VU Research Portal

Beyond the idea of culture

Graamans, E.P.

2020

document versionPublisher's PDF, also known as Version of record

Link to publication in VU Research Portal

citation for published version (APA)Graamans, E. P. (2020). Beyond the idea of culture: Understanding and changing cultural practices in businessand life matters.

General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.

• Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ?

Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.

E-mail address:vuresearchportal.ub@vu.nl

Download date: 20. Jul. 2022

[ 145 ]

Chapter 6.A different understanding of girl circumcision is imperative to change

[ 146 ]

Chapter 6.

[ 147 ]

A different understanding of girl circumcision is imperative to change

Once the case study on boardroom dynamics got published in a scholarly management journal (Graamans, Millenaar & ten Have, 2014), my colleagues and I continued to challenge and take issue with the opportunistic misuse of the notion of culture in the management of organizations. Our arguments were further expanded in a few Dutch-based, professional journals (Graamans, Otto, Smit & ten Have, 2017; Graamans, ten Have & ten Have, 2016a). We also entered the public debate with an opinion piece in a daily newspaper countering the current discourse on culture in corporate governance (Graamans, ten Have & ten Have, 2016b). Our main objection was that culture was presented as a groundbreaking solution while the behavioral science fundamentals to back it up were lacking, or at least were seriously flawed. In the meantime, I was conducting research on the introduction of cheaper surgical suture in the operating theatre of a large academic hospital in the Netherlands; a seemingly straightforward change initiative that met with great resistance, especially from members of the cardiac surgery department. The single practice of suturing with surgical suture material from a specific supplier proved to be tenacious, and this tenacity was not anticipated and properly accounted for by hospital management. I often use this case – as presented in Chapter 5 – in my lectures and presentations to make the point that some practices are not to be changed in a pick-and-choose manner. Suture as a tactile element in the day-to-day work environment of cardiothoracic surgeons is embedded within a complex social arrangement that ties elements of risk avoidance, professional accountability and direct patient care together in a way that feels secure. Almost needless to say, these feelings are genuinely felt. They are, therefore, as real as the financial cost of surgical suture and evidence-based standards of its quality. These feelings are by no means of lesser importance and, thus, need to be accounted for with the same managerial fervor.

In 2016, via Amref Flying Doctors in the Netherlands, the opportunity arose to write a research proposal on an entirely different issue with implications that reach beyond the confined scope of management, governance and organizations: the issue of ending the practice of girl circumcision. However, note that the underlying motifs are quite similar; in all these cases single practices treated as isolated ‘things’ simply continue to persist despite well-intended efforts to change or stop them. In the case of girl circumcision, it became apparent that with the passing of legislation that explicitly prohibits the practice and by organizing awareness campaigns on sexual and reproductive health and rights (SRHRs) change was just not happening fast enough (e.g., Skaine, 2005). Apparently, change requires more than the activation of new rules and persuasion by health-related arguments. So, health organizations started seeking after alternative, complementary approaches to change. One such alternative approach is the facilitation of alternative rites of passage (ARPs) for communities wherein girl circumcision is thought to signify a tran-sition into womanhood (Muteshi & Sass, 2005). What ARP exactly entails will be expanded upon in greater detail in the following chapters, but essentially it means that an

Chapter 6.

[ 148 ]

alternative rite is offered without ‘the cut’. The idea is that the social significance of girl circumcision is nonetheless accounted for and in this way important barriers to change can be broken. However, the ARP program came about by a trial-and-error process, without a clear theory or framework of culture by which to guide its design and imple-mentation. Although effecting change at a community-level and accounting for meanings ascribed to the practice by community members themselves is considered an enormous step forward, a lot remains to be done with respect to how these and other interventions aimed at ending girl circumcision are designed, implemented and assessed (e.g., Askew, 2005; Hughes, 2018). Additionally, Amref Health Africa, that started implementing or ‘facilitating’ ARPs in 2009 amongst Maasai and Samburu communities, was curious to know to what extent the program was indeed perceived as community-led and whether these alternative rites were seen as viable rites of passage actually able to replace ‘the cut’. Apart from effect studies that Amref Health Africa already embarked on and on the basis of which – for all the practical, ethical and methodological reasons – the precise effects of ARP proved difficult to establish (African Development and Health Research Centre [ADHRC], 2016; Kiage, Onyango, Odhiambo, Okelo & Sifuna, 2014), more questions related to the mechanisms and dynamics of change required answering. After some back and forth with the headquarters of Amref Health Africa and the Ethics and Scientific Review Committee in Kenya I was able to convince important gatekeepers of my inten-tions and expertise, even though my approach was rather unorthodox and I was not trained in one of the more commonly related fields such as medical anthropology, epide-miology or community health. To counteract possible shortcomings on my part, I made sure that experts from different disciplines were represented in the research team that I was leading. Eventually though, it was the continuous work of gaining and maintaining access to a tightly knit community and my acceptance of the guidance of community members themselves that was most fundamental to making this research project a success.

6.1 Girl circumcision: A tenacious cultural practice

One of the first questions I get asked when giving lectures and presentations on the practice of girl circumcision to predominantly western audiences is: why do they do it? No shortlist of reasons will provide a sufficient explanation. A more complete and satis-factory answer requires a contextualized understanding of what girl circumcision entails and how people organize their lives beyond this one practice, that is singled-out for change. First, in this paragraph the definition of girl circumcision – referred to as female genital mutilation or cutting (FGM/C) – and the different procedures that fall under this definition will be succinctly expanded upon. Second, the issue of ethnocentrism is touched upon by also critically looking at bodily modifications that are becoming increasingly common in the western world, and that might similarly be referred to as ‘mutilations’. And last, the use of propositional shortlists of reasons given for girl circum-cision is problematized.

Chapter 6.

[ 149 ]

It is unclear when and where the practice of girl circumcision originated. Some propose that the practice originated in ancient Egypt since mummified women dated from the 5th century before Christ were found to be circumcised (e.g., Barstow, 1999; Little, 2003; Ross, Strimling, Ericksen, Lindenfors & Mulder, 2016; Slack, 1988). However, earlier Egyptologist and anatomist Grafton E. Smith, who examined hundreds of mummies, pointed out the difficulty of drawing this conclusion solely based on medical examina-tions on mummies due to procedures on the female genital organs performed during the mummification process itself (in Knight, 2001). Even health clinicians having to perform physical examinations on the female genital organs of living girls – in the context of a criminal investigation for example – can have great difficulty in determining with any amount of certainty whether a girl has actually been circumcised or not (Berer, 2015; Johnsdotter, 2019). Factors such as wound healing, natural variability in the appearance of female genital organs, alternative, less drastic procedures being performed and lack of experience by the clinicians themselves contribute to this complexity.

To get a rough idea of the scale of the problem at present, it is estimated that worldwide 200 million girls and women have undergone circumcision (United Nations International Children’s Emergency Fund [UNICEF], 2016) and that, despite all the effort put into discouraging people to perform this practice, every year about 3 million girls are at risk of becoming circumcised (World Health Organization [WHO], 2018). Girl circumcision, or FGM/C, is defined as “... all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons” (WHO, 2018). This overarching definition refers to a variety of practices performed for equally as many reasons, as will be expanded upon in more detail. Although not frequently used by the members of respective FGM/C practicing communities them-selves, a classification has been developed for health professionals enabling them to make important distinctions in the different types of procedures performed between and within communities. The classification is as follows:

Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization. (WHO, 2008, pp. 4)

Chapter 6.

