Decline of Supportive Attitudes among Husbands toward Female Genital Mutilation and Its Association to Those Practices in Yemen

Objectives

To elucidate the attitudes of women and their husband’s towards female genital mutilation (FGM) and their associations with the continuation of FGM upon their daughters.

Methods

Subjects were 10,345 (in 1997) and 11,252 (in 2003) ever married women aged 15 to 49 years from the Yemen Demographic Health Surveys. Performances of FGM on the most-recently-born daughters were investigated. Attitudes of women and their husbands were assessed by their opinions on the continuation of FGM. The association between the attitudes of women and their husbands and performance of FGM on the most-recently-born daughters were investigated after adjusting for age and education of the women.

Findings

The percentage among the most-recently-born daughters who received FGM of women who had undergone FGM declined from 61.9% in 1997 to 56.5% in 2003 (p<0.001). The percentages of women who had undergone FGM and who supported the continuation of FGM and of husbands who also supported its continuation decreased from 78.2% and 60.1% in 1997 to 70.9% and 49.5% in 2003, respectively (both p<0.001). When the women or the husbands did not agree with FGM, it was less likely to be performed on their daughter than when the women or the husbands agreed in 1997 (odds ratio=0.11, 95% confidence interval 0.07-0.16 and odds ratio=0.07, 95% confidence interval 0.04-0.12, respectively) and in 2003 (odds ratio=0.12, 95% confidence interval 0.09-0.16 and odds ratio=0.11, 95% confidence interval 0.07-0.16, respectively).

Conclusion

Non-supportive attitudes of women and their husbands towards the continuation of FGM have become common and were associated with their decision not to perform FGM upon their daughters.     

Daughters at Risk of Female Genital Mutilation: Examining the Determinants of Mothers’ Intentions to Allow Their Daughters to Undergo Female Genital Mutilation

Female genital mutilation (FGM) is still a common practice in many countries in Africa and the Middle East. Understanding the determinants of FGM can lead to more active interventions to prevent this harmful practice. The goal of this study is to explore factors associated with FGM behavior among Iranian mothers and their daughters. Based on Ajzen’s theory of planned behavior, we examined the predictive value of attitudes, subjective norms, perceived behavioral control and several socio-demographic variables in relation to mothers’ intentions to mutilate their daughters. A paper-and-pencil survey was conducted among 300 mothers (mean age = 33.20, SD = 9.09) who had at least one daughter and who lived in Ravansar, a county in Kermanshah Province in Iran. Structural equation modeling was used to investigate the relationships among the study variables. Our results indicate that attitude is the strongest predictor of mothers’ intentions to allow their daughters to undergo FGM, followed by subjective norms. Compared to younger mothers, older mothers have more positive attitudes toward FGM, perceive themselves as having more control over their behavior and demonstrate a greater intention to allow their daughter to undergo FGM. Furthermore, we found that less educated mothers and mothers living in rural areas had more positive attitudes toward FGM and feel more social pressure to allow FGM. The model accounts for 93 percent of the variance in the mothers’ intentions to allow their daughters to undergo FGM. Intervention programs that want to decrease FGM might focus primarily on converting mothers’ neutral or positive feelings toward FGM into negative attitudes and on alleviating the perceived social pressure to mutilate one’s daughter. Based on our findings, we provide recommendations about how to curtail mothers’ intentions to allow their daughters to undergo FGM.     

Sex Differences in Mathematics and Reading Achievement Are Inversely Related: Within- and Across-Nation Assessment of 10 Years of PISA Data

