Female Genital Mutilation (FGM) has been considered as a gross violation of Human rights and a direct manifestation of gender inequalities and discrimination. Women and girls who have undergone FGM suffer both short and long-term health risks. Despite this, FGM is persistent in Eastern Uganda. The aim of this study was to explore the perceptions of women regarding the practice of female genital mutilation in Kapchorwa district. This study used an exploratory qualitative design to collect data. One focus group discussion was held with 12 women in rural Uganda. Thematic analysis was used to analyze the findings from the qualitative data. This study found out that women undertake FGM as a pre-requisite for marriage, to obtain respect, cultural identity and acceptance. Participants mentioned the health effects of FGM such as severe bleeding, painful childbirth experiences and infections. There were mixed perceptions regarding the practice of FGM in society which may reflect the need for more health education programs targeting communities within the Sebei region so as to eliminate this practice that is still common in this society.

Female Genital Mutilation (FGM) refers to all procedures related to the partial or total removal of the external female genital tissue for non-medical reasons [1]. The term female circumcision is used interchangeably with female genital mutilation to have a similar meaning in this study. FGM is divided under four categories; type I or clitoridectomy involves the partial or total removal of the clitoris; type II or excision involves the partial or complete cut of the clitoris, labia minora and/or labia majora; type III or infibulation includes the narrowing of the vaginal orifice and creating a covering seal; and type IV involves any other harmful practice to the female genitalia such as pricking, piercing or scraping [2]. In Uganda, FGM is practiced on girls from the age of 10 years and above among the ethnic groups of Sabiny (type II) and Pokot (type III) Eastern Uganda [3]. The Word Health Organization Report (2008) highlights the health effects of FGM on girls including immediate health consequences (severe pain, infections, excessive bleeding,) and long-term consequences (urinary problems, sexual problems, vaginal problems and childbirth complications). FGM is practiced in parts of Africa and Asia and varies according to context and or ethnicity. The practice of FGM is
usually performed by an older woman in the community for cultural reasons and has no benefit for girls/women. The reasons behind the practice are strongly linked to cultural issues like initiation from childhood into womanhood, maintain chastity and social identification. [4]. In parts of Eastern Uganda where FGM is practiced, uncircumcised women are often stigmatised and exempted from revered cultural tasks such as picking food from traditional stores (locally known as granaries), decorating houses and milking cows. For instance, Kiirya and Kibombo, 2008 argue that if an uncircumcised woman milks a cow, the milk is culturally viewed as contaminated and not fit for human consumption within this context. Uganda is a land locked country found in the Eastern part of Africa. Uganda's population is estimated at 34 million people with an estimated 105,186 people living in Kapchorwa district [5]. Uganda is divided into four regions; Northern, Central, Western and Eastern regions and further sub divided into 112 districts for administrative purposes [5]. FGM is practiced in the districts of Kapchorwa, Kween and Bukwo located in the Eastern part of Uganda. Despite FGM being banned in Uganda, the practice is still common in the villages of Kapchorwa district found in the Eastern part of the country. This study sought to explore women`s attitudes regarding female genital mutilation in Kapchorwa district.

Data for this study was analyzed using template analysis. This is a technique used in thematic analysis to organize and analyze textual data [9]. The discipline of producing a template enables the researcher to take a systematic and well-structured approach to data handling [10]. The transcript was read several times to become familiar with the data and then marked with emerging codes which were added to the template. An initial coding template following the structure of the FGD guide was developed.
The template was revised throughout this process with additional themes and sub themes inserted, deleted or collapsed until the final template was developed [10].

The findings of this study are described under three broad topics; 1) Attitudes regarding the practice of female genital mutilation; 2) reasons why women undergo female genital mutilation; and 3) the health effects of female genital mutilation. Attitudes regarding the practice of female genital mutilation Those opposed to the practice of FGM in the community

Some participants in this study opposed the practice of female genital mutilation in the community given the painful experiences they underwent during the time of mutilation and childbirth. "I strongly say no to the practice of female of genital mutilation because of the harmful consequences faced for example difficulty in childbirth and the shameful experience is that those who have not been circumcised laugh at us including the midwives, they harass us because of the scars in our private parts and feel stigmatized. So say that the practice should be stopped". P.2