[ 150 ]

In general, amongst the Maasai and Samburu communities in Kenya visited in this study type I and type II circumcision are practiced, but due to the fact that these communities are in transition, alternative procedures, classified under type IV circumcision, are likely to become more common (ADHRC, 2016; Kiage et al., 2014). Girls in these communities are at risk of having to undergo all types, except for type III. Type III, or infibulation, is generally understood to be the most drastic procedure and consequently carries, from a physical health perspective, the most risk. Infibulation is more likely to be practiced amongst communities in Somalia, Northern Sudan and Djibouti (United Nations Population Fund [UNFPA], 2018). However, there are severe short-term and long-term health risks associated with all types of FGM/C (mainly type I-III), such as infections, severe pain, excessive bleeding, menstrual problems, shock, sexual dysfunction, complica-tions during child birth and death due to infections and/or bleeding (Reisel & Creighton, 2015; WHO, 2018). Although most of these associations seem evident, little is known about the precise causal effects of FGM/C on sexual experience (e.g., Ahmadu & Shweder, 2009; Berg, Denison & Fretheim, 2010; Obermeyer, 2005). The psychological effects of undergoing FGM/C are similarly difficult to determine. Although a range of psycholog-ical problems can be associated with undergoing FGM/C, these are sometimes weighed against the negative social consequences to not undergoing FGM/C, such as having to endure bullying, abuse or expulsion from the community (e.g., Boyden, 2012; Gruenbaum, 2001), which can in some cases be equally, if not more, damaging to the human psyche. It just goes to show that health practitioners have to proceed with prudence and the greatest care. Not intervening might not be an option in light of the women’s health and rights issue at stake. Yet, intervening can severely endanger girls if done half-heartedly, one-sidedly or short-term, project based.

By now, the reader might have noticed that terms such as girl or female circumcision and the acronym FGM/C, for female genital mutilation or cutting, are used interchangeably. Some clarification is warranted for doing so. In Maa, the language spoken by Maasai and Samburu people, the term for both male and female circumcision is emorata. The fact that these very different practices are referred to by the same word is telling. During my field research I have heard many men talk about their circumcision and that of their women as essentially being equivalent practices. The terms ‘girl circumcision’ or ‘female circumci-sion’ itself is specious too, since for women tissue is not removed in a circular manner per se, as often is the case when the male foreskin is removed. In some cases, it would probably be better to speak of ‘female excision’ since tissue is also excised or scooped. However, because this terminology is not very common, I will not use it. Some social scientists and health professionals prefer the term ‘female genital cutting’ over the term circumcision and especially over the term mutilation. Cutting refers to a clinical procedure without immediately implying physical disfigurement and without thereby automatically evoking judgement on a group of people that have practiced it for generations and to whom this practice is normal, or even natural. As Gruenbaum (2001), who extensively studied girl circumcision as practiced in Sudan, states: “If the very meaning of what it is to be ‘a natural woman’ can be embedded in female circumcision, tenacity to the practices and

Chapter 6.

[ 151 ]

resistance to change is predictable” (p. 69). Therefore, also within the organization that I was embedded with, Amref Health Africa, some staff members were advocating the sole use of the term female genital cutting, and its acronym FGC, for it being less confronta-tional and more conducive to working with respective communities on the gradual abandonment of this practice. The practice is also often referred to as ‘the cut’, as in the campaign slogan ‘Stop the cut’. To emphasize the gravity and harmfulness of this practice, however, the term ‘female genital mutilation’ is still frequently and purposively used by members of leading governmental and non-governmental organizations, including staff members of Amref Health Africa.

Mutilation is “an act of physical injury that degrades the appearance or function of any living body” (Wikipedia, n.d.). To add another point, I would like to stress that construing the practice of girl circumcision as degrading the appearance of the body, does not take into account that beauty is always in the eye of the beholder. Another bodily modification that is common amongst the members of some East African communities, such as the Maasai and Samburu, is the removal of one or two front teeth in the lower jaw. Although the reasons given for this practice vary as is the case with reasons given for girl circumcision - health-related, rite of passage, etcetera (Hassanali, Amwayi & Muriithi, 1995; Mutai et al., 2010), people often told me that the reason for pulling the bottom front tooth is simply ‘beautification’. In the beginning, when I first noticed this feature and found out it was not caused by tooth decay, I perceived it as mildly unattractive and lightly estranging. I got used to it though, and as my field work continued, I began to find it normal. As more time passed and I developed friendships with Maasai and Samburu people who had deciduous or permanent teeth pulled as young children, it became a feature that I was gradually becoming to perceive as charming. You might say, that I can see the beauty of it now. Obviously, I come from a different part of the world. Where I am from we have our own practices of bodily modification, that we would never call mutilations, but certainly bear all the hallmarks of it; tattoos, piercings, cosmetic surgeries and hours of self-torture in gyms to meet an untenable beauty ideal, and that in some cases has little to do with health or longevity. Even the practice of surgery on the female genital organs ‘for non-medical reasons’ – quotation marks referring to the above definition of FGM/C by the WHO – is on the increase in the western world, and this increase in not caused by immigration per se (e.g., Braun, 2010; Goodman, 2016). Some of these practices are referred to by the terms ‘female genital cosmetic surgery’ (FGCS) or ‘female genital plastic and cosmetic surgery’ (FGPCS), and not, needless to say, by the term ‘female genital cosmetic mutilation’ (FGCM?). McDougall (2013) in her eloquently written paper with the title “Towards a Clean Slit: How Medicine and Notions of Normality are Shaping Female Genital Aesthetics” published in Culture, Health & Sexuality exposes this practice in western or mainstream medicine as “an increasingly cultural and commercial pursuit, one that has important implications for women, and for men.” (p. 785). My point of highlighting this phenomenon in the West is to help readers from cultures less acquainted with the topic of girl circumcision to develop a base attitude of suspended judgement. Suspended judgement is a first requirement for conducting, but also reading about, qualitative research of the kind I did. Studying ‘others’

Chapter 6.

[ 152 ]

Chapter 6.

also means constantly reflecting on yourself and on where you think you are coming from. What I did not find, however, was my research subjects taking offence at a certain termi-nology. Of course, although I occasionally explicitly probed for it, I might not have noticed, since the subtilities of language could literally have gotten lost in translation, however qualified my translators were or eloquently my research subjects mastered English. During my field research the terms used to signify the practice of girl circumcision were employed interchangeably and so they are in this dissertation; cutting to refer to the procedure, muti-lation to refer to official documents in which it is used as such, and circumcision because it is common language. I contemplated employing the unusual terminology ‘female sexual mutilation’ (see also: Assaad, 1982), with its acronym FSM, to steer the debate in the direction of the expressive body and away from all the clinical talk of the microfunctional body, as expanded upon in § 2.2.1. To not add to any further confusion and to avoid the stigmatization of circumcised girls and women as not being able to enjoy sex – which is not necessarily true – I decided not to employ the term FSM.

As indicated above, the reasons for performing the practice of girl circumcision vary consid-erably among regions, communities and even within communities (e.g., Gruenbaum, 2001; UNICEF, 2013). In a systematic review, Berg and Denison (2013) examined the factors that perpetuate and that hinder FGM/C as perceived by members of practicing communities that live in western countries. They found that the main factors for the continuance of girl circumcision mentioned were marriageability, sexual morals, religion, health benefits and male sexual enjoyment, and – how else? – cultural tradition as a major culprit. Factors for discontinuance were health consequences, illegality, host society discourse rejection and religion. Aside from the fact that this is a study on factors as perceived by migrants living in western countries and one should therefore be careful to generalize these findings, this list also shows that reasons given or factors identified can actually be quite ambiguous. Religion and health, for example, can be factors that either perpetuate or hinder the practice of girl circumcision. It just depends on the region, the imam or priest, which religious verses are emphasized, and how health is approached. Male sexual enjoyment as a factor that perpetuates FGM/C is also a dubious one, because that one likely depends on the specific type of procedure performed on the female genital organs. Sexual experience is a complex issue, and the female genital organs are not only to be understood biologically or mechanistically. Sexual experience is not to be approached solely as the mutual rubbing of nerve endings. It is first and foremost an expressive practice performed with expressive bodies of meaning. To be able to conclude anything about sexual experience, sexuality must be treated as such, as expressive practices that structure the affective system wholly. Apart from that, in the study that I conducted numerous men confided to me that they enjoy sex more if the woman they are intimate with enjoys sex too, instead of – as rendered in the language of my interviewees, as it is – her spreading her legs to just get it over with. Quite a few men knew the difference by having experienced both. The verdict was clear. And the verdict was as paradoxical as it was painful for those girls and women already circumcised. The men preferred women who were not circum-cised, because, in the words of one young man, ‘they act all crazy’ during the act. I am not

[ 153 ]

Chapter 6.

stating here, though, that male sexual enjoyment cannot be a perpetuating factor either, in some other communities where other types of procedures are performed embedded within different social arrangements. But it just goes to show that an understanding of embodied experience within local social arrangements is essential to understand what exactly is going on. The most problematic factor that Berg and Denison mention is, of course, cultural tradition. Very few researchers have asked themselves the question whether culture was not used as an excuse or as a cover-up. In any case, it is always too abstract and too vague to be considered a factor that is actionable. As explained in the previous chapters, approaches to change need to be based on contextualized knowledge in order to be effective. That is why these kinds of lists with ‘usual suspects’ are only helpful to the extent that they can function as a checklist of possible grounds to cover for more thorough follow-up research.