We analyzed one decade of data collected by the Programme for International Student Assessment (PISA), including the mathematics and reading performance of nearly 1.5 million 15 year olds in 75 countries. Across nations, boys scored higher than girls in mathematics, but lower than girls in reading. The sex difference in reading was three times as large as in mathematics. There was considerable variation in the extent of the sex differences between nations. There are countries without a sex difference in mathematics performance, and in some countries girls scored higher than boys. Boys scored lower in reading in all nations in all four PISA assessments (2000, 2003, 2006, 2009). Contrary to several previous studies, we found no evidence that the sex differences were related to nations’ gender equality indicators. Further, paradoxically, sex differences in mathematics were consistently and strongly inversely correlated with sex differences in reading: Countries with a smaller sex difference in mathematics had a larger sex difference in reading and vice versa. We demonstrate that this was not merely a between-nation, but also a within-nation effect. This effect is related to relative changes in these sex differences across the performance continuum: We did not find a sex difference in mathematics among the lowest performing students, but this is where the sex difference in reading was largest. In contrast, the sex difference in mathematics was largest among the higher performing students, and this is where the sex difference in reading was smallest. The implication is that if policy makers decide that changes in these sex differences are desired, different approaches will be needed to achieve this for reading and mathematics. Interventions that focus on high-achieving girls in mathematics and on low achieving boys in reading are likely to yield the strongest educational benefits.     

Bevölkerungswachstum: Bildung ist die Lösung

Population growth – education is the answer Over the last decades world population has been constantly growing by some 80 million per year. Whereas the growth rate as well as the fertility rate have been cut by half since the 1970th, population growth will continue well over mid‐century. As the developed countries have completed the demographic transition from high mortality and fertility rates to low ones, population growth is fading out there or has already been reversed into decline. In the least developed countries mortality has fallen as well, whereas fertility decline has stalled. Therefor population growth is very high making the solution of the widespread problems in this part of the world more and more difficult. One obvious way out of this trap would be a better education that could open new development perspectives. A positive side effect is that educated women have much less offspring than their counterparts who never went to school.     

A Description of Female Genital Mutilation and Force-Feeding Practices in Mauritania: Implications for the Protection of Child Rights and Health

Objectives

To establish the prevalence of female genital mutilation (FGM) and force feeding (gavage) practices among children in Mauritania; to investigate factors related to FGM and gavage practices and attitude in Mauritania; and to explore implications related to the protection of children’s rights and welfare.

Methods

Data from the Mauritania 2000–2001 DHS were used in this analysis. Data were collected from men and women about their attitude toward the continuation of FGM and gavage; women only were asked if they ever experienced one of these practices. Chi-square statistics were used to investigate differences in attitude and practice of FGM and gavage by demographic characteristics. Binary logistic regression was used to identify socio-demographic factors related to FGM and gavage outcomes.

Findings

The overall prevalence of FGM was 77% but varied depending on ethnicity. The majority of both female and male respondents favored the continuation of the practice (64% and 70%, respectively). Almost a quarter (23%) of women reported being force fed as a child and 32% of women and 29% of men approved the continuation of the practice. Gavage is almost exclusively practiced among Arabs.

Conclusion

The practice of both FGM and gavage is ongoing, although the prevalence and attitude towards both appears to vary as a function of ethnicity, wealth, education, marital status, and age. Contextually relevant intervention and enforcement strategies are needed to challenge these cultural norms and protect the rights and welfare of children in Mauritania.     

The first case of lymphogranuloma venereum in a woman in East-Central Europe and its multiple co-infections

We are reporting the first case of lymphogranuloma venereum in women in East-Central Europe. A 22-year-old heterosexual woman attended our department of venereology. She complained about a burning sensation in the urethra and vaginal discharge. Many tests were performed, and lymphogranuloma venereum, syphilis, gonorrhea, chlamydial urethritis and cervicitis, genital herpes, genital warts, and hepatitis C were diagnosed. Lymphogranuloma venereum was originally endemic in tropical and subtropical areas, but since 2003, outbreaks of this infection have been reported in North America, Europe, and Australia in men who have sex with men (MSM) community. To date, all cases of lymphogranuloma venereum in the Czech Republic appeared in men, predominantly in HIV-positive MSM. There are not many evidences about lymphogranuloma venereum (LGV) in women in developed countries. This report underlines the need for awareness of lymphogranuloma venereum in women among gynecologists, venereologists, and other physicians not only in Western Europe, but across all European countries.     

