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. 2024 May 17;19(5):e0299034. doi: 10.1371/journal.pone.0299034

Female genital mutilation and safer sex negotiation among women in sexual unions in sub-Saharan Africa: Analysis of demographic and health survey data

Richard Gyan Aboagye 1,2, Bright Opoku Ahinkorah 3,4,5, Abdul-Aziz Seidu 5,6,7, James Boadu Frimpong 8,9, Collins Adu 10,11,*, John Elvis Hagan Jr 8,12, Salma A E Ahmed 4, Sanni Yaya 13,14
Editor: Stefano Federici15
PMCID: PMC11101093  PMID: 38758930

Abstract

Background

The practice of female genital mutilation is associated with harmful social norms promoting violence against girls and women. Various studies have been conducted to examine the prevalence of female genital mutilation and its associated factors. However, there has been limited studies conducted to assess the association between female genital mutilation and markers of women’s autonomy, such as their ability to negotiate for safer sex. In this study, we examined the association between female genital mutilation and women’s ability to negotiate for safer sex in sub-Saharan Africa (SSA).

Methods

We pooled data from the most recent Demographic and Health Surveys (DHS) conducted from 2010 to 2020. Data from a sample of 50,337 currently married and cohabiting women from eleven sub-Saharan African countries were included in the study. A multilevel binary logistic regression analysis was used to examine the association between female genital mutilation and women’s ability to refuse sex and ask their partners to use condom. Adjusted odds ratios (aORs) with a 95% confidence interval (CI) were used to present the findings of the logistic regression analysis. Statistical significance was set at p<0.05.

Results

Female genital mutilation was performed on 56.1% of women included in our study. The highest and lowest prevalence of female genital mutilation were found among women from Guinea (96.3%) and Togo (6.9%), respectively. We found that women who had undergone female genital mutilation were less likely to refuse sex from their partners (aOR = 0.91, 95% CI = 0.86, 0.96) and ask their partners to use condoms (aOR = 0.82, 95% CI = 0.78, 0.86) compared to those who had not undergone female genital mutilation.

Conclusion

Female genital mutilation hinders women’s ability to negotiate for safer sex. It is necessary to implement health education and promotion interventions (e.g., decision making skills) that assist women who have experienced female genital mutilation to negotiate for safer sex. These interventions are crucial to enhance sexual health outcomes for these women. Further, strict enforcement of policies and laws aimed at eradicating the practice of female genital mutilation are encouraged to help contribute to the improvement of women’s reproductive health.

Background

Female genital mutilation (FGM) is a major public health concern and human rights issue affecting girls and women worldwide [1]. It is widely recognized as a grave violation of human rights, with detrimental effects on the physical and mental wellbeing of millions of girls and women. In addition, it places a significant burden on a country’s financial resources [2]. FGM is highly prevalent in 30 countries, putting an estimated three million girls at risk of undergoing the practice annually [1, 2]. It is most prevalent in Africa but also occurs in Asia and other parts of Europe where there are communities with origins in FGM-practicing societies [3]. In some parts of Africa, FGM is deeply rooted in religious facets and social mores, with justification including the preservation of virginity, marriage requirements, cultural identity, hygiene, conjugal fidelity, honour, fertility beliefs, initiation rites, and notions of purity [2, 4, 5]. The World Health Organization (WHO) classifies FGM into four categories. Types 1 and 2, known as clitoridectomy and excision respectively, involves the partial or complete removal of the clitoris and labia. Type 3, known as infibulation, involves cutting and repositioning the labia to create a partial covering, sometimes requiring the stitching together of the tissues (this is the most extreme form of FGM). Type 4 involves the piercing or scraping the genitalia [2].

According to a UNICEF report [1], over 90% of FGM incidents are Types 1 (primarily clitoridectomy), 2 (excision), or 4 (“nicking” without flesh removed), with the remaining 10% (nearly 8 million women) being infibulated. The countries that practice infibulation the most are Djibouti, Eritrea, Ethiopia, Somalia, and Sudan. In West Africa (e.g Guinea, Mali, and Burkina Faso), the tendency is to remove flesh (clitoridectomy and/or excision) rather than suture the labia minora and/or majora together [1]. FGM has adverse consequences, including extreme pain, haemorrhage, infection, cyst and keloidal formation, sexual dysfunction, chronic pelvic infection, obstetric issues, and death in the worst cases [1, 3, 6].

