||0.35||0.26–0.47|
|Breasts (yes = 1, other = 0)||63.2||43.5||2.23||1.85–2.70||1.91||1.51–2.42|
|Other (yes = 1, other = 0)||26.2||29.1||0.87||0.70–1.06||1.07||0.80–1.44|
|Sample size||827||1009|| || || || |
With respect to the women's experiences of orgasm during sexual intercourse, the results in Table 3 indicate that there was no significant difference between cut and uncut women in the proportions reporting that they always or usually experience orgasm during sexual intercourse. Despite this observation, uncut women were significantly more likely than cut women to report that the clitoris is the most sensitive part of their body. In contrast, cut women reported that the breast is the most sensitive part. None of the variables about sexual practices and sexual pleasure had a significantly different effect for women with type I compared with women with type II (results not shown), with the exception that the partner was significantly less likely to make the first move for women with type I relative to women with type II (OR 0.09, 95%CI = 0.01–0.75).
The effect of genital cutting on the women's self-reports of various pregnancy and lifecycle events was also determined. As shown in Table 4, the mean age of first menstruation (menarcheal age) for cut women was 14.6 years, whereas it was 14.4 years among uncut women. This difference was not statistically significant in the univariate analysis (P > 0.05). By contrast, the mean age of first intercourse, first pregnancy and marriage were significantly lower in cut women as compared with uncut women in the univariate analysis. However, only age at first pregnancy remained significantly different between cut and uncut women in the multivariate models controlling for women's age, religion, ethnic group, education and other covariates (Table 5). The latter model suggested that cut women were 1.25 times more likely to get pregnant at a given age than uncut women.
Table 4. The mean and median age at first marriage, first pregnancy, first intercourse and first menstruation for cut and uncut women.
|Marriage (N= 1711)3||22.9||25.8||23.3||25.3||<0.0001|
|Pregnancy (N= 1678)||22.1||24.3||21.9||24.2||<0.0001|
|Intercourse (N= 1518)||19.0||19.7||19.2||19.9||<0.0001|
|Menstruation (N= 1613)||14.6||14.4||15.0||14.9||>0.05|
Table 5. The crude and adjusted relative hazards ratio (HR) of first marriage, first pregnancy, first intercourse and first menstruation for cut relative to uncut women.
|Marriage (N= 1711)3||1.72||<0.0001||1.13||0.052|
|Pregnancy (N= 1678)||1.56||<0.0001||1.25||0.0003|
|Intercourse (N= 1518)||1.21||0.0003||1.09||0.154|
|Menstruation (N= 1613)||0.91||0.0565||0.97||0.655|
To assess and compare the prevalence of reproductive tract infections in the two groups of women, we asked them questions about their past experiences of symptoms of reproductive tract infections. The results of the crude and adjusted odd ratios for the self-reporting of these events are presented in Table 6. The results show that cut women are significantly more likely than uncut women to report lower abdominal pain, yellow, bad-smelling vaginal discharge, white vaginal discharge and genital ulcer. By contrast, there was no significant difference between cut and uncut women in their self-reporting of itching in the genital area, painful or burning urination and pain during intercourse. Finally, none of the self-reported symptoms of genital infections were significantly different for women with type I relative to type II female genital cutting (results not shown).
Table 6. Odds ratios (OR) for comparison of self-reported symptoms (yes = 1, no = 0) of genital infections between cut and uncut women (cut = 1, uncut = 0) (N= 1828).
|Repeated or recurring episodes of:|
|Lower abdominal pain||16.5||11.0||1.60||1.22–2.10||1.54||1.11–2.14|
|Yellow, bad-smelling discharge||6.3||2.4||2.74||1.68–4.49||2.81||1.54–5.09|
|White vaginal discharge||11.6||5.4||2.31||1.64–3.27||1.65||1.09–2.49|
|Itching in genital area||13.5||8.0||1.79||1.32–2.43||1.30||0.90–1.88|
|Painful or burning urination||3.6||2.2||1.68||0.96–2.94||1.29||0.65–2.57|
|Pain during intercourse||3.6||2.3||1.61||0.93–2.79||1.48||0.76–2.87|
The study investigated the effects of female genital cutting on the sexual and gynaecologic health of a cohort of women in Edo State, Nigeria. The prevalence of female genital cutting as confirmed by the clinical examination of the women was 45% while the proportion of uncut women in the sample was 55%. These relatively high proportions of cut versus uncut women in this cross sectional study provided a unique opportunity for comparing the women's experiences of sexuality and self-reports of gynaecologic complications. The analysis by type of cut was only performed for women with types I and II female genital cutting as there were too few cases of types III and IV female genital cutting in the sample. In types I and II female genital cutting, only the clitoris and/or labia minora are removed, with very little narrowing of the vaginal introitus.
The results of the study indicate that there was no significant difference between cut and uncut women in the odds of reporting that they had intercourse in the preceding week or month or in the frequency of reports of regular attainment of orgasm during sexual intercourse. By contrast, cut women were more likely to report that they, rather than their partners, make the first move during sexual intercourse. These data suggest that the removal of the clitoris or labia minora does not attenuate the intensity of emotional feelings during sexual intercourse. If anything, genital cutting may slightly increase the women's urge to engage in sexual intercourse with their regular sexual partners.