Female genital mutilation and cosmetic surgery: regulating non-therapeutic body modification

In the UK, female genital mutilation is unlawful, not only when performed on minors, but also when performed on adult women. The aim of our paper is to examine several arguments which have been advanced in support of this ban and to assess whether they are sufficient to justify banning female genital mutilation for competent, consenting women. We proceed by comparing female genital mutilation, which is banned, with cosmetic surgery, towards which the law has taken a very permissive stance. We then examine the main arguments for the prohibition of the former, assessing in each case both (a) whether the argument succeeds in justifying the ban and, if so, (b) whether a parallel argument would not also support a ban on the latter. We focus on the following arguments. Female genital mutilation should be unlawful because: (1) no woman could validly consent to it; (2) it is an oppressive and sexist practice; (3) it involves the intentional infliction of injury; (4) it causes offence. Our view is that arguments (3) and (4) are unsound and that, although arguments (1) and (2) may be sound, they support not only a ban on female genital mutilation, but also one on (some types of) cosmetic surgery. Hence, we conclude that the present legal situation in the UK is ethically unsustainable in one of the following ways. Either the ban on female genital mutilation is unjustified because arguments (1) and (2) are not in fact successful; or the law's permissive attitude towards cosmetic surgery is unjustified because arguments (1) and (2) are in fact successful and apply equally to female genital mutilation and (certain forms of) cosmetic surgery. The people of the countries where female genital mutilation is practised resent references to 'barbaric practices imposed on women by male-dominated primitive societies', especially when they look at the Western world and see women undergoing their own feminization rites intended to increase sexual desirability: medically dangerous forms of cosmetic plastic surgery, for instance....     

Female circumcision in multicultural Singapore: The hidden cut

In recent years discussion about female genital mutilation (FGM) has expanded and the UN has recently called for a universal ban of the practice. The practice in Southeast Asia is widespread among Malay Muslims and, although different styles and practices exist, procedures conducted in medical clinics are extremely minor and, according to gynaecological research, have no effect on sexuality due to the clitoris being left totally untouched. One of the states in which Malay Muslims maintain such a tradition is Singapore. Nonetheless, Singapore is rarely mentioned in academic studies or even in reports discussing the ritual. Even inside Singapore, only Malays tend to know of the tradition, while other ethnic groups remain oblivious to the fact that Singapore is among the states that allow such an operation. The present article does not discuss FGM per se and avoids contributing to the diatribe about labels and values, although these are, of course, extremely relevant. Instead it focuses on the reasons for the practice remaining hidden and undiscussed in Singapore, so much so that some respondents did not know that they had been circumcised.     

Rubella screening and immunisation of schoolgirls: results six to seven years after vaccination.

A long term follow-up study was carried out of girls given RA27/3 or Cendehill rubella vaccine in their 13th-14th year compared with a group of girls who had been found to be naturally immune at the age. A high proportion of the girls in all groups had persistent rubella antibody six to seven years after inclusion in the study, although some of these would have been considered to be susceptible to rubella by methods currently in use for screening for rubella antibody. Great care should be taken in interpreting the efficiency of the schoolgirl immunisation policy in the United Kingdom; women in their childbearing years who may have received vaccine but are found by a screening test to be seronegative should be retested by a more sensitive procedure before a final report is made.     

<Emphasis Type="Bold">On Female Genital Cutting: Factors to be Considered When Confronted With a Request to Re-infibulate</Emphasis>

According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient’s physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.     

S. haematobium as a Common Cause of Genital Morbidity in Girls: A Cross-sectional Study of Children in South Africa

Background

Schistosoma (S.) haematobium infection is a common cause of genital morbidity in adult women. Ova in the genital mucosal lining may cause lesions, bleeding, pain, discharge, and the damaged surfaces may pose a risk for HIV. In a heterogeneous schistosomiasis endemic area in South Africa, we sought to investigate if young girls had genital symptoms and if this was associated with urinary S. haematobium.

Methodology

In a cross-sectional study of 18 randomly chosen primary schools, we included 1057 schoolgirls between the age of 10 and 12 years. We interviewed assenting girls, whose parents had consented to their participation and examined three urines from each of them for schistosome ova.