"I stand out to tell you that many women and young girls have undergone very difficult experiences because of the practice being a cultural rite and tradition. I wish that they could understand how painful the practice is and I encourage other women who have not been circumcised to avoid being mutilated because it is very painful and it comes with adverse effects". P.4
"...I argue out all my friends to join hands and say no to female genital mutilation because it harms our lives including our psychosocial being...I think government needs to strengthen its fight against FGM by working with the local leaders and other authorities to stop the practice because it very bad. In 1995 my father tried to lure me to go for FGM promising me various gifts but I denied and ran away from home for some time, otherwise I was not going to escape the practice". P.6

The practice of female genital mutilation has caused very painful experience (psychological trauma and difficult childbirth) so they say no to the practice because they do not wish anybody else including their young daughters to undergo what they experienced. From the discussions with women in the community it appears that the effects of FGM outweigh the benefits. Eleven women out of the twelve women who participated in this study opposed the practice of FGM.
Those in support of the practice of female genital mutilation There was only one participant in the FGD who said that she was in support of the practice of FGM. This participant cited reasons in favor of FGM such as obtaining respect in the community and being loved by the husband.
"The practice should continue as am happily married and I support the practice because am well respected and loved by my husband. The most special thing is that am called a women of morality that every member of the community including my elders which pleases me so much". P.6

Dignity and respect

One participant in this study said she underwent FGM because she wanted to obtain respect from her husband and community, pick food from the granary and cow-dung from the kraal. "I accepted to be circumcised purposely so that I gain respect form my husband, and also to have access to pick cow-dung form the kraal and pick food from the granary ... the practice has earned me another level" P.1

The practice of female genital mutilation earns women respect from society in terms of social status and at traditional gatherings

A sense of cultural identity

Participants in this study said that FGM instills in them a sense of cultural pride and identity. "...if you are mutilated your husband feels proud to move with you wherever he is going including big ceremonial parties in the community and since I got circumcised I can enjoy going out to parties in the community...the practice has earned me another level...in our culture FGM earns you a special friend called Basiben [this means a circumcision friend]".P.3

Women that have undergone FGM develop friendships that are admired within the Sabiny culture. These friends are locally called "basiben" and the significance of these friends are to grace ceremonial functions such as naming of newborn, and other cultural functions.

Pre-requisite for marriage

Some participants in the focus group discussion said that FGM was a condition for them to get married "I feel traumatized because am also a victim and I got circumcised conditionally because my husband that am married to wanted me to get mutilated before he would marry me and because I loved him I couldn't hesitate to be cut..." P.4
"I would not have been married but because I underwent through FGM I found my marriage partner so easily..." P.1
"I got married at the age of 19 and I got mutilated because everyone would only get married after being mutilated. Therefore, marriage pushed me into the practice. Being mutilated would help you from cheating on your husband" P.2

It appears that some women in the community are forced to undergo FGM in order for marriage purposes. Women in this study were forced by their potential husbands and community members to undergo FGM as a way to promote marital faithfulness.

Health effects of female genital mutilation infections

One participant in this study said that infections have resulted from the cutting of young girls and women and that the infections cause inflammations and wounds that do not heal. Women who have fallen victims of FGM have suffered inflammations in the genitalia and had wounds which took a long while to heal. "Am a woman who has been circumcised but I have not faced many difficult situations either at the time of mutilation or childbirth. But I hear that now days there are a number of diseases that have evolved during the cutting of young girls and women... these infections cause inflammations and that some wounds do not heal at the expected time..." P.3

There have been reports regarding the differences between the past and the present with reference to the time taken for women to heal after undergoing FGM. Participants said that in the past women's wounds healed more easily compared to the present were wounds take a considerable time to heal. It was not possible to verify why these differences exist in this study as it was not asked accordingly.

Difficulty in childbirth

One participant shared her childbirth experience with the rest of the group indicating that it was a traumatic experience for her first born child.
"The practice of FGM has caused many challenges among women and girls...in addition, when it reached time that I was about to give birth to my first child, I faced difficult conditions that were too painful. I underwent a caesarean section because I failed to push the baby and this was due to the scar that was left in the place which was cut and so it was really a very painful experience".P.7

The practice of female genitalia mutilation causes a permanent scar in the external genitalia of a woman which makes the vagina inelastic which makes it difficult for a woman to have a normal delivery resulting into birth by caesarean section

Severe pain and bleeding

Participants in this study said that the practice of female genital mutilation is really a very painful practice that is felt most during the mutilation process and at childbirth "I remember the severe pain that I experienced in the mutilation process including very painful childbirth experience. This comprised of painful prolonged labor pains and dangerous heavy bleeding" P.4
Women in this study who underwent FGM reported that they experienced severe bleeding and prolonged labor during childbirth.

