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RHO archives : Topics : Harmful Traditional Health Practices

Key Issues

This section provides brief summaries of current research on harmful health practices relevant to low-resource settings. More detailed discussions of specific key issues are included in the Harmful Health Practices Annotated Bibliography page.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Communication for improved health

Growing evidence on health behavior highlights the importance of involving the community in health promotion strategies, fully understanding why and how behaviors exist and persist, and ensuring adequate time for sustainable change. Several models exist to guide program activities. For example, the Health Belief Model seeks to explain and predict behavior by analyzing attitudes and beliefs. To change behavior, an individual must believe that a health threat is serious and possible; that the new behavior will have a benefit; and that the new behavior will not have overly serious consequences. The Stages of Change model presents a cyclical process that includes precontemplation of the new behavior, contemplation, preparation, action, and maintenance.

Understanding where an individual or community is in the process is important in program research, design, and evaluation (AIDSCAP 1996). Diffusion theory looks at change from the perspective of groups rather than individuals (Rogers 1995). Community research should be considered in program design. Showing respect for the target audience through local initiative and involvement is vital to changing behavior (Werner 1982). For example, the Population Council evaluated whether a participatory approach can prove more effective than more traditional approaches in the fight against FGM. The study used social mapping, story telling, causal diagrams, and trend analysis to both assess the communities' attitudes and needs, and raise awareness of FGM (Laboratoire de Sant Communautaire, December 1998). Whether working on the level of the individual, organization, community, or larger policy, programmers are encouraged to adapt a model to serve as a practical framework for all project activities and to ensure that project goals are kept in focus (Nutbeam 1999).

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Physical effects of FGM

As efforts to end FGM have become more sophisticated, health advocates have realized that many commonly accepted beliefs about the physical dangers of FGM are based on anecdotal evidence (Obermeyer 1999; Slanger 2002; WHO 2001). Immediate complications of FGM are often described as including intense pain and/or hemorrhage, wound infection, damage to adjoining organs from the use of blunt instruments by unskilled operators, and urine retention from swelling and/or blockage of the urethra. Long-term complications are described as including painful or blocked menses, recurrent urinary tract infections, narrowing of the vagina, abscesses, development of cysts, keloid scarring, bleeding scars, painful tumors, increased risk of maternal and child morbidity and mortality, and infertility (Fernandez-Aguilar 2003; Penna 2002; Toubia 1993; WHO Information Pack).

Rigorous evidence about the nature and severity of these effects is lacking, however, as are data documenting the relationship between specific medical risks and type of FGM (Jones 1999; WHO 2001). This lack of systematic research on which complications pose the greatest risks—and where, why, and when they are most likely to occur—hampers efforts to focus on the greatest dangers facing women, children, and infants (Essen 2002; Slanger 2002). Some research, for example, indicates that appropriate delivery settings and medical response during childbirth may effectively eliminate FGM-related risks to both mothers and newborns. Having this type of information could enable programmers, policy makers, and health care practitioners to develop appropriate interventions.

The few scientific data available have yielded compelling but mixed results. A World Health Organization (WHO) review found that while FGM types I, II, and IV can interfere with childbirth, type III causes a direct mechanical barrier to delivery that may prolong or obstruct labor (WHO 2001). The obstruction can be effectively removed by episiotomy, however. The WHO review also indicates that a reduced vaginal opening resulting from FGM appears to cause other obstetric problems and may prevent pregnancy as well. Seven of the reviewed studies indicate that FGM may contribute to or cause maternal death as a result of obstructed labor that is not properly treated, and ten studies describe stillbirth or neonatal death as a result of FGM. The report also identifies postpartum genital wound infection and fistulae related to FGM (WHO 2001).

Researchers have found that women who have undergone FGM are more likely to experience gynecological and obstetric problems and stillbirth. (Jones 1999; Larsen 2002). Research from The Gambia found women with FGM type II had higher levels of bacterial vaginosis and herpes simplex (which may be associated with HIV infection), but no evidence of higher levels of many other commonly cited effects of FGM (Morison 2001).