In most countries in sub-Saharan Africa (SSA), the conventional social organization is generally patriarchal, with males dominating women [7]. Safer sex negotiation in sexual partnerships has several advantages, including a reduction in sexually transmitted infections (STIs) [8]. STIs, particularly HIV/AIDS, disproportionately affect women [9]. Women’s control over their sexual lives plays a significant role in determining their vulnerability to STIs [10]. The Sustainable Development Goal (SDG) 5 [11, 12] focuses on gender equality and empowerment of girls and women, including improving women’s ability to negotiate for safer sex. As a result, authorities, especially in low- and middle-income countries, are increasingly paying attention to issues related to women’s sexual autonomy [7].

The study utilized the normative social influence theory which explains how people’s behaviours are influenced by social norms [13]. Essentially, people conform to the social norms established within their community members and families to be accepted and to avoid marginalization or exclusion [14]. Research shows that people tend to act in accordance with established societal norms, and deviation from those norms can make it difficult or impossible to fit into the community [15]. A crucial aspect of the normative social influence theory is how norms are transmitted among males and females from childhood to adolescence and adulthood [13]. These norms become deeply ingrained by adulthood, making it challenging to break away from them. Therefore, women who have undergone FGM acquire a certain identity within the community that makes them less assertive in negotiating for safer sex compared to their peers who have not undergone FGM [16].

Previous studies have identified factors such as place of residence, marital status, age, and educational level to be associated with safer sex negotiation [17–20]. Although FGM is linked to harmful social norms that contribute to violence against girls and women, to the best of our knowledge, there is no research on the association between FGM and women’s ability to negotiate safer sex in SSA. In this study, we examined the association between FGM and safer sex negotiation among women in sexual unions in SSA.

Methods

Data source and study design

We analyzed cross-sectional data from the most recent Demographic and Health Surveys (DHS) conducted in 11 countries in SSA (Table 1). We included countries with the most recent datasets from 2010 to 2020. Only countries with variables on FGM, safer sex negotiation, and other variables considered in this study were included. In the DHS, respondents were selected using a two-stage cluster sampling method [21]. Structured questionnaires were used to collect data from the respondents on health and social indicators such as FGM, safer sex negotiation, and reproductive health and rights [21]. For this study, we included 50,337 currently married and cohabiting women of reproductive age (15–49 years). The datasets are freely accessible via this link: https://dhsprogram.com/data/available-datasets.cfm.

Table 1. Description of the study sample.

S/N Country Survey year Weighted N Weighted %
 1. Burkina Faso 2010 9,898 19.7
 2. Ethiopia 2016 2,541 5.0
 3. Gambia 2019–20 2,139 4.2
 4. Guinea 2018 2,577 5.1
 5. Kenya 2014 6,702 13.3
 6. Liberia 2019–20 2,142 4.3
 7. Mali 2018 2,279 4.5
 8. Nigeria 2018 8,443 16.8
 9. Sierra Leone 2019 5,745 11.4
 10. Senegal 2010–11 5,122 10.2
 11. Togo 2013–14 2,749 5.5
All countries 2010–2020 50,337 100.0
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Variables

Outcome variable

We considered two outcome variables: women’s ability to refuse sex and ask their partners to use condom. The respondents were questioned if they could refuse sex with their partners. Additionally, they were asked if they could ask their partners to use condoms. The response options for each of the two variables were the same: “no”, “yes”, and “don’t know/not sure/depends”. We used the definite response options in the final analysis. Hence, women whose response options were “don’t know/not sure/depends” were excluded. We maintained the dichotomized responses (0 = no and 1 = yes) in the final analysis. The coding and categorization were based on previous studies [20, 22–25].