Principal findings

One third of the girls reported to have a history of genital symptoms. Prior schistosomal infection was reported by 22% (226/1020), this was associated with current genital symptoms (p<0.001). In regression analysis the genital symptoms were significantly associated both with urinary schistosomiasis (p<0.001) and water contact (p<0.001).

Conclusions

Even before sexually active age, a relatively large proportion of the participating girls had similar genital symptoms to those reported for adult genital schistosomiasis previously. Anti-schistosomal treatment should be considered at a young age in order to prevent chronic genital damage and secondary infections such as HIV, sexually transmitted diseases and other super-infections.     

Breast cancer and the environment

The most recent estimate of the overall worldwide burden of cancer is that in the year 2000 more than 10 million new cancer cases occurred and approximately 6 million cancer deaths. Breast cancer accounts for about 1 in 10 cancers and is the most frequent cancer affecting women. Since 10% of all cancers in the world are breast cancer (only affecting half of the population as breast cancer almost exclusively concerns only women), it is being considered an epidemic. In terms of the absolute number of incident cases, breast cancer now ranks first not only in the industrialized world but also in the developing world. The worldwide mortality figure for the year 2000 was 370,000. However, there are marked geographical differences, with Africa and Asia currently having incidence rates some 10 times lower than those of North America and northern Europe. Studies of migrant populations have long indicated that the genetic background only plays a tiny, if any, role in these differences. Over time, clear increases have been seen in the global number of cases: from 572,000 in 1980 to 1,050,000 in 2000. This corresponds not only to a modest increase in incidence rates in countries with a long history of frequent breast cancer but also to marked increases in countries with previously low rates. The reasons for these increases are currently unexplained and a possible hypothesis relates to environmental factors. By contrast, in a number of countries in the western world mortality rates are stable, and, in the USA and the United Kingdom, even decreasing slightly. The aetiology of breast cancer has been the subject of hundreds of studies since the pioneering investigation of Lane Claypon in 1926. Risk factors belong to different domains: reproductive life, hormonal factors, diet, genetics (BRCA1, BRCA2) and exposure to radiation and selected chemicals. Yet, much breast cancer remains unexplained and new aetiological links must be sought such as occupational factors and exposure to pesticides and other endocrine disrupters. A recent international summit on breast cancer and the environment outlined the need for more research to be conducted into the effects of exposure in the vicinity of nuclear power plants or chemical landfill sites and, more generally, into contaminants in food, air, water and soil. This is particularly relevant in some parts of the world such as Africa.     

Patterns of sexual behaviour and reported symptoms of STI/RTIs among young people in Croatia--implications for interventions' planning

This paper describes some of the results of the first national-level survey on sexual behaviour and the distribution of risks to sexually transmitted infections (STIs), including human immunodeficiency virus infection (HIV), among youth in Croatia, and the nature and the extent of their vulnerability to these adverse health outcomes. The study was a cross-sectional, probability-based household survey conducted in 2005, and included 1093 respondents aged 18-24. This paper aims to describe the findings related to the knowledge of HIV transmission, key behavioural outcomes relevant for potential transmission of HIV and STIs, and correlates of genital discharge in young men and young women. More than 80% of young people know that the correct use of condoms protects against HIV and that HIV can be transmitted by someone who looks healthy. Fifty-nine percent of young men and 52.4% of young women reported using condoms during the first sexual intercourse, and 59.3% of men and 46.1% of women used condoms during the last sexual intercourse with a casual partner. This points to the gap between knowledge of condom use and the actual use of condoms as a high proportion of risky sexual contact remain unprotected. Having sexual intercourse frequently or regularly while consuming alcohol was reported by 19.2% of men and 7.6% of women. Much lower proportion are using drugs frequently or regularly during sexual intercourse (3.7% of men and 2.1% of women). Among those sexually experienced, 11.8% of men and 44.1% of women reported ever having a genital discharge. Higher presence of genital discharge in women is suggestive of reproductive tract infections that are not necessarily sexually transmitted. In the multivariate analysis, the lack of knowledge of whether chlamydial infections is an STI and having more than five partners in life were correlates of genital discharge in men, while in women the correlates included having more than five partners in life and not using condoms during the first sexual intercourse. Higher burden of STI-related symptoms was found among men who have men as sexual partners, those who paid for sex, and those with concurrent partnerships. These findings point out to the immediate need to strengthen sexual health education among young people and to the necessity for further development of other broad-based interventions to prevent adverse sexual health outcomes among both men and women, as well as those targeted towards more vulnerable subgroups.     