Other studies, however, have yielded different results. Two recent studies found no association between FGM and reproductive tract infections, HIV, or hepatitis B, and no association between FGM and perinatal death among immigrants in Sweden (Msuya 2002; Essen 2002). A Nigerian study found no connection between FGM and first-delivery complications or procedures, once socioeconomic variations were accounted for. The researchers concluded that, in places where FGM types I and II are most common, the impact of FGM on birth outcomes is overshadowed by womens basic necessities, including access to trained birth attendants and adequate clinical facilities(Slanger 2002). Research in Sudan has yielded information about the physical complications that men may experience as a result of FGM, including penetration difficulties and penis wounds, as well as psychological and economic problems (Almroth 2001).

Variations within the research findings highlight the need for continued research while simultaneously refining FGM research approaches. Just an importantly, there is signficiant need for empirical evidence concerning the effects of FGM on women and mens mental health, sexuality, and social roles in the community (Almroth 2001; Jones 1999).

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Exploring FGM attitudes and practices

Learning more about how and why FGM is practiced in various settings is key to developing prevention strategies. Where FGM is very widely practiced, for example, older members of the community often are influential in decisions to perform the procedure on young girls. Even where it is illegal (for example, in Burkina Faso), adults may continue the practice with their daughters despite the expressed desire to stop the practice (Laboratoire de Sante Communautaire et al, November 1998). In Kenya, it was found that mothers, grandmothers, and mothers-in-law were most influential in deciding on the practice (PATH 1996). Studies of families that have not practiced FGM have found that circumcision providers, who often are respected members of the community, are key in continuing the practice, because they believe FGM is important and benefit from it financially (Hassan 1995).

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Promoting alternatives to FGM

FGM-prevention strategies are constantly evolving through testing and refinement—and they are often controversial. One thing is clear, however, eliminating FGM is a lengthy and complex process. In Female Genital Mutilation Programmes to Date: What Works and What Doesn't, WHO and PATH identified a core set of overarching elements critical to ending FGM: strong institutions, government support, institutionalization of FGM issues into national health and development programs, properly trained health care providers, coordination among government and nongovernmental organizations, and appropriate advocacy efforts (WHO 1999).

On the program level, community-focused behavior change programs have been the most effective approach to promoting alternatives to FGM. This type of program often contains one or more of the following elements: integration of anti-FGM programs into womens social and economic empowerment, the use of alternative rituals, participatory empowerment of women and communities, social marketing to involve stakeholders, and learning from "positive deviants" (PRB 2001). Earning community trust is essential to efforts to stop FGM (Koso-Thomas 1992). Anti-FGM programs should begin with research, work with appropriate leaders, include and inform all affected members and decision-makers in the community, provide psychological support, and use local culture and customs (Rich 1996).

A program that employs many of these concepts has been underway in Kenya for several years. PATH and Population Action International (PAI) have worked closely with Maendeleo ya Wanawake Organization (MYWO), the largest women's organization in Kenya, to develop community-based programs to reduce the incidence of FGM through promotion of alternate "coming-of-age" rituals. (Please see the MYWO Program Example for a complete description of this program.) Assessments have shown the awareness-raising and attitudinal components that precede the public ceremonies, as well as the emphasis on finely tailoring each project to the specific socio-cultural setting of each location, have been integral to the effectiveness of these alternative rituals (Chege 2001).

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The role of the law and policy in preventing FGM

To date, only basic research has been done on the actual effects of laws and policies on harmful practices like FGM. International and national policy statements alone from the United Nations probably do not cause families to make the decision to stop FGM. But they can serve as important moral backing for national and local FGM eradication programs (RAINBO 1995; CRLP 2000).