Key explanatory variable

The main explanatory variable in this study was FGM, which was derived from the question “Have you yourself ever been circumcised?” The response options were “yes” and “no”. We recoded these dichotomized responses, assigning 0 for "no" and 1 for "yes". This coding approach was chosen based on existing literature that used the DHS dataset [26].

Covariates

The study included 14 variables as covariates. These variables grouped as individual and contextual level variables, were selected based on their significant association with safer sex negotiation in previous studies [20, 22, 24, 27, 28].

Individual level variables. From the DHS, we used the existing coding for women’s age (15–19; 20–24; 25–29; 30–34; 35–39; 40–44; and 45–49), educational level of the women and their partners (no education; primary; secondary; and higher), and current working status (no/yes). The marital status of respondents was recoded as “married” and “cohabiting”. Partners age was coded as 15–24; 25–34; 35–44; and 45+. Religion was recoded as “Christianity”; “Islam”; “African Traditional”; “No religion”; and “Others”. Frequency of listening to radio, frequency of watching television, and frequency of reading newspaper or magazines were all recoded as “not at all”; “less than once a week”; and “at least once a week”. Comprehensive HIV/AIDS knowledge was categorized into “no” and “yes”.

Contextual variables. Wealth index (poorest, poorer, middle, richer, and richest), place of residence (urban and rural), and studied countries were the contextual variables considered in our study.

Statistical analyses

All analyses were performed using Stata software version 16.0 (Stata Corporation, College Station, TX, USA). First, we used percentages to present the prevalence of FGM, women’s ability to refuse sex, and women’s ability to ask their partners to use a condom. We used cross-tabulations to examine the distribution of the outcome variables across FGM and the covariates. The Pearson’s chi-square test of independence was used to determine the variables with a significant association with the outcome variables. After this procedure, collinearity was checked among the studied variables using the variance inflation factor. The results showed that the minimum, maximum, and mean variance inflation factors were 1.00, 3.74, and 1.84, respectively. Hence, there was no evidence of high collinearity among the variables included in the study. A multilevel binary logistic regression analysis was used to examine the association between FGM and women’s ability to refuse sex and ask their partners to use condom. Four models were built to examine this association (Model O, I, II, and III). Model O was an empty model with no explanatory variable. We included FGM and individual-level variables in Model I. Model II was fitted to contain the contextual-level variables. Model III had all the explanatory variables (FGM and covariates). However, the results for Models 0 and III are presented in Table 3, with the complete tables containing the four models attached as a supplementary file. A Stata command “melogit” was used to fit the models. Akaike’s Information Criterion (AIC) test was used to compare the fitness of the model with the last model being the best-fitted model. The first model was selected because it is the empty model and subsequently compared its results with the last model which had the highest log-likelihood, and the least AIC values. Also, the association between FGM and the outcome variables per country was examined (Table 4). Adjusted odds ratios (aOR) with 95% confidence interval (CI) were used to present the results of the regression analyses. Statistical significance was set at p<0.05 in the chi-square test and regression analyses. All the analyses were weighted. We weighted the data at the country level by appending the dataset for all the countries. In doing this, we applied the women’s sample weights and strata. First, the women’s weighting variable (v005) was divided by 1000000 to generate a new variable called “= v005_pw”. Subsequently, we de-normalized the data using the command: v005 × (total female population 15–49 in the country)/ (total number of women 15–49 interviewed in the survey), and then re-normalized so that in the pooled sample the average is 1. We then appended the cleaned country-level dataset for the final analysis.

Table 3. Mixed effects analysis female genital mutilation and safer sex negotiation among women in sub-Saharan Africa.