Physical and psychological scars

In this study some participants said that the consequences of FGM had left them with physical and psychological scars that were constant reminders of an evil cultural practice. "All mutilated girls tie themselves culturally and dance the whole night while undergoing harsh and painful cultural practices, every friend of hers has scars in their hands developed during the cultural practice...these are permanent scars I do not wish any of the girls to go through this painful experience...'. P.5
The cultural practice involves rites of passage which include dancing the whole night prior to the cutting at dawn and other physical cuttings. These rites of initiation are not to be spoken about in public beyond the groups of women that have undergone the initiation. Efforts to obtain further details on the cultural rites prior to the cutting were futile.

Findings from this study are discussed within the broader literature on female genital mutilation conducted elsewhere on the global scene. Women in this study claimed that the rite of FGM instilled in them a sense of social identity and pride as they were accepted by their husbands and elders in the community. Data from the [11] showed that female circumcision is carried out as a ritual to initiate young girls into womanhood which qualifies them to get marriage. Womakuyu 2010 reported that FGM is considered as a traditional rite of passage for girls into womanhood which exerts a lot of pressure on uncircumcised girls. A study conducted by [12] showed that uncircumcised women could not undertake revered cultural tasks such as picking food from the granary, collecting cow-dung to decorate houses, milking cows and serving elders. This study also found that it was considered a cultural abomination/ taboo for women who have not undergone FGM to carry out home tasks as they were considered unclean. In this study, women who underwent FGM mentioned severe pain during the mutilation process and severe bleeding during childbirth. A factsheet published by the [13] highlights the health effects of FGM including severe pain/bleeding, increased need for caesarean delivery and difficult delivery.

This study found both positive and negative perceptions regarding the practice of FGM in Kapchorwa district. FGM is still prevalent in this community despite the practice being outlawed by the government of Uganda. There is need to strengthen women's empowerment and male involvement in the prevention of FGM in communities in Eastern Uganda.

1. World Health Organization . Factsheet on Female Genital Mutilation.2018.
2. Ahmed HM, Shabu SA, Shabila NP. A qualitative assessment of women's perspectives and experiences of female genital mutilation in Iraqi Kurdistan region. BMC Women`s Health. 2019;19:66.
3. Uganda Bureau of Statistics. Uganda Demographic and Health Survey 2016. Kampala, Uganda. UBOS and ICF International INC. 2016.
4. Masho SW, Mathews L. Factors determining whether Ethiopian women support continuation of female genital mutilation. Int J Gynaecol Obstet. 2009;107(3):232-235.
5. Uganda Bureau of Statistics. The National Population and Housing Census. 2014.
6. Bernard H. Research methods in anthropology: Qualitative and quantitative approaches. 3rd edition. Walnut Creek, CA: Alta Mira Press. 2002.
7. Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. AJTAS. 2016;5(1):1-4.
8. Race K, Hotch D, Parker T. Rehabilitation Program Evaluation: Use of Focus Groups to Empower Clients. Evaluation Review. 1994;18 (16):730-740.
9. Brooks J, King N, Wearden A. Couple`s experiences of interacting with outside others in chronic fatigue syndrome: A qualitative study. Chronic Ill.2014;10(1)5-17.
10. Ladur AN, van Teijlingen E, Hundley V. `Whose Shoes?`. Can an educational board game engage with Ugandan men on pregnancy and childbirth?

Pregnancy and childbirth. BMC Pregnancy and Childbirth. 2018;18:81

11. Uganda Bureau of Statistics. Uganda Demographic Health Survey. Kampala: UBOS and ICF International INC. 2011.

12. Kirya S, Kibombo R. Community Knowledge, attitudes and practices related to female genital cutting in Kapchorwa district. 2008.
13. World Health Organization. Eliminating Female Genital Mutilation: An Interagency Statement. WHO. 2008.