Results
Table 1 shows the profile of the respondents. The final sample was composed of 468 HCPs (41.6% women and 58.4% men), with an average age of 28.8 years. The sample is ethnically representative of the total Gambian population, according to the most recently published official data.
We found that a considerable proportion of HCPs (40.9%) observed girls and women with health complications resulting from the practice. Just under half of the respondents (42.5%) embraced its continuation and 7.6% reported to have performed it on girls. Detailed results in terms of KAP are presented in the following three subsections.
Knowledge
The assessment of HCPs' knowledge on FGM/C was performed by exploring the reasons given for the practice to be performed, as well as through acknowledging HCPs' awareness of its health consequences. The results are shown in Table 2.
According to HCPs, FGM/C is mainly performed because people believe that the practice is mandatory by religion (53.8%), consider it to be deeply rooted in the Gambian culture (48.2%) and view it as an effective measure to reduce women's sexual feelings (42.1%). Other given reasons include the fact that FGM/C is a rite of passage (34.4%), a good practice (23.3%), it helps to maintain virginity (13.5%), it reduces the rate of prostitution (11.1%), and does not violate human rights (0.6%).
Inter-ethnic analysis showed that the three most common answers for each ethnic group were the same found for the total group, showing a similar pattern of response. However, slight differences were found concerning the order of these three answers. Fula and Mandinka HCPs prioritised the fact that FGM/C is mandatory by Islam (58.7% and 54.9%), Serer and Wolof HCPs gave more importance to its cultural roots (80% and 55.3%), and Djola HCPs considered it to be important for attenuating sexual feelings (56.3%). Notably, significant differences were found among ethnic groups when HCPs were asked if they considered FGM/C to be mandatory by religion. While 50.3% of Mandinka HCPs answered affirmatively, only 8.3% of Wolof HCPs shared the same opinion (p = 0.000).
Inter-sex analysis showed that female and male HCPs also had similar opinions on the main three reasons given for FGM/C to be performed, although there were some nuances. More men than women considered that support towards FGM/C derives from the fact that it is mandatory by religion (56.3% vs. 48.8%) and attenuates sexual feelings (43.7% vs. 38.6%), whereas more women than men believed that people value the deep cultural roots of the tradition (55.1% vs. 43.7%). When asked if they consider FGM/C to be mandatory by religion, 40.2% men and 38.1% women responded affirmatively.
To evaluate HCPs' knowledge on FGM/C-related complications, respondents were asked to identify five health consequences through an open-ended question. A considerable percentage of HCPs were able to recognise the negative impact of FGM/C on the health of girls and women. The transmission of infectious diseases was the most reported consequence (59.1%), which might be explained by the recent campaigns that international organisations working in The Gambia have launched for the prevention and treatment of HIV/AIDS. Bleeding (53.4%), difficulties during delivery (46.3%), and reduction of sexual feelings (25.2%) were also mentioned. Notably, 2.1% of HCPs, all of them of Mandinka and Fula origin, believed that the practice has no consequences. Inter-sex analysis showed that more women pointed out difficulties during delivery (48.8% vs. 44.4% men), while more men referred to the transmission of infectious diseases (57.6% vs. 42.4% women). Additionally, more men than women considered that FGM/C has no consequences (3.1% vs. 0.8%).
A considerable proportion of HCPs (40.9%) observed girls and women with health complications resulting from FGM/C. However, the rate of complications was substantially different among the ethnic groups. More than half of Wolof and Serer (60.3% and 55.0%, respectively) HCPs reported having seen a girl or woman with FGM/C complications, while this rate was 41.5% in Djola, 39.7% in Fula, and 33.2% in Mandinka HCPs. We found that a higher percentage of women than men (51.1% vs. 33.8%) answered affirmatively.
Attitudes
Questions were designed to measure the attitude of HCPs towards the practice of FGM/C as follows: the feasibility of its elimination; different strategies to prevent FGM/C (including the role that can be played by Islamic leaders and by HCPs themselves); medicalisation; discrimination towards those who do not undergo FGM/C; and the involvement of men in the debate. The findings of attitude are shown in Table 3.