Variables Ability to refuse partner’s sex Ability to ask partner to use condom
Model O Model III aOR [95% CI] Model O Model III aOR [95% CI]
Fixed effect results
Female genital mutilation
Not undergone FGM Reference category Reference category
Undergone FGM 0.91*** [0.86, 0.96] 0.82*** [0.78, 0.86]
Women’s age (years)
15–19 Reference category Reference category
20–24 1.04 [0.95,1.15] 1.05 [0.96,1.16]
25–29 1.04 [0.94,1.15] 1.07 [0.97,1.18]
30–34 1.05 [0.94,1.17] 1.07 [0.96,1.19]
35–39 1.09 [0.98,1.22] 1.04 [0.93,1.16]
40–44 1.12 [0.99,1.26] 1.04 [0.92,1.17]
45–49 1.05 [0.92,1.19] 0.94 [0.83,1.06]
Marital status
Married Reference category Reference category
Cohabiting 1.33*** [1.20,1.46] 1.40*** [1.28,1.53]
Women’s educational level
No education Reference category Reference category
Primary 1.24*** [1.17,1.31] 1.37*** [1.29,1.45]
Secondary 1.47*** [1.37,1.59] 1.59*** [1.49,1.71]
Higher 2.03*** [1.78,2.33] 2.03*** [1.78,2.31]
Current working status
Not working Reference category Reference category
Working 1.06* [1.01,1.11] 1.17*** [1.12,1.23]
Religion
Christianity Reference category Reference category
Islamic 0.55*** [0.52,0.59] 0.62*** [0.59,0.66]
African Traditional 0.93 [0.82,1.07] 0.52*** [0.45,0.60]
No religion 0.64*** [0.52,0.79] 0.62*** [0.50,0.77]
Others 1.52 [0.73,3.16] 2.28* [1.07,4.87]
Comprehensive HIV and AIDS knowledge
No Reference category Reference category
Yes 1.18*** [1.14,1.24] 1.30*** [1.24,1.35]
Partner’s age (years)
15–24 Reference category Reference category
25–34 0.96 [0.85,1.09] 0.92 [0.82,1.04]
35–44 0.91 [0.80,1.04] 0.84* *[0.74,0.95]
45+ 0.85* [0.74,0.97] 0.69***[0.60,0.79]
Partner’s educational level
No education Reference category Reference category
Primary 1.14*** [1.07,1.22] 1.24*** [1.16,1.32]
Secondary 1.19*** [1.12,1.27] 1.40*** [1.32,1.49]
Higher 1.21*** [1.10,1.33] 1.43*** [1.31,1.57]
Frequency of watching television
Not at all Reference category Reference category
Less than once a week 1.06 [1.00,1.13] 1.20*** [1.12,1.27]
At least once a week 1.15*** [1.08,1.23] 1.25*** [1.18,1.34]
Frequency of listening to radio
Not at all Reference category Reference category
Less than once a week 1.15*** [1.09,1.23] 1.06 [1.00,1.12]
At least once a week 1.20*** [1.14,1.26] 1.15*** [1.09,1.21]
Frequency of reading newspaper/magazine
Not at all Reference category Reference category
Less than once a week 1.16*** [1.06,1.27] 1.29*** [1.18,1.40]
At least once a week 1.10 [0.98,1.23] 1.32*** [1.18,1.47]
Wealth index
Poorest Reference category Reference category
Poorer 1.01 [0.95,1.07] 1.07* [1.00,1.14]
Middle 0.99 [0.93,1.06] 1.13*** [1.06,1.21]
Richer 1.03 [0.96,1.11] 1.25*** [1.16,1.35]
Richest 1.06 [0.96,1.16] 1.38*** [1.26,1.51]
Residence
Urban Reference category Reference category
Rural 0.89*** [0.84,0.94] 0.88***[0.83,0.93]
Countries
Burkina Faso Reference category Reference category
Ethiopia 0.73*** [0.65,0.81] 0.73***[0.65,0.81]
Gambia 0.89* [0.80,1.00] 1.85***[1.65,2.07]
Guinea 0.93 [0.84,1.02] 0.71***[0.64,0.79]
Kenya 1.13* [1.03,1.25] 1.76***[1.60,1.94]
Liberia 2.53*** [2.20,2.90] 0.99 [0.88,1.11]
Mali 0.34*** [0.30,0.38] 0.75***[0.68,0.84]
Nigeria 1.04 [0.96,1.13] 0.74***[0.68,0.80]
Sierra Leone 2.21*** [2.04,2.40] 1.51***[1.40,1.64]
Senegal 0.35***[0.32,0.38] 0.70***[0.64,0.77]
Togo 1.44*** [1.28,1.61] 1.67***[1.49,1.87]
Random effect results
Primary Sampling Unit variance (95% CI) 0.41 [0.35, 0.47] 0.20 [0.17, 0.23] 0.60 [0.52, 0.68] 0.22 [0.18, 0.26]
Intra-Class Correlation Coefficient 0.11 0.06 0.15 0.06
Likelihood ratio Test 1242.69 (<0.001) 694.55 (<0.001) 1862.62 (<0.001) 735.93 (<0.001)
Wald chi-square Reference 5811.30*** Reference 6552.77***
Model fitness
Log-likelihood -33288.29 -29813.45 -33959.44 -30050.18
Akaike’s Information Criterion 66580.59 59718.91 67922.87 60192.35
Sample size 50,337 50,337 50,337 50,337
Number of clusters 1,608 1,608 1,608 1,608
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aOR = adjusted odds ratios; CI = Confidence Interval