Cost of Preventing,Managing, and Treating Human Papillomavirus (HPV)-Related Diseases in Sweden before the Introduction of Quadrivalent HPV Vaccination

Objective

Costs associated with HPV-related diseases such as cervical dysplasia, cervical cancer, and genital warts have not been evaluated in Sweden. These costs must be estimated in order to determine the potential savings if these diseases were eradicated and to assess the combined cost-effectiveness of HPV vaccination and cervical cancer screening. The present study aimed to estimate prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts from a societal perspective in Sweden in 2009, 1 year before the quadrivalent HPV vaccination program was implemented.

Methods and Materials

Data from the Swedish cervical cancer screening program was used to calculate the costs associated with prevention (cytological cervical cancer screening), management (colposcopy and biopsy following inadequate/abnormal cytological results), and treatment of CIN. Swedish official statistics were used to estimate treatment costs associated with cervical cancer. Published epidemiological data were used to estimate the number of incident, recurrent, and persistent cases of genital warts; a clinical expert panel assessed management and treatment procedures. Estimated visits, procedures, and use of medications were used to calculate the annual cost associated with genital warts.

Results

From a societal perspective, total estimated costs associated with cervical cancer and genital warts in 2009 were €106.6 million, of which €81.4 million (76%) were direct medical costs. Costs associated with prevention, management, and treatment of CIN were €74 million; screening and management costs for women with normal and inadequate cytology alone accounted for 76% of this sum. The treatment costs associated with incident and prevalent cervical cancer and palliative care were €23 million. Estimated costs for incident, recurrent and persistent cases of genital warts were €9.8 million.

Conclusion

Prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts are substantial. Defining these costs is important for future cost-effectiveness analyses of the quadrivalent HPV vaccination program in Sweden.     

Correcting contraceptive failure rates for sample composition and sample selection bias

Abstract

There is reason to believe that in the short run marriages are becoming more stable in some Western African countries such as Cameroon. One of the crucial questions facing these countries is whether fertility rates can be expected to increase or decrease due in part to the increased stability of marriages. Analyzing 1978 Cameroon World Fertility Survey data and using a multivariate regression model which compares the fertility rate of women who have had at least one marital disruption with that of continuously married women, we studied the relationship between marital instability and fertility. The results show that fertility rates for women married more than once are significantly lower than those for continuously married women even before the end of their first marriage. Furthermore, marital disruption significantly reduces fertility rates after the dissolution of the first marriage. Finally, even after the length of reproductive time lost is controlled, there is an inverse relationship between the number of marriages and fertility. The results are discussed in the context of economic development, modernization, and urbanization.     

Mother-to-child transmission of HIV in Botswana: an ethical perspective on mandatory testing

Mother-to-child transmission (MTCT) of HIV represents a particularly dramatic aspect of the HIV epidemic with an estimated 600,000 newborns infected yearly, 90% of them living in sub-Saharan Africa. Since the beginning of the HIV epidemic, an estimated 5.1 million children worldwide have been infected with HIV. MTCT is responsible for 90% of these infections. Two-thirds of the MTCT are believed to occur during pregnancy and delivery, and about one-third through breastfeeding. As the number of women of child bearing age infected with HIV rises, so does the number of infected children. It is apparent that voluntary testing in Botswana has made some valuable inroads in decreasing perinatal HIV transmission, but the statistics showing the increased rate of HIV infection among women 15-24 years of age are not very promising. After reviewing all the pertinent scientific data it is clear that mandatory HIV testing of all pregnant women in conjunction with the implementation of a full package of interventions would save thousands of lives -- mothers, newborns and others who could be infected as a result of these women not being aware of their HIV status. If the protection and preservation of human life is a priority in Botswana, then it is time to allow for mandatory HIV testing of all pregnant women, before it is too late for those who are the most vulnerable. To do less would be medically inappropriate and ethically irresponsible.     