6.2 AfirmstanceontheachievementofSustainableDevelopment Goal No. 5.3

As mentioned in Chapter 1, this research project aims to contribute to Sustainable Develop ment Goal No. 5, to achieve gender equality and empower all women and girls, and more specifically to No. 5.3, towards the elimination of harmful practices (United Nations Populations Fund [UNFPA], 2018). Amref Health Africa is an African-based non-governmental health organization that has aligned its vision to end FGM/C by 2030 (Amref Health Africa, 2017a). To be clear, Amref Health Africa’s programs to end girl circumcision are aimed at all types of procedures that fall under the definition of FGM/C as formulated by the World Health Organization (2018). This implies that medicalization of the practice to counteract at least some of the negative health consequences, such as infections and excessive bleeding, or advocating less damaging procedures that fall under type IV are not in any way advocated in their programs. When on June 18 of 2016 The Economist published an article suggesting that medicalization might deserve to be given a chance, it created quite a stir amongst several organizations spearheading anti-FGM/C programs. Five days later, dr. Githinji Gitahi, Group Chief Executive Officer of Amref Health Africa, reacted strongly in the following manner:

What exactly does The Economist consider a “nick” on the female genitalia of young girls? And, what “form” of FGM do you stand for – “the least nasty version” or none at all? The least nasty version still violates the health and well-being of girls each year. To say that a “symbolic nick” is better than being “butchered in a back room by a village elder” does not fit with the context of what the issue comes down to: humanity. We believe in community-led cultural alternatives to FGM through “alternative rites of passage” ceremo-nies. These have no forms of a cut, so girls are able to continue their education, which makes it less likely that they will become child brides. For us, there is no “least nasty version” of FGM, there is simply no FGM. (Gitahi, 2016)

[ 154 ]

Taking the above stance does not preclude practicing suspended judgement, as qualitative research of the kind I did requires. Practicing suspending judgement must not be feared or taken as the downplaying of the severity of girl circumcision. However, suspending one’s judgement while working on a more contextualized understanding of this practice can come accompanied by the uncomfortable feeling of realizing that if born into an arrangement wherein girl circumcision is practiced, one might very well partake in it. If readers get this kind of estranging feeling from reading this dissertation and thinking about its implications, I have done well. A good description of a social arrangement is exactly that, the uncomfortable crawling into someone else’s skin and into someone else’s environment. It also helps to understand that people that practice girl circumcision are good people, or at least just as good or bad as any other. People that practice girl circum-cision care about each other and want what they perceive is best for their families and communities. Although understandably it is much easier to judge others than to accept that it could have been ourselves partaking in the very thing we like to condemn whole-heartedly. But at risk of repeating myself and stating the obvious, contributing to stopping girl circumcision is clearly the goal of this research and indisputably so. The underlying rationale is based on the two pillars, that FGM/C “is a violation of human rights” (WHO, 2008, pp. 8) and “has harmful consequences” (WHO, 2008, pp. 11).

6.3 Reconsidering attitudes and norms

Some anthropologists (e.g., Abu-Lughod, 1991) and especially cultural psychologists (e.g., Baerveldt, 1998; Verheggen, 2005; Voestermans & Verheggen, 2013) have problematized the notion of culture as a construct which could be of help in understanding human behavior. The idea of culture itself could very well be the culprit of common misunder-standings about the production of behavior and of upholding barriers to change. For it is often used as an excuse for behavioral patterns that are harmful to at least a part of the populace and beneficial to another, more privileged part. However, although the idea of culture is not given up easily, the word culture itself is sometimes replaced for words representing the same idea. For example, if harmful practices, such as girl circumcision, are framed in terms of a culture, it might evoke resistance on the part of the communities targeted. People might feel their culture is under attack and instead hold on to those practices, however harmful, even more. It leads to a rather strange situation. The emphasis is moved away from culture – in order to safeguard the idea and avoid people’s sensitivities about it – to norms. Indeed, Hughes (2018) noticed that in the discourse about behavior change related to the practice of girl circumcision culture change is no longer the objective. Instead, social norms change appears to have become the new buzzword. Verheggen (2005) foresaw that as soon the problematic nature of the culture notion becomes obvious, people shift to other notions. But that does not help much. Scripts, schemata, climate, shared values, norms, attitudes and all kinds of other representationalist notions suffer from the same problematic: the attention is on concepts instead of the behaviors those

Chapter 6.

[ 155 ]

concepts are purported to elucidate. They obfuscate the production of the behavior in a community by taking out the experiential dimension of the people in that community and replacing it with a rather speculative conceptual machinery. This trend can be observed in reports from the WHO and UNICEF, the biggest organizations that spearhead the worldwide campaign against girl circumcision.

6.3.1 On attitudes to girl circumcisionIn keeping with ideas and propositions stemming from a particular branch of cognitive behavioral science, UNICEF made several recommendations in a report from 2013 titled Female Genital Mutilation / Cutting: A Statistical Overview and Exploration of the Dynamics of Change. Two of these will be highlighted, because they are specifically relevant to the aim of this research, albeit by employing a radically different psychological paradigm:

• “ Seek change in individual attitudes about FGM/C, but also address expectations surrounding the practice within the larger social group” (UNICEF, 2013, pp. 116)

• “ Find ways to make hidden attitudes favoring the abandonment of the practice more visible” (UNICEF, 2013, pp. 117)

These kinds of statements indicate that thinking in terms of ‘hidden attitudes’ is believed to be an important key to change. An attitude is seen as either an operational determinant of behavior, a direct lever of change, or both. Although it is generally presumed that attitudes determine behavior, this relation is not claimed to be straightforward. The main idea is that behavior is determined by the intention to perform that behavior – as outlined in the currently still rather dominant Theory of Planned Behavior (TPB; Ajzen, 1991) and Theory of Reasoned Action (TRA; Fishbein & Ajzen, 1975). This intention is measured by combining for attitudes, social norms and behavioral control into one measurable concept of behavioral intention.

Yet, clinging on to the notion of ‘hidden attitudes’ can lead us up the wrong track. Granted, there is strong evidence that, as a measurable concept, attitude – together with the other variables of the TPB – predicts behavior to some extent (e.g., Armitage & Conner, 2001), and therefore has some utility in the planning and design of behavior change interventions (e.g., Fishbein & Ajzen, 2010; Sheeran et al., 2016; Steinmetz, Knappstein, Ajzen, Schmidt & Kabst, 2016). However, this notion suffers from the same problematic as detailed earlier, and throughout this dissertation; it gives us little insight into how behavioral patterns are produced – between people – and how these, in turn, become naturally compelling.

The TPB has been widely criticized, and for different reasons (e.g., Sniehotta, Presseau & Araújo-Soares, 2014). Discursive psychologists Jonathan Potter and Margaret Wetherell (1987) in their book Discourse and Social Psychology: Beyond Attitudes and Behaviour – a book I often refer to throughout my articles – already highlighted some of the problems

Chapter 6.