A substantial percentage of HCPs (42.5%) believed that FGM/C should continue to be practiced, although this opinion was more commonly shared among traditionally practicing ethnic groups. The strongest support came from Mandinka (57.3%), Fula (42.9%) and Djola HCPs (39.0%), and the lowest support from Serer (23.8%) and Wolof HCPs (20.7%) (p = 0.000). A similar tendency was found in those believing that the practice can be eliminated, with the highest proportion in Serer (64.7%) and Wolof (64.3%), and the lowest in Mandinka (39.2%), Fula (38.2%), and Djola HCPs (31.7%). Inter-sex differences also existed. Men were more supportive towards FGM/C than women (45.7% vs. 37.4%), and less confident on the feasibility of it being abandoned (43.4% vs. 48.6%).
Regarding strategies to prevent the practice, Mandinka, Djola, and Fula HCPs were less eager for the idea of religious leaders preaching against FGM/C, with this strategy finding the strongest support among Wolof (71.2%) and Serer HCPs (76.2%). When asked if HCPs have a role to play in eliminating FGM/C, 73.0% of the respondents answered affirmatively. However, while the majority of Wolof and Serer HCPs (89.7% and 90%, respectively) welcomed this idea, Mandinka HCPs were not that supportive (59.8%) (p = 0.002). When these results were examined for a difference between sexes, women appeared to be more favourable than men to this suggestion (77.4% vs. 70.2%).
Table 3 shows that 42.9% of all HCPs considered medicalisation as a safer practice, compared with how the cutting is traditionally performed by a circumciser, and this belief was more prevalent among Mandinka (56.1%), Djola (46.2%), and Fula HCPs (41.7%) than the other ethnic groups. However, 16.5% of the respondents viewed medicalisation as a way of encouraging FGM/C and 40.6% defended that it should be stopped at all levels. Wolof and Serer HCPs showed the highest support to stop medicalisation (73.1% and 68.4%, respectively), while only one fourth of Mandinka HCPs (26.2%) agreed with this idea. Women, more than men, stand against medicalisation (52.5% vs. 32.5%, p = 0.000).
Discriminatory attitudes towards those who do not undergo FGM/C were found in 12.8% of HCPs, and this attitude was the most common among Mandinka and Djola HCPs (16.6% and 14.6%, respectively). When these results were examined for a difference between the sexes, women had a more discriminatory attitude than men (14.1% vs. 11.8%). However, when inter-sex analysis was conducted within the ethnic groups, an exception was found for Mandinka and Djola HCPs, where men's support for discrimination was slightly higher than that for women.
A high percentage of HCPs (78.3%) considered that men should be concerned about the debate on FGM/C. Serer and Wolof HCPs expressed the strongest support for men's involvement (90.5% and 89.8%, respectively), followed by Djola (85.4%), Fula (83.3%), and Mandinka (69.5%). This opinion was also more popular among men than in women (80% vs. 75%).
Practices
The practices concerning FGM/C were assessed by investigating if FGM/C was performed in the HCPs' family/household, if they intended to subject their own daughters to FGM/C, and if they had ever performed FGM/C during their medical practice. The results for practices are shown in Table 4.
A total of 68.6% of HCPs reported that FGM/C is practiced in their family/household. Inter-ethnic analysis showed that the rate of prevalence of FGM/C in HCPs' families/households was comparable with the last available figures, published by UNICEF in The Gambia, strengthening the credibility of our study's results. FGM/C was practiced among the families/households of 85.7% Mandinka, 85.0% Djola, 63.3% Fula, 42.9% Serer and 19.0% Wolof HCPs. Even though the intention of HCPs to carry on with the practice of FGM/C, by subjecting their own daughters to it, was considerably less than the rate of FGM/C in their family/household, this rate was still high, particularly among Mandinka (64.3%), Djola (47.5%), and Fula HCPs (43.6%) (p = 0.000).
When these practices were examined in both sexes, more men than women assumed that FGM/C is practiced in their families/households (70.8% vs. 58.5%), and admitted their intention to have it performed in their daughters (48.8% vs. 40.8%). This intra-sex tendency was maintained throughout all ethnic groups, except for Fula and Serer, among whom more women expressed this desire. An inverse relationship was found between HCPs' reported rates of intention to subject their daughters to FGM/C and rates of exposure to FGM/C health consequences.
Finally, we also found that medicalisation was a reality in The Gambia, with 7.6% of HCPs admitting to having performed FGM/C in girls. This was more frequent among Djola (9.8%) and Mandinka HCPs (8.0%) than among other ethnic groups. More women than men carried out FGM/C during their medical practice (7.4% vs. 6.9%).