Postponing or rejecting parenthood? Results of a survey among female academic professionals

The current surge in childlessness is often seen as an alternative lifestyle amidst growing pluralism and individualism. The results of this study indicate that several subgroups of childless women need to be differentiated: those who actively decide to forgo children in favour of other life pursuits and those who merely defer the decision. Both have accumulated a high degree of human capital in their education or career-building paths. Thus, the increase of a woman's time invested in education or career formation takes its toll on the time available for childrearing. A survey performed among female academics (N = 193) brought to light that among childless women, many merely mean to postpone motherhood until their career prospects are established. Differences between those who outwardly reject motherhood and those who defer the decision can be seen in a variety of job- and career-related aspects. However, due to misconceptions about fertility, many of those who merely intended to postpone children may inevitably end up 'involuntarily childless'. As this trend is most likely to increase in the near future, the resolution of this conflict will be an important milestone in the development of modern industrialized countries. As can be seen from this survey, financial benefits will not induce women to enter into motherhood. Rather, societal and infrastructural changes have to be brought about in order to induce women to enter into motherhood.     

Estimates for worldwide laboratory animal use in 2005

Animal experimentation continues to generate public and political concern worldwide. Relatively few countries collate and publish animal use statistics, yet this is a first and essential step toward public accountability and an informed debate, as well as being important for effective policy-making and regulation. The implementation of the Three Rs (replacement, reduction and refinement of animal experiments) should be expected to result in a decline in animal use, but without regular, accurate statistics, this cannot be monitored. Recent estimates of worldwide annual laboratory animal use are imprecise and unsubstantiated, ranging from 28-100 million. We collated data for 37 countries that publish national statistics, and standardised these against the definitions of 'animals', 'purposes' and 'experiments' used in European Union Directive 86/609/EEC. We developed and applied a statistical model, based on publication rates, for a further 142 countries. This yielded our most conservative estimate of global animal use: 58.3 million animals in 179 countries. However, this figure excludes several uses and forms of animals that are included in the statistics of some countries. With the data available, albeit for only a few countries, we also produced, by extrapolation, a more comprehensive global estimate that includes animals killed for the provision of tissues, animals used to maintain genetically-modified strains, and animals bred for laboratory use but killed as surplus to requirements. For a number of reasons that are explained, this more-comprehensive figure of 115.3 million animals is still likely to be an underestimate.     

Impact of mucosal inflammation on cervical human immunodeficiency virus (HIV-1)-specific CD8 T-cell responses in the female genital tract during chronic HIV infection

The female genital tract is the major route of heterosexual human immunodeficiency virus (HIV) acquisition and transmission. Here, we investigated whether HIV-specific CD8 T-cell-mediated immune responses could be detected in the genital mucosa of chronically HIV-infected women and whether these were associated with either local mucosal HIV shedding or local immune factors. We found that CD8⁺ T-cell gamma interferon responses to Gag were detectable at the cervix of HIV-infected women but that the magnitude of genital responses did not correlate with those similarly detected in blood. This indicates that ex vivo HIV responses in one compartment may not be predictive of those in the other. We found that increased genital tumor necrosis factor alpha (TNF-α) and interleukin-10 (IL-10) levels correlated significantly with levels of Gag-specific CD8⁺ T cells at the cervix. Women who were detectably shedding virus in the genital tract had significantly increased cervical levels of TNF-α, IL-1β, IL-6, and IL-8 compared to women who were not detectably shedding virus. We were, however, unable to detect any association between the magnitude of cervical HIV-specific responses and mucosal HIV shedding. Our results support the hypothesis that proinflammatory cytokines in the female genital tract may promote HIV replication and shedding. In addition, we further show that inflammatory cytokines are associated with increased levels of HIV-specific CD8 effector cells at the genital mucosa but that these were not able to control genital HIV shedding.