[ 156 ]

of traditional attitude research. Their objections, I contend, should not be discarded as positivism-bashing, but have substantial merit. Their critique is summarized as follows: the problems with this kind of research are “the status of the ‘object’ which the attitude assesses; the dubious translation from participants’ terms to analysts’ categories; and the assumption that attitudes are enduring entities which generate equivalent responses from occasion to occasion” (1987, p. 53). Indeed, consistency can only be expected if respon-dents are able to relate to these ‘objects’ from experience and have given them extensive forethought (e.g, Westerhof, 2003). But even if the latter is the case, social practices at an experiential level remain out of sight and levers of change that resonate at a community -level cannot be revealed this way.

Despite all the flaws, assessing attitudes about girl circumcision will remain an important practice, if only for the fact that policy makers, donors, and the like need to get a general idea about the scale of the problem and somehow monitor progress being made. But if these endeavors are not followed-up by thorough qualitative investigation, the numbers produced can be quite misleading. To measure people’s attitudes to girl circumcision, respondents are asked whether they think girl circumcision should be continued or stopped. The measures encountered during pre-research also have the option of ticking ‘do not know’ or ‘other’ (e.g., Kiage et al., 2014; Van Rossem, Meekers & Gage, 2016). The respondents are left to figure out what exactly is implied with the object of thought; the practice of girl circumcision. Someone might be triggered, at that particular moment in time, to think in terms of mutilation, implying damage to the body and therefore tick ‘stopped’. Someone might be triggered to think in terms of emorata, which in turn may evoke its social function as a rite of passage and therefore tick ‘continued’. And then there is the problem of the great variety in practices that all fall under the broad definition of FGM/C. A respondent might tick the box indicating the practice should be stopped, but condone other procedures that fall under category IV circumcision, such as pinching, piercing, scratching or pricking. Another respondent might answer similarly, but at that moment has procedures in mind performed under unhygienic conditions by non-medi-cally trained birth attendants. He or she may be perfectly okay with procedures of whatever kind performed in sanitary, hygienic circumstances by a trained medical professional. These are rough examples, but it should be clear, that without talking to the people concerned it is impossible to flesh out what any particular survey score means, and what kind of practices aggregate outcomes reflect. It is important to closely examine variability in people’s accounts, instead of primarily relying on supposed stable underlying mental states or explain away variability by adding more and more modifying variables to uphold the notion of attitude. Namely, because studying people’s accounts often reveals that people are far less consistent than generally presumed.

6.3.2 On girl circumcision and social normsThat UNICEF and others – in an attempt to account for ‘the social’ or ‘the cultural’ – are indeed modeling or advocating a ‘theory-of-planned-behavior’-like approach to change becomes even more evident by its emphasis on another supposed determinant of girl

Chapter 6.

[ 157 ]

circumcision: the social norm (e.g., Easton, Monkman & Miles, 2003; Hayford, 2005; Mackie & LeJeune, 2009; Shell-Duncan & Hernlund, 2006; UNICEF, 2005, 2010). The idea of norms put forward by political scientist Gerry Mackie (1996) and more recently by philosopher Cristina Bicchieri (2005) has greatly influenced UNICEF’s approach to change and public health discourse more generally. Bicchieri’s latest definition of a social norm is formulated as follows:

A social norm is a rule of behaviour such that individuals prefer to conform to it on condition that they believe that (a) most people in their reference network conform to it (empirical expectation) and (b) that most people in their reference network believe they ought to conform to it (normative expectation). (2017, p. 35)

Bicchieri’s rather cognitivist approach is different from the cultural psychological frame adopted in my research. Agreements (A1), conventions (C) and arrangements (A2) are about physical, tangible and group-typical patterns of behavior. These are the shapes of behavior that can actually be observed while spending time within a group or community, and that its members continuously enact. Therefore, ACAs are non-propositional, i.e., do not have to be construed in a survey. There are requirements, for example, of what young-sters need to do and the skills they need to master to be considered full-fledged men or women (A1). There are unwritten rules, conventions and customs community members abide by, and have developed a feel for, to be considered part of the community and respective subgroups within that community (C). And feelings, preferences and tastes amongst community members have become aligned in such a way that interactions run smoothly, with or without words (A2). From this perspective, group-specific patterns do not come about by the ‘internalization’ of norms or by referencing to beliefs, but by repeated practice – explicitly by training and implicitly by play – within the group or community one belongs too. The ACA-framework and underlying enactive theory is about peeling away the cognitive, mentalistic layers superimposed upon embodied practices. In contrast, Bicchieri’s theory – in tune with the current Zeitgeist of economic algorithms and the popularity of social norms – feeds into the seductive promise of measurability and scalability. However, the physicality involved in shaping preferences and tastes remains by and large ignored; as if preferences and tastes are completely bodiless. According to her, preferences – to conform to whatever norm – are held to be conditional to having beliefs (Bicchieri, 2014). The cultural psychological frame adopted in this dissertation aims to explain the normativity of patterned behavior as a matter of group-be-longing, but does not postulate norms, or even beliefs, prior to practice. This does not mean that beliefs and cognitions do not matter. However, the onus is on the affective structuring of preferences, taste and cognition within the community one belongs to. From the very beginning, for instance, children appear to be naturally inclined to cooperate in a way that makes meaningful play possible (Tomasello, 2009). Based on short bodily interactions and the early affective formation of preferences, they start to engage in meaningful games. They do so because it feels good, not because they believe it

Chapter 6.

[ 158 ]

feels good. Similarly, as grown-ups, once our affective system has become firmly attuned to our community, beliefs can support our behavior, but are not conditional upon it.

In Bicchieri’s (2017) definition, for a norm to work – and to uphold the very notion itself – conditions must be met based upon beliefs or cognitions about a certain threshold of the conformation of others to that same norm. It feeds into the seductive promise that norms can be measured, and that change will happen automatically once a threshold is reached, without much further effort. Hughes (2018) makes the case that in Kenya, where governmental and non-governmental organizations have been combatting the practice of girl circumcision for two decades now, the prediction of the effects of social norms approaches should have been visible. According to her, they are not. In another study on girl circumcision no evidence was found for hypotheses formulated based on the social norms approach either (Efferson, Vogt, Elhadi, Ahmed & Fehr, 2015). Researchers have identified common pitfalls in applying social norms approaches to change (e.g., Cislaghi & Heise, 2018, 2019; Mackie & LeJeune, 2009), but few are asking the more difficult question of how to address the tenacity of embodied practices and the affective struc-turing of preferences and taste. It is just not part of our theories of change, and therefore we are blind to it.

To sum up: the ideas of ‘hidden attitudes’ and ‘social norms’ might have utility as reference points or, to some extent, in assessing the effectiveness of our intervention strategies. That is, only if empirical research has first firmly established a relation between these constructs and specific health-related outcomes. However, in doing so these constructs are often misconstrued as operational determinants of behavior. And this is a tenacious mistake. Secondly, there is much talk of the need for newer ‘community-led’ and ‘bottom-up’ approaches to change, but if only the words are replaced, i.e., social norms change for culture change and facilitation for implementation, the end result will be more of the same. Community-led and bottom-up, as I understand it, also implies removing some of the propositional, cognitive layers inherent in our research methods to enable us to see how behavior is produced between people, and by people themselves. Hopefully, this way levers of change will be revealed that resonate with the people concerned. ACAs are shapes of behavior to be observed, empirically and methodically, and therefore fit into the objective of creating newer community-led and bottom-up approaches to change. In summary, taking into account the different objections to the mainstream approach of behavior change as it relates to girl circumcision, exploring an innovative cultural psycho-logical approach to understanding and effecting change is justified and necessary.

6.4 For fear of another ‘culture clash’

With respect to the issue of girl circumcision the need to develop newer community-led and bottom-up approaches to change does not only originate from the fact that change is

Chapter 6.