* p < 0.05

** p < 0.01

*** p < 0.001

Table 4. Association between female genital mutilation and safer sex negotiation by country.

Country Ability to refuse partner’s sex aOR [95% CI] Ability to ask partner to use condom aOR [95% CI]
Burkina Faso 0.86* [0.75, 0.99] 0.81** [0.70, 0.93]
Ethiopia 0.81 [0.64, 1.02] 0.85 [0.66, 1.09]
Gambia 1.17 [0.91, 1.50] 0.85 [0.66, 1.10]
Guinea 0.46** [0.27, 0.78] 0.25*** [0.14, 0.44]
Kenya 0.80** [0.68, 0.93] 0.64*** [0.55, 0.75]
Liberia 1.03 [0.78, 1.37] 0.97 [0.78, 1.19]
Mali 0.79 [0.52, 1.19] 1.53 [0.98, 2.40]
Nigeria 0.89 [0.77, 1.02] 0.88 [0.77, 1.01]
Sierra Leone 0.71 [0.47, 1.05] 1.23 [0.87, 1.74]
Senegal 1.19 [0.99, 1.43] 0.94 [0.79, 1.14]
Togo 1.01 [0.70, 1.44] 0.62** [0.44, 0.87]
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Adjusted for the covariates; aOR = adjusted odds ratios; CI = Confidence Interval

* p < 0.05

** p < 0.01

*** p < 0.001

Ethical consideration

We did not seek ethical clearance for this study since the DHS dataset is available in the public domain. Detailed information about the DHS data usage and ethical standards are available at http://goo.gl/ny8T6X.

Results

Prevalence of female genital mutilation and safer sex negotiation among women in sub-Saharan Africa

Fig 1 depicts the prevalence of FGM and safer sex negotiation per country. FGM was found to be prevalent in 56.1% of the women included in the study. Guinea had the highest prevalence (96.3%), while Togo had the lowest (6.9%). The prevalence of women’s ability to refuse sex and ask for condom use were 60.0% and 50.9%, respectively. Liberia had the highest percentage of women who said they were able to refuse sex (85.4%), while Mali had the lowest (30%). Kenya had the highest percentage of women who could ask their partners to use condoms (79.4%), while Guinea had the lowest (35.7%).

Fig 1. Prevalence of female genital mutilation and safer sex negotiation among women in sub-Saharan Africa.

Fig 1

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Distribution of safer sex negotiation across female genital mutilation and covariates

Table 2 shows the results of the distribution of safer sex negotiation (refuse sex and ask for condom use) across FGM as well as the association between the explanatory variables and safer sex negotiation. Among women who had undergone FGM, the prevalence of women’s ability to refuse sex and ask their partner to use condom were 56.8% and 44.6%, respectively. FGM status was associated with women’s ability to refuse sex (p<0.001) and to ask partners to use condoms (p<0.001). Additionally, all the covariates had a statistically significant association with the outcome variables (p<0.001).

Table 2. Distribution of safer sex negotiation across female genital mutilation and covariates.