Many of the same issues apply to legislation. Some argue that making FGM illegal drives the practice underground where it is harder to address. The same process also moves FGM further away from the hands of trained health professionals and institutions. Yet advocates for anti-FGM legislation feel strongly that it serves to delineate right from wrong and gives support to local efforts to end the practice. Human rights experts are refining a framework based on the idea that the most effective legal responses to FGM are  through implementation of human rights treaties (Rahman 2000). The intensity of these issues is demonstrated by a high-profile, multi-year effort to re-legalize FGM in Egypt. Ultimately, the country's highest court dictated that it must remain illegal.

FGM has been illegal in Sudan for decades with little effect. Other countries, including Burkina Faso and Ghana, have passed legislation banning FGM and have even arrested FGM practitioners. Nevertheless, in Burkina Faso, the outcome of these efforts is not clear (Laboratoire de Sant Communautaire, December 1998). Many industrialized nations have legislated against FGM as well, including the United States and Britain, where some immigrants have brought the practice with them (Crawley 1997).

Some critics have charged that laws in Egypt and Senegal banning FGM were not the result of the internal will, but actually were created to please Western human rights advocates and U.S. government financial aid officials (Economist 1999). However, the force of this charge is diminished by the “Cairo Declaration on Legal Tools to Prevent FGM.” Drafted during the June 2003 Afro-Arab Expert Consultation on the topic, this meeting included representatives of governments and NGOs from 28 FGM-practicing countries, as well as international experts. The declaration calls for outlawing the practice, within certain parameters (Afro-Arab Expert Consultation 2003).

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FGM and the international medical establishment

As modern medical practice becomes more institutionalized in developing countries and as FGM-practicing communities emigrate globally, interaction between the two worlds has become more common. By necessity, medical practitioners worldwide are learning more about FGM, its physical complications, the cultural context, and prevention.

In South Africa, the obstetrics and gynecology unit at Johannesburg Hospital reports an increasing number of clients affected by FGM. Physicians-in-training in South Africa therefore are being taught how to address complications resulting from FGM (Magardie 1999). Health providers in the U.S. also report seeing more FGM cases. In response, the American College of Obstetrics and Gynecologists has issued its first clinical guidelines to help providers understand the implications of FGM, as well as how to help prevent the practice (ACOG 1999). In Boston, the African Women's Health Practice serves women who have undergone FGM. In the United Kingdom, health care providers are seeking to understand the legal ramifications of treating women or girls affected by FGM. Issues to consider include national laws outlawing the practice, laws protecting children, and codes of professional conduct. Health care providers in the United Kingdom and elsewhere are learning how to communicate with and educate their communities about the cultural and medical aspects of the issue(Hopkins 1999; Toubia 2000; British Medical Association 2001).

Medicalization issues are complex. For example, some Médecins Sans Frontières (MSF, or Doctors Without Borders) staff members decided to take a "pragmatic" approach to FGM by providing circumcisors with clean medical instruments for performing the procedure. The organization has since stated that they will not encourage the practice in any way (Veash 1999; Anonymous 1999). Another advocate suggests reconsidering the medicalization issue, as a component of a harm reduction strategy, serving as an intermediate step to abandoning that practice (Shell-Duncan 2001). Since 1995, the World Health Organization has been clear about its stand, with many organizations worldwide strongly endorsing their position: "WHO strongly condemns the medicalization of female genital mutilation. That is, the involvement of the health professions in any form of female genital mutilation in any setting, including hospitals or other health establishments." As the issue becomes better understood, more organizations are standing with WHO on this issue. The “Cairo Declaration on Legal Tools to Prevent FGM” drafted by representatives of 28 countries at the June 2003 Afro-Arab Expert Consultation clearly states that medical practitioners should in no way be involved with FGM. International ethics scholars are increasingly weighing in on the issue—FGM is a human rights abuse, and physicians have a role to play in eliminating it (Cook 2002; Nour 2003).