[ 159 ]

happening too slow, but also originates from the fear of another ‘culture clash’. As expanded upon in Chapter 1, cultures do not clash, of course. It is a metaphorical statement, that needs to be clarified immediately once uttered. In a position paper Amref Health Africa (2017b) deploys this metaphor to provide legitimacy for their alternative rites of passage in the following manner:

Through socio-anthropological studies, ways of combating the practice while avoiding a culture clash are being explored and encouraged. Along these lines, Amref is committed to working with communities to identify and support alternative rites of passage and to scale up this model where applicable.

This quotation is provided here, because it is one of the reasons why Amref Health Africa decided to support this cultural psychological research. It also exemplifies the context in which the allocation of resources to it was accounted for. Amref Health Africa wants to avoid a ‘culture clash’ and is looking for alternative ways to encourage people to abandon the practice of girl circumcision. This caution to avoid a ‘culture clash’ originated in the first half of the previous century before Amref Health Africa was even founded. British missionaries launched a campaign against the practice of girl circumcision among the largest ethnic group of Kenya, the Kikuyu. This campaign culminated in what came to be known as the female circumcision controversy, in the period between 1929 to 1932. Some Kikuyus resisted based on the argument that girl circumcision is an essential part of their culture and therefore cannot be abandoned. When missionaries made Kikuyu church members take a vow against this cultural practice, this heightened the conflict. Resisting the campaign against girl circumcision came to be seen as part of the broader resistance against British colonial rule (see also: Beck, 1966; Hetherington, 1998; Mufaka, 2003; Murray, 1974, 1976; Thomas, 2000, 2003). Allegedly, this even led to the murder of an American missionary, Hulda Stumpf, because of her firm stance against the practice of girl circumcision (The New York Times Archives, 1930). This is just one example of the backlash that can be caused by attempting to change a culturally embedded practice. Especially, if those that practice it perceive the change to be initiated by outsiders – those not belonging to their ethnic group or community – resistance is bound to happen. No wonder then, that politicians, religious leaders and health workers are careful to touch upon the proverbial viper’s nest issue of girl circumcision. Albeit with limited success, over the years governments and non-governmental health organizations have nonetheless put in considerable effort in discouraging people to perform this practice.

6.5 Alternative rites of passage

It was in the context of Amref Health Africa’s Alternative Rite of Passage that the research questions were jointly formulated. In this paragraph, the idea for alternative rites and its design and implementation will be further expanded upon. To assess if and how these

Chapter 6.

[ 160 ]

alternative rites are embedded within the communities in which Amref Health Africa is active a thorough understanding of the relevant agreements and conventions, and social arrangements in which girl circumcision is performed is sought after.

For Maasai and Samburu communities the practice of girl circumcision is generally under-stood to signify, amongst other things, a transition into womanhood and therefore to function as a rite of passage (e.g., Saitoti, 1980, Spencer, 1965). By undergoing this practice, a girl earns her right to marry – or more accurately, to be married off – and bear children. Additionally, because a girl is now eligible for marriage, her father is able to receive a bride price, usually in the form of highly valued cattle (see also: Kiage et al., 2014; Nguura, 2012). It also increases a mothers’ social status, for example by making her eligible to become a member of a women’s council (Thomas, 2003). Generally speaking, a girl is seen as ready for circumcision by the time she reaches puberty, although much wider age ranges are reported (Kiage et al., 2014). All these things considered, it is intuitively appealing and seems justified to try and lever change at the core of its assumed cultural meaning as a rite of passage. This approach intends to offer an alternative for girls within their existing social arrangement. An alternative ritual is organized in which girls do not get cut, and are encouraged to complete their education and to not let themselves be married off.

The first organization to implement alternative rites of passage in Kenya was the non-profit voluntary women’s organization Maendeleo Ya Wanawake Organization (MYWO) in 1996 (Chege, Askew & Liku, 2001; Muteshi & Sass, 2005). Since then many more governmental and non-governmental health organizations in Kenya, Amref Health Africa being one of them, are either involved in or are implementing alternative rites of passage. So much so even, that the Anti-FGM Board, which is part of the Kenyan Ministry of Public Service, Youth and Gender Affairs, has formulated official guidelines for conducting alternative rites of passage. The guiding principles are:

Principle 1: ARPs should be community-ledPrinciple 2: ARPs should be based on passion, trust, honesty and integrityPrinciple 3: ARPs should be culture-sensitivePrinciple 4: ARPs should be inclusivePrinciple 5: ‘Do No Harm’(Anti-FGM Board, 2018, pp. 3-4)

Chapter 6.

[ 161 ]

Furthermore, it is suggested that during the final graduation ceremony the following aspects need to be paid attention to:

• Identification of a ‘symbol’; during the ARP process, the steering committee should identify a ‘symbol’ that will be significant to/with ARP in their community.

• The girls taken through ARP should be in traditional attire.• A public declaration; the ceremony should entail a public declaration

against FGM by the custodians of culture and reformed female circum-cisers in the community and support for the promotion of education for girls undergoing ARP. The cultural elders should also bless the girls, empowering them to be accepted by their society without the cut.

• Blessings and awards; the declaration is followed by a traditional celebra-tion and graduation of girls who are then awarded with a gift, certificate or anything else that the specific community deems fit for the occasion.

(Anti-FGM Board, 2018, pp. 7-8)

Images 6.2-7 are made during a visit to an alternative rite of passage ceremony facilitated by Amref Health Africa in 2016 during the data collection phase of this research. These images illustrate some of the above aspects being accounted for. Image 6.1 is a printout of the program that prepares girls for the final graduation ceremony. This example is included to give the reader a general idea of what an alternative rite of passage entails. Despite recent efforts by the Anti-FGM Board to standardize the design of ARPs and coordinate its implementation across Kenya, in practice they can vary considerably, depending on the organization that facilitates them – religious or secular – or what cultural leaders deem important aspects in the design of the rite and the program as a whole (see also: Hughes, 2018).

Image 6.1 - Printout of three-day program of the alternative rite of passage

Chapter 6.

[ 162 ]

Image6.2-Eldersprepareareaforgivingblessingsduringfinalgraduation

Image6.3-Girlsintraditionalattiregathertoreceiveblessingfromtheelders

Chapter 6.

[ 163 ]

Image6.4-Girlskneeldownandwavetheirschoolnotebooks

Image6.5-Elderscircumambulatethegirlstogivethemtheirblessings

Chapter 6.

[ 164 ]

Image6.6-Eldersreceiveshukas(traditionalrobes)asagift

Image6.7-Womenobservethespectaclefromadistance

Chapter 6.

[ 165 ]

French anthropologist Arnold Van Gennep coined the term rites of passage in the eponymous book Les Rites de Passage in 1909. With this term he construed a special category of rites signifying a transition from one phase to another. Van Gennep further subdivided rites of passage into rites of separation (preliminal), rites of transition (liminal) and rites of incorporation (postliminal). As an example and contextualized to the topic under investigation, in the preliminal phase of the rite a Samburu girl is physically separated from her parents and siblings to whom she likely has developed a deep attach-ment. She is separated from the boyfriends she was previously encouraged to mingle – and even be intimate – with. This separation occurs quite abruptly. As I understood from two key informants, especially amongst the Samburu – more so than amongst the Maasai – it is common for a girl to be married off right after she gets cut, on the same day that is. She recovers from the procedure in the homestead of her new family-in-law. However, she is only fully incorporated into the arrangement of Samburu womanhood as she delivers a healthy child.

For all the rigidity and harshness, at least in this traditional arrangement it is always relatively clear, for both boys and girls, what is expected during transitioning and where it will eventually lead to. As these traditional communities are in transition themselves, other concepts are needed to account for the many uncertainties present day youngsters face when transitioning into adulthood. The concept of ‘waithood’, for instance, can be used for the liminal phase between childhood and adulthood as being a state of stagnancy and uncertainty for modern day youngsters (Honwana, 2012; Singerman, 2007). Modernity brings its own set of challenges. Youngsters – all over the world – must figure out how to shape their lives in the wake of many uncertainties; factors on which neither their caretakes nor they themselves seem to have much influence.