Variables Weighted N Weighted % Refuse sex Yes (%) p-value Ask for condom use Yes (%) p-value
Female genital mutilation <0.001 <0.001
Not undergone FGM 22,082 43.9 64.2 59.0
Undergone FGM 28,255 56.1 56.8 44.6
Women’s age (years) <0.001 <0.001
15–19 2,915 5.8 54.0 45.7
20–24 8,392 16.7 59.7 52.3
25–29 11,171 22.2 61.3 54.9
30–34 9,482 18.8 60.4 52.2
35–39 8,262 16.4 61.1 50.3
40–44 5,750 11.4 60.3 47.6
45–49 4,365 8.7 58.4 43.9
Marital status <0.001 <0.001
Married 46,728 92.8 58.4 49.2
Cohabiting 3,609 7.2 80.6 72.6
Women’s educational level <0.001 <0.001
No education 25,534 50.7 49.4 35.2
Primary 11,111 22.1 65.3 61.2
Secondary 10,636 21.1 73.4 69.6
Higher 3,056 6.1 83.4 79.5
Partner’s educational level <0.001 <0.001
No education 23,275 46.3 48.5 34.9
Primary 9,325 18.5 64.0 58.4
Secondary 12,343 24.5 71.5 66.3
Higher 5,395 10.7 76.8 71.9
Partner’s age (years) <0.001 <0.001
15–24 1,723 3.4 63.8 56.1
25–34 13,795 27.4 63.4 57.6
35–44 16,543 32.9 61.3 53.4
45+ 18,276 36.3 56.0 43.1
Current working status <0.001 <0.001
Not working 15,675 31.1 54.2 46.8
Working 34,662 68.9 62.7 52.7
Religion <0.001 <0.001
Christianity 19,129 38.0 75.8 67.9
Islamic 29,571 58.8 49.7 40.5
African Traditional 1,161 2.3 61.4 32.7
No religion 421 0.8 63.0 51.9
Others 55 0.1 79.4 80.3
Comprehensive HIV and AIDS knowledge <0.001 <0.001
No 27,789 55.2 54.9 44.2
Yes 22,548 44.8 66.3 59.1
Frequency of reading newspaper/magazine <0.001 <0.001
Not at all 42,913 85.3 57.5 46.7
Less than once a week 4,391 8.7 74.6 73.3
At least once a week 3,033 6.0 75.0 77.5
Frequency of listening to radio <0.001 <0.001
Not at all 15,949 31.7 56.5 42.6
Less than once a week 10,928 21.7 60.1 50.6
At least once a week 23,459 46.6 62.4 56.7
Frequency of watching television <0.001 <0.001
Not at all 26,827 53.3 57.4 42.7
Less than once a week 7,477 14.8 60.6 54.5
At least once a week 16,033 31.9 64.2 62.9
Wealth index <0.001 <0.001
Poorest 8,718 17.3 53.0 36.5
Poorer 9,468 18.8 55.4 41.7
Middle 9,794 19.5 56.2 47.0
Richer 10,618 21.1 62.2 56.1
Richest 11,738 23.3 70.2 67.6
Residence <0.001 <0.001
Urban 19,636 39.0 67.9 63.3
Rural 30,701 61.0 55.0 43.0
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Association between female genital mutilation and safer sex negotiation

Table 3 presents the results of the association between FGM and safer sex negotiation among women in SSA. Women with a history of FGM had lower odds of refusing sexual intercourse from their partners compared to those who had not experienced FGM (aOR = 0.91, 95% CI = 0.86, 0.96). Women who had experienced FGM were also less likely to request their partners to use condoms during sex compared to those with no history of FGM (aOR = 0.82, 95% CI = 0.78, 0.86). With the covariates, cohabiting women were more likely to negotiate for safer sex compared to married women. Higher educational status of women and their partners enhanced the likelihood of safer sex negotiation. Compared to women who were not exposed to television, radio, or newspapers/magazines, those who were exposed had higher odds of negotiating for safer sex. In comparison to non-working women, employed women were more inclined to negotiate for safer sex. Compared to women without comprehensive HIV and AIDS knowledge, those with comprehensive HIV and AIDS knowledge were more likely to negotiate for safer sex. Women in rural areas had lower odds in negotiating for safer sex compared to women in urban areas. The complete results for the association between FGM and women’s ability to negotiate for condom use as well as women’s ability to refuse partner’s sex in SSA are provided as S1 and S2 Tables in S1 File.