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Male circumcision

Probably one of the oldest surgeries in history, male circumcision is the surgical removal of the skin sleeve and mucosal tissue that naturally cover the glans (head) of the penis. This double layer is also known as prepuce, or foreskin. Religious male circumcision has been a common thread among the many branches of Judaism for thousands of years; the circumcision generally occurs on the eighth day of life. Some Muslims also practice religious male circumcision, between the ages of four and eleven years. Christianity attaches no religious meaning to circumcision (Smith 1998). Male circumcision became popular in England and the United States during the Victorian era when it was prescribed as a preventive approach to masturbation as well as alcoholism and other maladies (CRC 2000; Smith 2001).

Many cultures, particularly cultures in Africa, practice male circumcision as part of manhood or coming-of-age rituals. In Southeast Asia, male circumcision may be associated with implants or traditional practices such as sexual intercourse with a prostitute or widow to promote healing of circumcision cuts (Hull 2001). The geography of the practice is dynamic; as it lessens in one country, the incidence of male circumcision may increase elsewhere. In Tanzania, for example, research indicates the practice is increasingly popular (Nnko 2001). In industrialized countries, many health care practitioners have determined that the health benefits of male circumcision are too minimal to warrant the practice (AAP 2001; CRC 2000). Others have suggested that the damage caused by the loss of the foreskin and the risks inherent in the procedure are substantial (CRC 2000; Harryman 2001). Some groups, like the Australian College of Paediatrics, suggest that male circumcision may be a human rights violation (ACP 1996).

Recently, international researchers have begun to explore possible links between circumcision and reduced vulnerability to HIV infection. (See RHO's HIV/AIDS section for a discussion of this topic.) Controversy surrounds the notion of advocating for male circumcision, particularly in Africa. Advocates point to the staggering death toll from HIV/AIDS, while opponents fear that promoting the protective effects of circumcision might be viewed as an excuse for risky sexual behavior.

A major issue concerning male circumcision is that, like many traditional surgical procedures, it is often performed in unsafe conditions, using unsafe techniques. Each year, for example, South African hospitals treat hundreds of men suffering from circumcision-related infections that lead to penis amputations and even death—and the number of casualties increases each year. The South African government is trying to regulate the practice, with vigorous opposition from traditional leaders, who believe their territory is being infringed upon and are also unhappy with womens participation on the legislative teams proposing regulation (Sidley 2001; Samayende 2001).

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Effects of drying agents and dry sex

Effects of drying agents and the accompanying sex include vaginal abrasions, sores on male and female genitals, swelling and peeling of the vagina, discharge, and infections. These effects may result from several factors, including the agents themselves, injuries from unlubricated sex, and changes in vaginal pH (van de Wijgert 2000). In cases where abrasive substances remain in the vagina during sex, incidents of irritation and injuries may increase. Drying agents have been classified as desiccants, irritants, and astringents (Dallabetta 1995). The link between dry sex practices and potential HIV infection remains uncertain, yet the potential effects of the practice are worrisome, as risk of HIV transmission is known to increase when lesions, ulcerations, or abrasions are present. Use of drying agents also may mask symptoms of existing sexually transmitted infections (STIs), thereby increasing the risk of HIV transmission (PATH/Outlook 1997).

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The implications of dry sex practices on reproductive health programs

Dry sex practices have implications for reproductive health programs. For example, dry sex practices can affect condom use, as dryness of the vagina may lead to condom breakage. (In an effort to prevent breakage, couples sometimes use Vaseline as a lubricant, but Vaseline also can cause condom breakage.) Also, individuals practicing dry sex may believe that they need to have skin-to-skin, condom-free sex (Civic 1997; Sandala 1995; Baleta 1998). Some programs in Africa are considering the increased promotion of spermicides, given their potential to protect against disease and prevent pregnancy. It may be difficult to promote spermicide use (or, ultimately, microbicide use) where dry sex is the norm, however (Dallabetta 1995; Baleta 1998; Kun 1998).