An older and more prescriptive concept by which to address this liminal phase is ‘commu-nitas’ (Turner, 1969). This rather complex concept is used to signify bottom-up change made possible by creating a realm where everybody is equal and authoritarian structures are set aside. This allows for a free flow of ideas, so it is argued. Youngsters are not left to wait, but can partake in “positive community action” (Bigger, 2010, p. 8). Anthropologist Victor Turner (1982) in his book From Ritual to Theatre: The Human Seriousness of Play emphasized the importance of play in this regard. It is in theatre, carnival, fests and dance that ingrained practices are made visible, are acted out and are reflected upon in a realm that is open to members of different classes and ages within the larger community. It is interesting to note that ARPs are, by and large, festive events wherein music, dance, theatre and fashion shows form a substantial part of the program, as well as that ARPs are events that are open to participation for community members of all strata. Also, the idea of ‘communitas’ reflects my own struggle in trying to get to terms with what I call a “sultry reality which has no discourse [or articulated, pre-given structure]”, and where “change comes about not by rationales, but by just doing what you are not supposed to be doing: dancing without thinking, acting out the forbidden and transgressing for the sake of transgressing” (Graamans, 2018, para. 2). Following Verheggen (2005), I use the notion

Chapter 6.

[ 166 ]

of ‘dancing’ to emphasize the physicality, or embodiment, involved in acting out new practices that challenge the existing order. Again, sifting through the theoretical store-house of modern psychology, it is the ACA-framework – agreements (A1), conventions (C) and social arrangements (A2) – that seems best suited to empirically investigate both the more articulated, experience-remote (A1), and less articulated, more experience-near ways (C and A2) by which people express group-membership. From the former, people derive at least some feeling of belonging to the community and a superficial sense of identity. From the latter people derive a very strong feeling of belonging and a deep sense of identity. This is expressed in practices within a physical, concrete environment and therefore not in need of argumentative structure or discourse per se.

So, the aim is to explore in more detail both how Amref Health Africa’s ARP-program addresses current issues youngsters are faced with and how these alternative rites fit into the traditional arrangement as rites of passage, if at all. Concerns about its cultural embed-dedness, underlying theoretical framework and lack of research assessing program implementation have been expressed by Amref Health Africa herself, and are mirrored in recent literature (Droy et al., 2018; Hughes, 2018; Mepukori, 2016; Prazak, 2016). It is with these objectives in mind that the research questions have been jointly formulated. To understand the specifics of the terminology used, for example related to conceptually distinguishing ACAs, I refer to Chapter 2.

6.6 Studypurposeandobjectives

The purpose of this study is to gain a better understanding of the different positions people can take up in relation to the practice of girl circumcision and to qualitatively assess how, if at all, alternative rites of passage can best be employed. In order to do so the following specific objectives have been formulated:

Researchobjective1:

To identify agreements, conventions and arrangements relevant to the practice of girl circumcision amongst Maasai and Samburu communities visited in this study.

Researchobjective2:

To develop an intelligible framework of girl circumcision that engages with the complex behavioral dynamics of change amongst Maasai and Samburu communities visited in this study.

Researchobjective3:

To gain insight into the changeability of the social patterning of behavior relevant to the practice of girl circumcision amongst Maasai and Samburu communities visited in this study.

Chapter 6.

[ 167 ]

6.7 Research questions

To better understand why some people remain committed to the group-typical practice of girl circumcision despite seemingly strong arguments against it and to be able to lever change in ways that resonate with the target community, an answer to the following questions is sought after:

Research question 1:

What behavioral patterns relevant to the practice of girl circumcision can be distinguished amongst the Maasai and Samburu communities visited in this study?

Sub-question1a:

What are the agreements made on the practice of girl circumcision amongst the Maasai and Samburu communities visited in this study?

Sub-question1b:

What are the conventions related to the practice of girl circumcision amongst the Maasai and Samburu communities visited in this study?

Sub-question1c:

What are the social arrangements in which the practice of girl circumcision is embedded amongst the Maasai and Samburu communities visited in this study?

Research question 2:

How do the sets of agreements, conventions and arrangements related to the practice of girl circumcision amongst the Maasai and Samburu communities visited in this study relate to one another?

Research question 3:

What are opportunities for change and areas of concern with regards to Amref Health Africa’s approach to help bringing an end to the practice of girl circumcision within the Maasai and Samburu communities visited in this study?

6.8 Meetingresearchobjectives

For a relatively small-scale qualitative study the research objectives were quite ambitiously formulated. Success was by no means guaranteed. It was difficult to know beforehand whether the research participants were going to be willing to share their perspective on and experiences with girl circumcision and related, confidential practices. In preparation for this research, we contacted community leaders to lay the foundation for my field work. Through their mediation I was able to stay at kraals, visit or stay with families, graze

Chapter 6.

[ 168 ]

livestock, attend rites of passage and other ceremonies, go on long walks, and participate in the the-day-to-day activities of their communities. They also arranged, at my insistence, that I could speak with some of the fiercest opponents of anti-FGM programs, on their own turf. We drank tea with goat milk and sometimes talked hours on end. The fact that I was genuinely grateful for their openness, especially on issues they were well aware I did not agree with, made them open up even more. Sometimes, they opened up to a level where they dared to express doubts about the conservative position, they defended so strongly moments earlier. This frequently happened when in the conversations feelings of loss related to loved ones were evoked; a father that expressed regret for expelling his daughter, because of her persistent refusal to get cut; recollecting a fatal case of a girl in the village that passed away as a result of complications after getting cut, and so forth. By carefully building rapport, some research participants were willing and able to share their stories and even touch upon sensitive topics such as adultery, sexual play, love, trauma and other, more hidden concerns. The openness of these participants and their feedback in the months thereafter made it possible to meet the research objectives and find answers to the research questions to great extent.

The paper in Chapter 7 is published in the international peer-reviewed journal Sexual and Reproductive Health Matters. It expounds in more detail why a specific cultural psycho-logical approach to researching different ways of encouraging people to abandon the practice of girl circumcision is warranted and highly needed. Chapter 8 is a paper published in 2019 in the international peer-reviewed journal Culture, Health & Sexuality. In this paper the agreements, conventions and arrangements relevant to the practice of girl circumcision amongst the Maasai and Samburu communities visited in this study are summarized (research objective 1). Also, a framework is presented that engages with the complex behavioral dynamics of change within and surrounding these communities (research objective 2). Chapter 9 is a paper published in 2019 in the African peer-reviewed The Pan African Medical Journal. In this paper some of the implications for anti-FGM programs, Amref Health Africa’s alternative rite of passage being the focal point, are discussed in more detail (research objective 3).

Chapter 6.

[ 169 ]

References

ReferencesAbu-Lughod, L. (1991). Writing against culture. In R. G. Fox (Ed), Recapturing

anthropology: Working in the present (pp. 137-162). Sante Fe, NM: School of American Research Press.

African Development and Health Research Centre (2016). Alternative rite of passage (ARP) scale-up project in Kenya and Tanzania: End term evaluation. Nairobi, KE: Amref Health Africa.

Ahmadu, F., & Shweder, R. (2009). Disputing the myth of sexual dysfunction of circumcised women: An interview with Fumbai S. Ahmadu. Anthropology Today, 25(6), 14-17.

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2),179-211.

Amref Health Africa (2017a). Our vision to end FGM/C by 2030. Nairobi, Kenya. Retrieved from https://view.publitas.com/amref-flying-doctors/ amref-our-vision-to-end-fgm-c-by-2030/

Amref Health Africa (2017b, May 4). Amref ’s position on female genital mutilation/cutting. Retrieved from https://amref.org/position-statements/amref-health-africas- position-statement-on-female-genital-mutilationcutting/

Armitage, C. J., & Conner, M. (2001). Efficacy of the Theory of Planned Behavior: A meta-analytic review. British Journal of Social Psychology, 40, 471-499.