These results must be interpreted in conjunction with the question we asked when we requested the women to name the most sensitive part of their body. The results of the multivariate analysis of the responses to this question revealed that cut women were significantly less likely to report that the clitoris was the most sexually sensitive part of their body. By contrast, cut women were significantly more likely to report that the breasts were the most sexually sensitive parts of their body. These results indicate that genital cutting does not eliminate sexual feelings in women, as is currently believed by traditional defenders of the practice. Rather, sexual feelings in cut women would be maintained by a shift of the point of maximal sexual stimulation from the clitoris and/or labia to the breasts, allowing women to continue to enjoy this normal biologic function.
A relevant question is whether cut women are more or less sexually active than uncut women. Unfortunately, this question has not been adequately answered by this study as we were not able to elicit information on the women's number of sexual partners. However, we asked proxy questions that enabled us to compare responses on the intermediate outcomes of sexuality in the two groups of women. These proxy questions included the women's age of first menstruation, age of onset of sexual intercourse, age of marriage and age of first pregnancy. The results of the multivariate analysis of the responses to these questions revealed that cut women were more likely to get pregnant at an earlier age than uncut women. Age at first pregnancy may be evidence of earlier sexual maturity of cut women compared with uncut women. However, it may also be evidence of the cultural and social pressures on women in this community because the same cultural factors that produce genital cutting may also lead women to seek early pregnancy. Cut women are perhaps more integrated into the local culture and, in this setting, have been shown to have lower levels of education compared with uncut women17. This results in early pregnancy even for cut women with the same level of education as uncut women. Further inferential studies, especially of a qualitative nature, are required to elucidate the mechanisms associated with the earlier age of pregnancy reported in cut women.
One adverse outcome of sexuality in this population is their increased risk of reproductive tract infections and sexually transmitted infections18,19. We decided to use the prevalence of reproductive tract infections in the two groups of women as a robust outcome measure to determine their risks of exposure to adverse sexuality outcomes. We used self-reporting of symptoms of reproductive tract infections as a measure rather than laboratory testing as laboratory confirmation of all sexually transmitted infections were poorly developed in the participating institutions. In addition, we reasoned that since the syndromic approach was the method used in the hospitals to diagnose reproductive tract infections on a regular basis, it would be better to use the same method in comparing the exposures of cut and uncut women to reproductive tract infections. Although self-reporting of reproductive tract infections symptoms would be less accurate than laboratory-based diagnosis20,21, there is no reason to believe that the pattern of self-reporting of RTI symptoms will be different between cut and uncut women.
The results suggest that cut women were significantly more likely to have experienced repeated or recurring episodes of lower abdominal pain and whitish vaginal discharge. In particular, cut women were up to 2.8 times more likely to have experienced yellow, bad-smelling vaginal discharge and more than four times more likely to have had genital ulcers compared with uncut women. However, genital ulcers were relatively rare among both cut and uncut women.
However, as elicited, symptoms of reproductive tract infections may have captured all gynaecologic infections including those due to childbirth, abortions and sexually transmitted infections. The contribution of reproductive tract infections is more apparent from the fact that cut women were consistently more likely to have been pregnant than uncut women and had an average of 4.3 children compared with uncut women who had an average of 2.2 children. This suggests that complications of pregnancy may have played a key role in increasing the frequency of self-reporting of reproductive tract infections in cut women. However, it is possible that sexually transmitted infections may also be more prevalent in cut women as a result of increased frequency of use of multiple sexual partners by cut women. It has been suggested by women rights advocates in Nigeria that the use of multiple sexual partners may be more common in cut women than uncut women because the removal of the clitoris may increase women's desire for more sexual partners who can assist them in achieving orgasm. Additionally, cut women may have acquired these infections from their sexual partners who may be patronising other women because of failure of their women to satisfy them sexually. These propositions are of interest and warrant further investigations using qualitative research design, or with a cohort of unmarried women who may be more willing to answer questions on their sexual behaviour.
The results of this study have implications for targeting interventions to reduce the practice of female genital cutting in Nigeria. A common reason often put forward by proponents for continuation of the practice of female genital cutting in Nigeria is the perception that genital cutting would reduce the rate of promiscuity in women and enhance the reproductive health of women. This argument has been used by moralists, traditional and religious leaders to counter the campaigns of various advocacy groups working to stop the practice of female genital cutting in the country. The results of this study indicate that genital cutting does not reduce the level of sexual activity in women. By contrast, the results of the study suggest that genital cutting may predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infections. This information would be useful for targeting future community awareness campaigns aimed at preventing female genital cutting.
The study was conducted by the Women's Health and Action Research Center (WHARC), a Nigerian NGO whose mission is to promote the reproductive health of women through research, documentation, advocacy and training. The authors would like to thank the Ford Foundation for providing continuous institutional funding to WHARC to this day. The authors would also like to thank the School of Public Health of the University of Heidelberg in Germany for providing partial funding for this project.