Association between female genital mutilation and safer sex negotiation by country

Table 4 present the results of the association between FGM and safer sex negotiation segregated by country. We found that women from Burkina Faso, Guinea, and Kenya who had undergone FGM were less likely to refuse sexual intercourse with their partners. Also, the odds of women’s ability to ask their partner to use a condom was lower among women with a history of FGM from Burkina Faso, Guinea, Kenya, and Togo.

Discussion

The study examined the association between FGM and safer sex negotiation among women in sexual unions in SSA. The findings indicate that women who have undergone FGM are less likely to refuse sexual intercourse and request condom use from their partners. These findings are consistent with other recent studies which have also identified FGM as a significant factor that influences women’s sexual behaviours in various African countries [13, 29]. The practice of FGM, primarily used in certain societies to regulate sexual desire and ensure the virginity and chastity of females until marriage, can have an impact on women’s capacity to negotiate safe sex [13]. Chai et al. [13] suggests that women within FGM practicing communities may face stigma when expressing their sexual needs due to taboos around sexuality, sexual morals, and sociocultural expectations. This assertion aligns with the normative social influence theory and previous research indicating that in many of these communities, FGM is viewed as a cornerstone of moral virtue, making women who initiate sexual acts or negotiate during sex appear promiscuous [30]. Consequently, these social dynamics can limit women’s sexual autonomy. However, factors such as high educational status, lack of financial dependence, access to resources and information can enhance women’s autonomy, thereby increasing their ability to negotiate safer sexual behaviours.

Country-specific variations were observed, with the lower odds of refusing partner sex among women who have undergone FGM in Burkina Faso, Guinea, and Kenya. Similarly, women who have undergone FGM in Togo were less likely to ask their partners to use a condom. These findings are consistent with the findings of earlier studies conducted in Kenya [13] and the United States [29], further supporting the influence of FGM on women’s sexual behaviour and autonomy. Given these findings, efforts should be directed towards the elimination of violence against women and girls in SSA, as well as promoting of family planning using a holistic approach.

Educated women are more inclined to weigh the advantages over the disadvantages when making decisions regarding their health [31]. Prior studies have suggested that better education for women and girls may reduce FGM and that educated women have economic power and can choose whether to undergo FGM [31, 32]. We also found that women with higher educational levels were more likely to deny sexual intercourse from their partners and request that they use a condom. These findings are consistent with those of prior studies [12, 25]. Women with higher levels of education are better informed when it comes to making important decisions about their sexual lives and health, which increases their sexual autonomy [33]. Women with higher education may have greater financial empowerment, making them more likely to negotiate for safer sex with their partners [12].

However, women who were cohabiting were also more likely to decline sex from their partners and encourage condom use, consistent with the findings of previous study [34]. One possible explanation for this finding is that cohabiting women may be more autonomous in their sexual decisions, making them more likely to deny sex from their partners and ask them to use condoms. It is also possible that cohabiting women were shielding themselves from the stigma and guilt associated with being pregnant outside of marriage, making them more inclined to negotiate for safer sex from their intimate partners [34]. Nevertheless, women with partners who have higher levels of education were more likely to refuse intercourse and request condom use. This may be because women with more educated partners understand the importance of respecting their female partners’ sexual life decisions about their sexual lives, as well as the potential consequences of going against their partner’s wishes. This understanding increases their chances of negotiating for safer sex.

Women who had comprehensive HIV and AIDS knowledge were more likely to deny sex from their partners and request that they use a condom. The current study’s findings are consistent with those of earlier studies [23, 34, 35]. Women who have a thorough understanding of HIV and AIDS could be aware of the repercussions of their behaviours in connection to their sexual lives, which could improve their sexual autonomy [23, 35].