Askew, I, (2005). Methodological issues in measuring the impact of interventions against female genital cutting. Culture, Health & Sexuality, 7(5), 463-477.

Assaad, F. (1982). The sexual mutilation of women. World Health Forum, 3(4), 391-394.Anti-FGM Board (2018, July). Guideline for conducting an Alternative Rite of Passage.

Retrieved from http://antifgmboard.go.ke/wp-content/uploads/2018/12/Alternative-Rite-of-Passage2-1-Copy.pdf

Baerveldt, C. (1998). Culture and the consensual coordination of actions [Doctoral dissertation]. Nijmegen, NL: University of Nijmegen.

Barstow, D. G. (1999). Female genital mutilation: The penultimate gender abuse. Child Abuse & Neglect, 23(5), 501-510.

Beck, A (1966). Some observations on Jomo Kenyatta in Britain, 1929–1930. Cahiers d’Études Africaines, 6(22), 308-329.

Berer, M. (2015). The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain? Reproductive Health Matters, 23(46), 145-157.

Berg, R. C., & Denison, E. (2013). A tradition in transition: factors perpetuating and hindering the continuance of female genital mutilation/cutting (FGM/C) summarized in a systematic review. Health Care for Women International, 34(10), 837-859.

[ 170 ]

Berg, R. C., Denison, E. M. L., & Fretheim, A. (2010). Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/C): A systematic review of quantitative studies (Report No. 13-2010). Retrieved from Norwegian Knowledge Centre for the Health Services Oslo: https://brage.bibsys.no/xmlui/bitstream/handle/ 11250/2378046/NOKCrapport13_2010.pdf?sequence=1

Bicchieri, C. (2005). The grammar of society: Nature and dynamics of social norms. Cambridge, UK: Cambridge University Press, Cambridge.

Bicchieri, C. (2014). Social epistemology: Some personal reflections. In V. F. Hendricks & R. K. Rendsvig (Eds.), Socio-epistemic phenomena: 5 questions. Copenhagen, DK: Automatic Press / VIP. Retrieved from https://www.academia.edu/5838524/Social_ Epistemology_Some_Personal_Reflections

Bicchieri, C. (2017). Norms in the wild: How to diagnose, measure and change social norms. New York, NY: Oxford University Press.

Boyden, J. (2012). Why are current efforts to eliminate female circumcision in Ethiopia misplaced? Culture, Health & Sexuality, 14(10), 1111-1123.

Braun, V. (2010). Female genital cosmetic surgery: A critical review of current knowledge and contemporary debates. Journal of Women’s Health, 19(7), 1393-1407.

Chege, J. N., Askew, I., & Liku, J. (2001). An assessment of the Alternative Rites Approach for encouraging abandonment of female genital mutilation in Kenya. Washington, DC: FRONTIERS in Reproductive Health and Population Council.

Cislaghi, B., & Heise, L. (2018). Theory and practice of social norms interventions: Eight common pitfalls. Globalization and Health, 14(83), 1-10.

Cislaghi, B., & Heise, L. (2019). Using social norms theory for health promotion in low-income countries. Health Promotion International, 34(3), 616–623.

Droy, L., Hughes, L., Lamont, M., Nguura, P., Parsitau, D., & Wamue Ngare, G. (2018). Alternative Rites of Passage in FGM/C abandonment campaigns in Africa: A research opportunity. LIAS Working Paper Series, 1, 1-21.

Easton, P., Monkman, K., & Miles, R. (2003). Social policy from the bottom up: Abandoning FGC in Sub-Saharan Africa. Development in Practice, 13(5), 445-458.

Efferson, C., Vogt, S., Elhadi, A., Ahmed, H. E. F., & Fehr, E. (2015). Female genital cutting is not a social coordination norm. Science, 349(6255), 1446-1447.

Female genital mutilation: An agonising choice (2016, June 18). The Economist. Retrieved from https://www.economist.com/leaders/2016/06/18/an-agonising-choice?frsc=dg%7Ca

Fishbein, M. (1967). Readings in attitude theory and measurement. New York NY: John Wiley.

Fishbein, M. & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research. Reading, MA: Addison Wesley.

Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. New York, NY: Psychology Press.

Gitahi, G. (2016, June 23). On female genital mutlation. Letters to the editor. The Economist. Retrieved from http://www.economist.com/news/ letters/21701734-letters-editor#

References

[ 171 ]

Goodman, M. P. (2016). Female genital plastic and cosmetic surgery. Hoboken, NJ: John Wiley & Sons.

Graamans, E., Millenaar, L., & ten Have, W. D. (2014). Dynamieken binnen het topmanagementteam van een grote zorgorganisatie: Een cultuurpsychologisch perspectief. Tijdschrift voor Management & Organisatie, 68(3), 22-42.

Graamans, E., Otto, M., Smit, S., & ten Have, W. D. (2017). Cultuurverandering is verandering van afstemming. Opleiding & Ontwikkeling, 1, 28-34.

Graamans, E., ten Have, S., & ten Have, W. D. (2016a). Een alternatief voor opportunistisch gebruik van het begrip ‘cultuur’ in organisaties. Holland / Belgium Management Review, 165, 32-39.

Graamans, E., ten Have, W. D., & ten Have, S. (2016b, March 10). Cultuur van organisatie doet niets, mens doet ertoe: Corporate Governance Code beter baseren op wat mensen individueel en in groepsverband werkelijk drijft. Het Financieele Dagblad, pp. 11.

Graamans, E. (2018, May 1). ‘Discourse’ or dancing: Talking or doing tolerance in Amsterdam [Blogpost]. Retrieved from https://www.linkedin.com/pulse/dancing-discourse-tolerance-amsterdam-ernst-graamans/

Greenwood, J. D. (1994). Realism, identity and emotion: Reclaiming social psychology. London, UK: Thousand Oaks.

Gruenbaum, E. (2001). The female circumcision controversy: An anthropological perspective. Philadelphia, PA, US: University of Pennsylvania Press.

Hassanali, J., Amwayi, P., & Muriithi, A. (1995). Removal of deciduous canine tooth buds in Kenyan rural Maasai. East African Medical Journal, 72(4), 207-209.

Hayford, S. R. (2005). Conformity and change: Community effects on female genital cutting in Kenya. Journal of Health and Social Behavior, 46(2), 121-140.

Hetherington, P. (1998). The politics of female circumcision in the central province of colonial Kenya, 1920–30. The Journal of Imperial and Commonwealth History 26(1), 93-126.

Honwana, A. (2012). The time of youth: Work, social change, and politics in Africa. Sterling, VA: Kumarian Press.

Hughes, L. (2018). Alternative Rites of Passage: Faith, rights, and performance in FGM/C abandonment campaigns in Kenya. African Studies, 77(2), 274–292.

Johnsdotter, S. (2019). Meaning well while doing harm: Compulsory genital examinations in Swedish African girls. Sexual and Reproductive Health Matters, 27(2). Advance online publication.

Kiage, P., Onyango, E., Odhiambo, D., Okelo, M., & Sifuna, S. (2014). Alternative rite of passage (ARP) scale-up project in Kenya and Tanzania: ARP baseline survey. Nairobi, KE: Amref Health Africa.

Knight, M. (2001). Curing cut or ritual mutilation? Some remarks on the practice of female and male circumcision in Graeco-Roman Egypt. Isis 92(2), 317-338

Little, C. M. (2003). Female genital circumcision: Medical and cultural considerations. Journal of Cultural Diversity, 10(1), 30–34.

References

[ 172 ]

Mackie, G. (1996). Ending footbinding and infibulation: A convention account. American Sociological Review, 61(6), 999-1017.

