It is appropriate to begin an analysis of female circumcision in Eritrea with a brief review of principal published source material related to this traditional and religious practice. Focusing on major available health articles will permit adequate planning of a program to curtail the further spread of this practice and to reduce the already alarmingly high incidence of high-risk circumcision among Moslem women in Eritrea. The proposed program will then be described in latter sections of this paper.

The Eritrean National Statistical Office (NSO, 1995) in its Demographic and Health Survey has devoted Chapter 12 to "Female Circumcision". The data presented can be considered secondary in nature since it was compiled from a combination of surveys and interviews, and then published in a cohesive manner under the auspices of the Office. Since thousands of women, however, were interviewed by government health officials to compile this data, the results are especially significant even if the source is technically categorized as secondary.

Emphasis, in much of this data, is placed on who performs the procedure (traditional birth attendants) and on problems associated with circumcision of female children or women. Among other compelling data, National Statistical Office charts and tables show that 2,979 women with ‘no education at all’ received circumcision, whereas only 181 of those with a secondary education had been (in the survey conducted) subjected to this practice (NSO, 1995, 169). Attitudes are discussed, in depth, in this article, as are types of circumcision.

Another excellent source of information on female circumcision practices in Eritrea is the World Health Organization. Professor Rushwan writing in the WHO publication World Health (September 1995) makes an excellent case, medically and ethically, against the practice of female circumcision. Dozens of similar studies published by the WHO are available and have generally adopted the same anti-circumcision position, particularly where practitioners are under-equipped or poorly trained in the execution of any of the three most common procedures: clitoridectomy, excision and infibulation. Each of these procedures, in the order presented, carries increasingly greater health risks.

Additionally, there are several less substantial sources of data and commentary that, for the most part, support the previous NSO and WHO findings. Among them are UNICEF publications, independent medical journals and many feminist journals which directly refer to these types of practices as Female Genital Mutilation (FGM).

But, there are opposing viewpoints, in favor of Islamic female circumcision rites and rituals, most of which have origins in The Holy Koran. For example, Aldeeb Abu-Sahlieh refers those interested to specific passages of Islamic Revelation pertaining to the justification of female circumcision (August 1998).

Indeed, feelings run strong on this issue as can be seen in this emotional quotation from Zemhret Hadgu, currently in Eritrea:

Thus, there is also informal literature, as can be briefly seen above, strongly opposed to overturning the current religious practice of female circumcision in Eritrea. Program planning, in the interest of human health, must be aimed at reversing these types of attitudes.

Due to the intrinsic dangers associated with female circumcision as described in the foregoing literature, there are a number of valid reasons for organizing an awareness campaign aimed at those who either perform, or are subjected to, this widespread practice. One such reason, constituting the primary rationale behind the program, involves the high incidence of infection and related complications resulting in sterility, kidney dysfunction, or septicemia. Another reason can be ascribed to the perpetuation of secondary status for women in Eritrea through imposition of this procedure. By eliminating or reducing the incidence of female circumcision, women should become healthier and more socially and professionally mobile in Eritrean society, thus contributing more meaningfully to the economic productivity of the nation.

In view of the health hazards associated with circumcision of females within the Moslem Community of Eritrea, the mission of the projected program is to control hazards and minimize malpractice through a concerted campaign of health education and health promotion among the affected or prospective members of the targeted community. The program will also tangibly provide a wide variety of prevention activities in order to reduce the influence of the socio-cultural trends underpinning this practice.

GOAL: Given the negative effects of female circumcision, both socio-dynamically and physiologically, the most important goal of the planned program is to discourage this traditional practice within the Moslem community of Eritrea, through awareness, sensitization and educational strategies. There are a number of critical steps or stages leading to attainment of program objectives that will, most logically, be discussed in more depth under the Needs Assessment sub-heading.

OBJECTIVES: There are a number of specific administrative objectives, of course, that include the hiring of at least six female health educators from each Moslem Province within a six month period of program initiation. There are three such Provinces in the program. Teaching the specific complications of female circumcision in the female Moslem community of Eritrea is another objective. And, using this program, attempting to decrease the circumcision factor by 25% within a year is still another objective. A more detailed list of proposed administrative and program objectives, encompassing (for the most part) the ‘who, what, when, why and where’ concept, is provided in Appendixes A and B, where at least ten are itemized.

To implement goals and achieve the objectives mentioned above, provincial needs will have to be determined prior to design and planning of the sensitization program. Rather than relying on secondary data, it is crucial to obtain primary field data for use in implementing the program and for determining its scope and magnitude. The intent of the program is, of course, to induce a behavior change in the populations affected by this practice. Certainly, the female population will be targeted, but also the male population responsible for perpetuation of female circumcision under the guise of religious or traditional intent. There will be a pre-determined methodology applied, along with a survey questionnaire to assess the direction of the program’s thrust and the severity of the health risks actually or potentially involved. A theoretical model will be applied, as well, that of Freire, to ensure order and cohesion in implementation of these program stages.

Part of Needs Assessment involves the Methodology of Data Collection. In the case of this program, it is based on focus group discussion. The researcher intends to design a focus group questionnaire in order to stimulate the discussion. Ten open-ended questions will elicit responses from the focus group participants. Appendix D contains the questions to be asked during the group session. All questions will be phrased in the neutral sense to facilitate objective interpretation of responses.

Standard statistical analysis cannot be applied since results will be qualitative. However, a general direction can be ascertained on the basis of comments recorded during the group sessions. Careful notation of major concerns and issues will be maintained throughout the focus group procedure. Keeping in mind that such results cannot be ‘generalized’ in the statistical sense of the term, focus group data will be both prioritized and validated, insofar as possible. The methods of data analysis are further explained in Appendix E.

