Examining Associations Between Female Genital Mutilation and the Human Immunodeficiency Virus

Ibrahim Puri, Jessica

doi:https://doi.org/10.21985/n2-njem-wy70

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Examining Associations Between Female Genital Mutilation and the Human Immunodeficiency Virus

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The potential association between Female Genital Mutilation (FGM) and the incidence of Human Immunodeficiency Virus (HIV) has been a part of academic discourse for three decades. By considering the mixed reports on the association between FGM and HIV so far, this dissertation contributes to the current state of research by providing new information, first through a systematic review of existing research, and then through two secondary analyses of a nationally representative sample of women residing in Sudan. Taken together, the three studies show that within a complex and nuanced relationship is a positive social association between FGM and HIV, where social factors within a given geographic location influence rates of FGM as well as HIV literacy. The findings demonstrate that confounders such as education, wealth, and living in urban (or modernized areas) contribute to which form of FGM women experience (medicalized or traditional). Additionally, the dissertation demonstrates different levels of HIV literacy and testing activity among women who experience medicalized and traditional FGM. The systematic review showed mixed findings on the association between FGM and HIV. Among studies examining the association between FGM and HIV, studies reported either positive, negative or no association between FGM and HIV. Among those reporting positive and negative associations, researchers discussed the potential for “indirect positive associations” where other factors independently associated with FGM and HIV may create a bridge to connect the two. There were contradictory reports from studies that examined the associations on different populations within the same country. I concluded that these findings were mixed due to heterogeneity in samples and multiple contextual factors (e.g., the age of participants, sample source and sample size) that may have been specific to the location of each study. Furthermore, the systematic review revealed multiple gaps in current knowledge specifically on medicalized (vs. traditional) FGM, data outside the continent of Africa, data from women older than age 50, and data on the type of FGM potentially associated with HIV. More high-quality studies (guided by conceptual frameworks and demonstrating reasons for chosen methodology) are necessary to provide strong evidence for conclusions within the reviewed studies. Studies 2 and 3 were secondary data analyses of nationally representative data from the sub-Saharan nation of Sudan. Sudan was selected for its high prevalence of FGM (medicalized and traditional) as well as it’s vulnerable position for increased HIV incidence. The data source (Multiple Indicator Cluster Surveys) did not include HIV status of their participants. Instead, it included responses to survey questions that addressed HIV literacy and HIV testing activity among Sudanese women of reproductive age. Despite the lack of data on HIV status, examining the association between FGM and HIV literacy and testing is important because women who have undergone FGM may be less likely to seek out sexual health information and services due to cultural taboos and stigma surrounding discussions of sexuality and reproductive health. Additionally, due to traditions and social norms (similar to those surrounding FGM in Sudan), women may lack agency in navigating safer sexual options for themselves, potentially increasing vulnerability to HIV transmission. Given these possibilities, social and cultural factors can cause FGM and health literacy to travel together, resulting in an increased risk of HIV transmission and limited access to HIV prevention and treatment services. Higher levels of HIV literacy are often associated with a reduced risk of HIV infection because people who are more knowledgeable about HIV are better equipped to protect themselves from the virus. For its place within the HIV care continuum, examining FGM groups enables future interventions to target those who are at risk of failure to follow through with HIV testing, adherence to Highly Active Antiretroviral Therapy (HAART) or engagement in HIV care by virtue of the social stigma and lack of empowerment present among those who are of a traditionally cut versus medically cut group. Study 2 of this dissertation focused on FGM group and HIV literacy (i.e., HIV knowledge and toward people living with HIV) in Sudan. The sample selected were women who reported traditional or medicalized FGM, and those who were uncut at the time of data collection. Examining HIV knowledge and attitudes among women of different FGM cut groups served to provide information on the potential norms surrounding FGM that impact HIV-specific health literacy. After controlling for other potential explanatory variables (i.e., age, wealth, education, and location), results indicated that FGM group was significantly correlated with knowledge of HIV among women in Sudan. Specifically, those in the medicalized cut group reported the most accurate knowledge of HIV in the study sample, and those of traditional cut reported the least. Furthermore, those in the medicalized cut group were also among the wealthiest and most educated in the population and were more represented in urbanized areas. Attitudes toward people living with HIV did not differ across the three FGM cut groups, as they all reported highly stigmatizing views toward HIV. As a result of their wealth, education, and proximity to care (i.e., urban residence), those of medicalized cut were able to afford the more expensive form of FGM (i.e., medicalization) and had access to more HIV-specific information. By viewing the findings in this study along with other reports on criminalization, I concluded that medicalized FGM is contributing to slowing down progress toward eradicating FGM in its entirely, especially as criminalization (as reported in other studies) has resulted in increased prices of the medicalized form, allowing the wealthier to promote continuation. Additionally, considering that those that were traditionally cut are most represented in the poorest quintile and among the least educated in rural areas, efforts to increase HIV knowledge must target those of traditional cut as these additional confounders contribute to their low knowledge of HIV. Extending the findings from Study 2, Study 3 further explored the association of stigmatizing views and HIV testing activity in the same sample. HIV testing is important because it informs intervention efforts on the prevalence of the virus in a population and advances informed self-care for the infected individual(s). Based on other studies that report stigma as a predictor of HIV testing, this analysis aimed to determine if despite general stigmatized views, belonging to an FGM group could show differences in HIV testing activity. Results indicated that Sudanese women who experienced medicalized FGM had higher odds of having been tested for HIV when compared with the uncut. Those in the traditional cut group reported no statistically significant difference from the uncut in the odds of having been tested. Furthermore, while the traditionally cut group reported no statistically significant difference in knowing where to test compared to the uncut, those in the medicalized cut group were less likely to know where to test for HIV compared to those in the uncut group (but more likely to test as noted above). The result on odds of knowing where to test among the medicalized group contradicts other findings reported up until this point, as it should seem obvious that if those of medicalized cut had higher knowledge of HIV and higher odds of ever testing for the virus, they should report higher odds of knowing where to test. One possible explanation for this unexpected finding might have been miscommunication at the point of data collection, where participants assumed that they were asked about HIV-specific testing centers outside of hospitals and clinics. The results in these studies create a foundation for examining power dynamics within FGM-practicing communities that also influence HIV literacy and likelihood of testing. For instance, the majority of participants in the sample for Studies 2 and 3 were cut by medical professionals. Although medical professionals are in trusted positions to provide the best possible care for their patients, those who provide FGM services are contributing to a slower rate of eradication by providing a seemingly safer option for FGM to their patients without knowledge on the long-term health consequences. Thus, efforts to eradicate HIV among Sudanese women should begin with and be directed toward medical professionals. Interventions must also include those in positions of authority (like religious leaders) who contribute to the social norms surrounding female sexual and reproductive health. On another level, society-wide stigmatized views of HIV, compounded with silence surrounding FGM practices have the power to subjugate a woman’s reach in accessing necessary services along the HIV continuum of care. Taking this intersectional view, those of traditional cut (who are also the poorer and least educated in FGM practicing communities) can be the focus for comprehensive HIV education. Additionally, I recommend caution in making blanket statements regarding the association of stigmatizing attitudes and HIV testing activity, as contextual factors (such as residence location and education level) likely influence associations across different FGM-practicing communities. Building upon this dissertation, future research has the potential to create directional hypotheses on the type of FGM potentially associated with incidence of HIV, examine long-term effects of medicalized FGM, conduct similar comparative studies on data from countries outside Africa, examine potential pathways between medicalized FGM and HIV, and examine medical provider knowledge and attitudes toward the association between FGM and HIV.

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