Mackie, G., & LeJeune, J. (2009). Social dynamics of abandonment of harmful practices:. A new look at the theory. Special series on social norms and harmful practices. Innocenti Working Paper No. 2009-06. Florence: UNICEF Innocenti Research Centre. Retrieved from UNICEF Innocenti Research Centre website: https://www.unicef-irc.org/publications/pdf/iwp_2009_06.pdf

Mepukori, D. N. (2016). Is Alternative Rites of Passage the key to abandonment of female genital cutting? A case study of the Samburu of Kenya [Unpublished BA thesis]. Durham, NC: Duke University. Retrieved from https://dukespace.lib.duke.edu/dspace/bitstream/ handle/10161/11858/Mepukori%20Honors%20Thesis.pdf?sequence=1

Mufaka, K. (2003). Scottish Missionaries and the Circumcision Controversy in Kenya, 1900–1960. International Review of Scottish Studies, 28, 47–58.

Muteshi, J., & Sass, J. (2005). Female genital mutilation in Africa. An analysis of current abandonment approaches. Nairobi, KE: Programme for Alternative Technology in Health.

McDougall, L. J. (2013). Towards a clean slit: how medicine and notions of normality are shaping female genital aesthetics. Culture, Health & Sexuality, 15(7), 774-787.

Murray, J. (1974). The Kikuyu female circumcision controversy : with special reference to the Church Missionary Society’s “sphere of influence” [Doctoral dissertation]. Los Angeles, CA: University of California.

Murray, J. (1976). The Church Missionary Society and the “Female Circumcision” issue in Kenya 1929-1932. Journal of Religion in Africa, 8(2), 92-104.

Mutai, J., Muniu, E., Sawe, J., Hassanali, J., Kibet, P., & Wanzala, P. (2010). Socio-cultural practices of deciduous canine tooth bud removal among Maasai children. International Dental Journal, 60(2), 64-98.

Nguura, P. N. (2012). Pregnancy and childbirth among the Maasai: A gendered cultural space. In A. van der Kwaak, G. Baltissen, D. Plummer, K. Ferris, & J. Nduba (Eds.), Understanding nomadic realities: Case studies on sexual and reproductive health and rights in Eastern Africa (pp. 29-35). Amsterdam, NL: KIT Publishers.

Obermeyer, C. (1999). Female genital surgeries: The known, the unknown, and the unknowable. Medical Anthropology Quarterly, 13(1), 79–106.

Obermeyer, C. M. (2005). The consequences of female circumcision for health and sexuality: An update on the evidence. Culture, Health & Sexuality, 7(5), 443-461.

Potter, J., & Wetherell, M. (1987). Discourse and social psychology: Beyond attitudes and behaviour. Thousand Oaks, CA: Sage.

Prazak, M. (2016). Making the mark: Gender, identity and genital cutting. Athens, OH: Ohio University Press.

Reisel, D., & Creighton, S. M. (2015). Long term health consequences of Female Genital Mutilation (FGM). Maturitas, 80(1), 48-51. 

References

[ 173 ]

Ross, C. T., Strimling, P., Ericksen, K. P., Lindenfors, P., & Mulder, M. B. (2016). The origins and maintenance of female genital modification across Africa: Bayesian phylogenetic modeling of cultural evolution under the influence of selection. Human Nature, 27(2), 173-200.

Saitoti, T. O. (1980). Maasai. New York, NY: Abrams Books.Sheeran, P., Maki, A., Montanaro, E., Avishai-Yitshak, A., Bryan, A., Klein, W. M. P.,

Miles, E., & Rothman, A. J. (2016). The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: A meta-analysis. Health Psychology, 35(11), 1178-1188.

Shell-Duncan, B., & Hernlund, Y. (2006). Are there ‘stages of change’ in the practice of female genital cutting? Qualitative research findings from Senegal and The Gambia. African Journal of Reproductive Health, 10(2), 56-71.

Singerman, D. (2007). The economic imperatives of marriage: Emerging practices and identities among youth in the Middle East (Working Paper No. 6). Dubai, UAE: The Middle East Youth Initiative, Wolfensohn Center for Development. Retrieved from https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1087433

Skaine, R. (2005). Female genital mutilation: Legal, cultural and medical issues. Jefferson, NC: McFarland.

Slack, A. T. (1988). Female circumcision: A critical appraisal. Human Rights Quarterly, 10(4), 437-486.

Sniehotta, F. F., Presseau, J., & Araújo-Soares, V. (2014). Time to retire the theory of planned behaviour. Health Psychology Review, 8(1), 1-7.

Spencer, P. (1965). The Samburu: A study of gerontocracy in a nomadic tribe. London, UK: Routledge & Kegan Paul Limited.

Steinmetz, H., Knappstein, M., Ajzen, I., Schmidt, P., & Kabst, R. (2016). How effective are behavior change interventions based on the theory of planned behavior? A three-level meta-analysis. Zeitschrift für Psychologie, 224(3), 216-233.

Thomas, L. (2000). “Ngaitana (I will circumcise myself)”: Lessons from colonial campaigns to ban excision in Meru, Kenya. In B. Shell-Duncan & Y. Hernlund (Eds.), Female ‘Circumcision’ in Africa: Culture, controversy and change (pp. 129-150). London, UK: Lynne Rienner Publishers.

Thomas, L. (2003). Politics of the womb: Women, reproduction and the state in Kenya. Berkeley, CA: University of California Press.

Tomasello, M. (2009). Why we cooperate. Cambridge, MA: MIT Press.Turner, V. W. (1969). The ritual process: Structure and anti-structure. London, UK:

Routledge & Kegan PaulTurner, V. W. (1982). From ritual to theatre: The human seriousness of play. New York,

NY: PAJ Publications.United Nations Children’s Fund (2005). Changing a harmful social convention: Female

genital mutilation/cutting. Florence, IT: UNICEF Innocenti Research Centre.United Nations Children’s Fund (2010). The dynamics of social change: Towards the

abandonment of female genital mutilation/cutting in five African countries. Florence, IT: UNICEF Innocenti Research Centre.

References

[ 174 ]

United Nations Children’s Fund (2013). Female genital mutilation/cutting: A statistical overview and exploration of the dynamics of change. New York, NY: UNICEF. Retrieved from https://www.unicef.org/publications/index_69875.html

United Nations Children’s Fund (2016). Female genital mutilation/cutting: A global concern. New York, NY: UNICEF. Retrieved from https://www.unicef.org/media/files/FGMC_ 2016_brochure_final_ UNICEF_SPREAD.pdf

United Nations Children’s Fund (2018). The Sustainable Development Goals Report 2018. New York, NY: UNICEF. Retrieved from https://unstats.un.org/sdgs/files/report/2018/ TheSustainableDevelopmentGoalsReport2018-EN.pdf

United Nations Populations Fund (2018). Female genital mutilation (FGM) frequently asked questions. Retrieved from https://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions

Van Gennep, A. (1960). The rites of passage (M. B. Vizedom and G. L. Caffee, Trans.) London, UK: Routledge & Kegan Paul. (Original work published 1909)

Van Rossem, R., Meekers, D., & Gage, A. J. (2016). Trends in attitudes towards female genital mutilation among ever-married Egyptian women, evidence from the Demographic and Health Surveys, 1995-2014: Paths of change. International Journal for Equity in Health, 15(1), 1-14.

Verheggen, T. (2005). Culture alt delete: On the misperception of culture in psychology [Doctoral dissertation]. Heerlen, NL: Open Universiteit Nederland.

Voestermans, P., & Verheggen, T. (2013). Culture as embodiment: The social tuning of behavior. Malden, MA: John Wiley & Sons.

Westerhof, G. (2003). Statements and stories: Towards a new methodology of attitude research. West Lafayette, IN: Purdue University Press.

Woman missionary murdered in Africa (1930, January 6). The New York Times Archives. Retrieved from https://www.nytimes.com/1930/01/06/archives/woman-missionary-murdered-in-africa-miss-hulda-stumpf-american-is.html

World Health Organization (2008). Eliminating female genital mutilation: An interagency statement. Geneva, CH: Department of Reproductive Health and Research World Health Organization.

World Health Organization (2018). Female genital mutilation: Fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/

References