Female genital mutilation/circumcision (FGM/C), or female circumcision, refers to all intentional acts that partially or totally remove the external female genitalia or female genital organs of young girls for cultural, traditional, or nonmedical reasons ^[1][2][1,2]. It is estimated that currently more than 200 million girls and women have undergone FGM in countries where this practice is endemic [3]. Recent studies indicate that FGM/C still occurs throughout Africa, the Middle East, and Asia [4]. FGM/C can have serious adverse effects on the physical and mental health of women in both the short and long term [5]. In the short term, excessive bleeding, shock, genital tissue swelling, fever, infection, and problems with urination and wound healing are the most common issues associated with female genital mutilation. The long-term physical effects of FGM/C include genitourinary infections (chronic pelvic infections, reproductive tract infections, genital infections, and vaginitis) and painful sexual intercourse [6]. One way of eliminating FGM/C is providing appropriate knowledge about FGM/C to the people who are involved in this practice, taking into account their sociocultural and personal sensitivities [7], although FGM/C has already endured for centuries because of tradition and culture [8]. Equipping people with information about the disadvantages of FGM/C remains crucial to alter their attitudes [9]. Furthermore, the literature provides evidence that the practice of FGM/C is performed in every social stratum, among both rich and poor people, educated and uneducated, as well as in both urban and rural regions. There is, however, evidence that women in the middle economic range are more likely to report themselves as having had FGM/C [10].

FGM/C is mostly carried out among countries in Africa, Asia, and Middle East. Studies show that the prevalence of FGM/C varies by region and ethnicity [11]. Regional location and ethnicity has an important role in women circumcision status. For example, a study conducted in northern Ghana, Bawku municipality reported a high prevalence of FGM/C (82%), while overall prevalence of FGM/C in Ghana is 4% [12].

As FGM/C is a cultural practice, efforts to end it require understanding the beliefs, attitudes, and perceptions that have sustained this practice over the centuries ^[13][14][13,14].

2. Current Insights on Attitudes toward Female Genital Mutilation/Circumcision

This work aimed to assess the attitudes toward FGM/C between the first study published on this topic in 1978 and studies published till August 22, 2021. The results of this study indicate that approximately 50% of the total participants across all of the studies reviewed believe that FGM/C is not a harmful practice for women. Looking at all studies published between 2010 to 2015, still around 51% of participants had negative attitudes toward FGM/C. Also, more than 60% of the general population and about 40% of health care professionals show negative attitudes toward FGM/C. The results demonstrate that despite many efforts to ban FGM/C in countries around the world, positive attitudes toward FGM/C are still far from being eradicated and have hardly changed over the past decades. Therefore, to eradicate the practice of FGM/C, a major attitudinal change is required.

It is interesting that from 1978 to 1995 there was only one study that investigated attitudes toward FGM/C (with inclusion of estimates). The rapid increase in studies on attitudes toward FGM/C after 2000 shows that FGM/C is an important problem that has gained increased attention worldwide. UNICEF’s 2016 report highlights that health care providers perform FGM/C due to erroneous information ^[15][16][58,59]. This is consistent with our finding that 37% of health care professionals are willing to perform FGM/C. One explanation for this is that FGM/C is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirth ^[17][60]. Our findings suggest that health care professionals do not consider the adverse consequences of FGM/C and insist on continuing this practice for sociocultural reasons rather than for reasons related to health care. This issue reflects deeply rooted cultural and social concerns among health care professionals with regard to continuing the practice.

Our results further revealed that women with FGM/C were more likely to disapprove of the continuation of FGM/C. One plausible explanation is that circumcised women have experienced the harmful effects of FGM/C ^[18][24], and they are therefore well aware of the negative health consequences of the practice, like difficulties in pregnancy or sexual dissatisfaction. Therefore, circumcised women can play a key role in encouraging the abandonment of FGM/C. Women with FGM/C can act as communication channels for both training and educational programs, because their audience will be confronted with their real experiences of FGM/C. Women with FGM/C might have an impact on the communities in which they live by serving as role models for decision-makers, influencing policies and working collaboratively with organizations advocating for FGM/C eradication. Empowering women might be a solution, so that they also can help to correct misconceptions, guiding families, and especially young couples, and informing them about the adverse consequences of FGM/C.

Our findings also demonstrate that the majority of students have negative attitudes toward this practice. This can be explained by the fact that students are in an educational environment, and their knowledge and attitudes are affected by their general education ^[19][32]. Still, eliminating FGM/C is difficult because of the time it requires to change traditional beliefs and attitudes. A substantial effort to improve knowledge among FGM/C-practicing cultural groups seems to be necessary ^[20][40]. Previous studies have recommended that education on the harmful effects of FGM/C could deter people from advocating for the practice and help change beliefs in traditional cultural contexts ^[19][21][32,61].

Analyzing the 18 studies from 1978 to 2021 on people’s attitudes toward circumcising their own daughters now or in the future showed that approximately 40% of the participants considered performing this procedure on their daughters. In such a situation, health care professionals might be in a good position to inform people about the negative effects of FGM/C. To protect the next generation from the harmful impacts of FGM/C, Desrumaux and Ballo have suggested that a change might be possible by employing a social change strategy based on health promotion and human rights ^[22][62]. This strategy would require a long-term approach within the education system and could lead to a change social dynamics if a majority of women refuses to have their daughters circumcised. According to the authors of that study, both political and social actors have to be involved to change attitudes toward FGM/C, and education has to be translated into action by establishing new institutional structures within the community ^[23][24][63,64]. Social actors can promote the full participation of young people—and especially young men, whose role is essential in the transformative process—to create an environment that is favorable to change ^[25][65].

3. Conclusions

Despite many efforts to ban FGM/C in countries around the world, positive attitudes toward FGM/C are still far from being eradicated and have hardly changed, indicating that a major attitudinal change is required to eliminate this practice. This issue reflects deeply rooted cultural and social concerns among health care professionals with regard to continuing the practice. It seems that circumcised women can play a key role in encouraging the abandonment of FGM/C through educational and cultural campaigns.