Because this program is primarily educational in nature, the theoretical model best utilized for ensuring its success is the Theory of Freeing (TF), proposed and perfected by Friere in the early 1970s. He and his colleagues felt that empowerment could be achieved through participation of the citizenry in their own educational process. Education leads to changes, he felt. This theory can definitely be applied to behavioral change in the health sector.

By listening (for example during focus group sessions) and then engaging in dialogue, action can be achieved resulting in change. Continuous re-thinking of problems allows on-going progress to be made. When applying this theory to the female circumcision program, through lay educators, long term behavioral change can be achieved, thus (hopefully) leading to a reduction in the number of circumcision procedures performed annually in targeted societal and geographic sectors. The mechanisms of the program will not only achieve these behavioral modifications, but will enable program personnel to continuously evaluate progress being made.

In Appendix C, projected expenditures and resource allocation categories are presented in detail. All Line Item Budget Projections are specifically related to the Program’s goals and objectives, and will be subject annually to approval by the Program Director, in conjunction with the Program’s Board. The annual budgeted total is NFA 520,062. Appendix C shows the relative amounts of funding expended for each category. Each of these categories is justified by essential needs, easily shown to be vital for overall program operation. Personnel, Project Management, Transport Facilitation all form the core of a well-structured and effective sensitization program of this type.

What is so encouraging about a program such as that described in this report is that the Friere theoretical model, stressing the notion that education promotes change, is likely to produce tangible results, on a small, but ever-widening scale throughout the country. This year-long program can be repeated in successive years keeping the same budgetary parameters and guidelines previously described. If new questions are needed to stimulate discussion of female circumcision, under varying local conditions where prevailing attitudes may be different, they can be easily re-formulated. The goals and objectives itemized above, with special attention to reduction of the incidence of female circumcision by 25% annually, are realistic and achievable in Eritrea.

Although there is obviously considerable opposition and resistance to change of religious and traditional practices in East Africa, it is feasible to envisage modest gains that could provide a foundation for expanding this ‘Friere inspired’ approach on an ever more effective basis.

Aldeeb Abu-Sahlieh, S. "Muslims’ Genitalia in the Hands of the Clergy: Religious Arguments about Male and Female Circumcision, NCBI,

http://members.nbci.com/nonviolence/sami/articles/eng-articles/9901-1/circumcision/article01.htm [August 1998].

…………….. Demographic and Health Survey, National Statistics Office (NSO), Asmara, Eritrea, 1995.

Hadgu, Zemhret Female Circumcision: Your Initial Reaction", BBC News Talking Point, http://newsvote.bbc.co.uk/low/english/talking_point/newsid_442000/442000.asp [September, 14, 1999].

McKenzie, J and Smeltzer, J. Planning, Implementing, and Evaluating Health Promotion Programs: A Primer, Second Edition, Allyn and Bacon, Boston, 1997.

Rushwan, H. "Female Circumcision", World Health, World Health Organization, Khartoum, Sudan, http://srv02.anaserve.com/~mbali/rushwan.htm [September 1995].

1. Teaching Participants – Two hours per week for two weeks, to raise their awareness and to enable them to play a critical role in achieving program success.

2. Teaching Traditional Doctors – Separate instruction, twice weekly for one week. Purpose: to achieve their cooperation in discouraging the practice whenever possible.

3. Contacting Supporting Agencies – Governmental and non-governmental agencies will be included in the contact campaign. Purpose: to coordinate efforts and improve interagency cooperation and communication.

4. Facilitation of Education through Distribution of Pamphlets – Dissemination of female circumcision information in public gathering areas, such as schools, health service settings and social clubs. At regular intervals.

5. Organizing Mass Education: Youth associations, schools, women’s associations, recreational leader groups and so forth. Once per week for one month.

1. Translation of pamphlets into the Tigre dialect.
2. Weekly supervision of all program sites.
3. Interfacing with women’s associations periodically.
4. Restocking of program supplies.
5. Coordination of Transport of lay health educators.
6. Preparation of radio broadcasts.

• Analyzing reactions of the targeted population

• Assessing the impact of the program’s intervention

• Periodically updating the goals and objectives, as required by on-going changes.

• Reallocating funding shown on Appendix C, as needs dictate but with proper authorization.

• Professional interfacing with other government agencies.

1. What are the differences in terms of the health effect of male and female circumcision?
2. What do females think about circumcision?
3. What are your personal thoughts about female circumcision?
4. To what extent is female circumcision supported by health care professionals?
5. What reactions do females have toward the circumcision procedure?
6. Have you had any training in the area of female circumcision? If so, how was the training helpful to you?
7. How do you think females are convinced that circumcision is necessary?
8. How do you think the program can best achieve its objectives of educating target populations about female circumcision?
9. How do you think that female circumcision will be practiced after implementation of the program?
10. Should men be interested in actively participating in this program? Why? Why not?

• Responses from the focus group will be prioritized by the group participants. A consensus will reached on each priority and its degree of significance will be ranked.

• The Program Director will assign a "feasibility quotient" to each priority.

• The highest priorities with the highest feasibility quotients for obtaining behavioral change will be selected as practical tasks for the program to accomplish.

• The feasibility quotient will be determined by a modified multivariate analytical approach (to the extent possible due to the qualitative data generated), in view of the many variables involved, e.g. strict Moslem practices, women’s powerlessness, distance, educational levels, actual cost of effecting behavioral change, etc.