Various programming approaches must be considered in conjunction with sound knowledge of local dry sex issues. Women and their partners should be educated about the potential risks of certain drying agents and products. If local drying agents are found to be especially dangerous, less problematic local alternatives may need to be promoted (for instance, cold water may be viewed as an acceptable drying agent in Zimbabwe) (Civic 1996). The health risks of douching also should be considered (PATH/Outlook 1997). Since information on dry sex often is passed down through traditional channels, community-based interventions may be useful in changing beliefs and practices (Sandala 1995). Programs must work to develop sensitive approaches that incorporate culturally specific sexual values as well as healthy behaviors. Male community members, as well as females, should be involved these efforts. (For more information about gender issues and men's involvement in reproductive health, see RHO's Gender and Sexual Health and Men and Reproductive Health sections).

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Sex-selective technologies

Traditionally, infant sex selection has ranged from a pregnant mother’s use of traditional medicine and spiritualism to the extreme of infanticide. Since the late 1970s, modern technology has made sex-selective abortions possible. Newer techniques allow sex selection through in vitro fertilization and artificial insemination, but ultrasound technology is by far the most commonly used method of sexing fetuses. The strong preference for sons that exists in many societies now is aided by this technology.

This long-held bias for sons is rooted in family economics. Men and boys are more likely to earn wages, whereas daughters often must be married off with a dowry. Sons are more likely to be able to provide support for aged parents. In addition, religion may reserve highly important roles only for sons. “Small family” trends and governmental policies also exacerbate the problem, as parents have fewer opportunities to produce a son (Mallik 2002; Ooman and Gantra 2002). In many societies, women who are unable to produce a male heir face stigma, ill-treatment, and even abandonment.

Son preference manifests itself today through cultural and religious norms that deny girls and women equal access to food, health care, education, and other life-sustaining resources—and may deny them life, through infanticide and violence (Mallik 2002; Ooman and Gantra 2002). Throughout India, China, Taiwan, and Korea, among other countries, sex-selective abortion is an increasingly popular practice. It is often most common in more affluent segments of society, where people are aware of and can afford the services (Lancaster 2002; Mallik 2002; Ooman and Gantra 2002).

Long before India demonstrated the demographic effect of sex-selective abortion, it had a skewed ratio of women to men compared with those of similar countries. The many millions of women “missing” from the population had died because of the complex manifestations of gender bias (Gardner 2003). (See RHO’s Gender and Sexual Health section for more information on the effects of gender bias on women's health.) Now, sex-selective abortions are apparently amplifying that imbalance. In the United States, there are 1,029 women for every 1,000 men; Indonesia, 1,004; Brazil, 1,025; and Nigeria, 1,016 (Gardner 2003). Today, for every 1,000 Indian men, there are 933 women. The disproportion among children is even worse: In 1981, there were 962 girls for every 1,000 boys in India; in 1991, there were 945; in 2001, 927 (Mallik 2002).

Several countries have passed laws intended to combat sex-selective abortion, including Korea (1987), China (1989), and India (1994). The laws tend to ban sex determination tests, but not abortions afterward. The laws are difficult to enforce since the technology and services are offered for other, legal reasons. Also, there seems to be little political will to enforce them (Gardner 2003; Mallik 2002).

Opponents of sex-selective abortion pointedly do not call for stricter abortion laws, because most abortions are the result of unwanted pregnancy. Also, opponents are concerned that women seeking the services, themselves victims of gender bias, should not be further punished. Therefore, opponents support holding the medical profession accountable for unethically, illegally offering—and even encouraging—sex-selective practices (Ooman and Gantra 2002). Also, governments must take responsibility for raising awareness of the laws and enforcing them as best they can. In India, this includes registration of ultrasound machines and the professionals who use them (George 2002). However, laws will not ultimately solve the problem. The only real solution to sex-selective practices is improved status for women and girls. Policy initiatives are necessary that both protect girl children and support increasing their status—including those that support daughters' self-esteem and self-assertiveness. Girls and women need access to education, paid employment, and inheritance (Bélanger 2002; Mallik 2003; Ooman and Gantra 2002).

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Working together: Western medicine and traditional healers

Because most belief systems have impacts—potentially positive, negative, or mixed—on health, it is important for all types of practitioners to be aware of other systems that may affect their efforts. A local cultural system can be seen as having three overlapping parts: the popular, the professional, and folk sectors (Asclepion 2002). "Conjoint treatment," which means linking Western medicine together with the other sectors, can improve reproductive health outcomes, in part because health is affected by psychological and social factors. Advocates of this approach believe that while the Western doctors role is to cure disease, indigenous healers are often charged with curing the illness—that is, addressing the holistic condition of the patient (Fadiman 1997; Anonymous 1999). Advocates also caution against overly romanticizing indigenous systems; a wide range of people fall into the category of "traditional healers." For example, intervention by a Hmong spiritual doctor, a txiv neeb, may be viewed as safe from a Western medical perspective (since it relies on no physical intervention), while "traditional healers" in Namibia have been prosecuted for encouraging sexual intercourse with minors to "cure" HIV (a false premise) (Ahmad 2001; Fadiman 1997).

Collaboration between Western practitioners and traditional birth attendants, who deliver two-thirds of the worlds babies, is already improving reproductive, maternal, and newborn health in many countries. (Kamal 1998). Traditional practitioners—including herb vendors and traditional doctors relying on a wide variety of techniques—are often called upon to induce abortion, especially in countries where the practice is illegal (Cadelina 1999; Pick 1999). By linking to family planning resources, for example, these providers have the potential to increase women's access to contraceptive services and help prevent future abortions (Sharma 1999). Efforts to enlist traditional circumcisors in the anti-FGM movement have had mixed results, however, due in part to the difficulty convincing excisors (for example, in Mali) of the dangers of FGM (WHO 1999; Population Council 1999). A growing number of collaborations to prevent and treat STIs and HIV/AIDS have fostered programs in Central African Republic, Kenya, Uganda, South Africa, and Zambia (Anonymous 1999; Green 1995; Hojer 1999; Nakyanzi 1999).

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The Patient Explanatory Model

The Explanatory Model (EM) is a simple concept: A health practitioner seeks to comprehend a patients vision of the health issue in question, and the resulting understanding informs the practitioners own explanation of the medical diagnosis, treatment, and/or recommendations. The practitioner and patient work together to agree on a course of action that is acceptable to both. Explanatory models have been tailored to foster deeper understanding of many health issues, from malaria to home-based family care to HIV infection (Hodgson 2000). This approach is especially popular in cross-cultural settings, where misunderstandings and miscommunication are a common barrier to high-quality care. The process of understanding can begin with eight simple questions (Kleinman):

  1. What do you call the problem?
  2. What do you think has caused the problem?
  3. Why do you think it started when it did?
  4. What do you think the sickness does? How does it work?
  5. How severe is the sickness? Will it have a short or long course?
  6. What kind of treatment do you think the patient should receive? What are the most important results you hope he/she receives from this treatment?
  7. What are the chief problems the sickness has caused?
  8. What do you fear most about the sickness?

Some researchers also recommend, when appropriate, the involvement of a "cultural broker," who in many cases may also serve as a language interpreter and as a bridge—an "insider" capable of mediating issues of custom and tradition on behalf of the health provider who is the "outsider." The broker frames the medical information so the patient can understand it. The cultural broker must have the respect and trust of the health provider, the patient, and often the family and community; in many settings that means this person must have sufficiently high status. In some cases, a traditional healer may be a likely candidate for the role (Fadiman 1997).

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