Women who were exposed to mass media (television, radio, newspapers, or magazines) were more likely to refuse sex from their partners and request condom use. This finding is consistent with previous studies [22, 36–38]. The positive association between exposure to mass media and sexual autonomy [36, 37, 39] could be due to the information received about the adverse effects of not practicing safe sex, empowering them to negotiate for safer sex.

Other results showed that women living in rural areas were less likely to refuse sexual intercourse and request condom use from their partners. This aligns with a study conducted in SSA that found that women in rural areas had less autonomy in making informed decisions, such as negotiating for safer sex [12]. Lack of comprehensive sexual education may contribute to this lack of sexual autonomy among rural women [12].

Strengths and limitations

The study has several strengths. The use of DHS data and robust statistical procedures support the reliability of our findings. Additionally, our findings bridge gaps in the current research on the association between FGM and safer sex negotiation. However, it is important to acknowledge the study’s limitations. FGM was self-reported, likely leading to under-reporting. Furthermore, the cross-sectional design makes it difficult to establish causation between FGM and negotiation for safer sex. Also, the statistical analysis did not consider the role of social norms, despite the discussion of their connection to FGM and safer sex negotiation. Therefore, caution should be exercised when interpreting the study’s findings. It is also important to note that our inferences are based on data from the standard DHS.

Conclusion

The study findings highlight that women who have undergone FGM are less likely to negotiate for safer sex. This observation emphasizes the need for planned health education and promotion interventions that support these women in negotiating safer sex. Policymakers should prioritize the development and implementation of specific interventions aimed at preventing FGM, which is associated with adverse sexual and reproductive health outcomes.

Supporting information

S1 File. Supporting information containing S1 and S2 Tables.

(DOCX)

pone.0299034.s001.docx (25KB, docx)

Data Availability

https://dhsprogram.com/data/available-datasets.cfm.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Joseph Donlan

31 May 2022

PONE-D-21-27783Female genital mutilation and safer sex negotiation among women in sexual unions in sub-Saharan Africa: Analysis of Demographic and Health Survey dataPLOS ONE

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Reviewer #1: The authors have tackled a very important societal practice that has short and long term physical and psychological impact on women and girls. Their use of multi-country DHS dataset is also commendable as it presents an opportunity to understand how widespread the FGM practice is and also examine its impact in a diverse setting. However, the authors have not done a robust analysis of the dataset. Below are some concerns and suggestions.

The main concern is that the authors have not discussed the underlying mechanisms and linkages between FGM and other socio-demographic factors, considering that FGM is more likely to be done before marriage (<15yrs). The paper would benefit from some in-depth discussion of the link between FGM and the outcomes as well as link between FGM and socio-demographic factors. Two-thirds of the discussion is on the association between the outcomes and socio-demographic factors, with little focus on FGM (as their main exposure), which is the focus of the paper.

The other concern is on the analysis procedure. Much as it is important to look at the overall association between FGM and the outcomes, the analysis would have benefitted from individual country estimates, considering the wide variation in FGM (6.9% in Togo vs 96.3 % in Guinea) as well as safe sex practices across settings (30% in Mali vs 85% in Liberia). It is not clear if the authors examined the heterogeneity in the both the outcome and main exposure across the countries and how this was accounted for in the pooled analysis. It would important to examine how the risk of unsafe sex varies across the different settings.

In the data analysis section, the authors outlined four models they fitted but do not explain to the reader the criteria used in selecting the two models they present in table 3.

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PLoS One. 2024 May 17;19(5):e0299034. doi: 10.1371/journal.pone.0299034.r002

Author response to Decision Letter 0

10 Jul 2022

COMMENTS

Reviewer #1: The authors have tackled a very important societal practice that has short and long term physical and psychological impact on women and girls. Their use of multi-country DHS dataset is also commendable as it presents an opportunity to understand how widespread the FGM practice is and also examine its impact in a diverse setting. However, the authors have not done a robust analysis of the dataset. Below are some concerns and suggestions.

Our response: Thank you. We have addressed all the comments raised.

The main concern is that the authors have not discussed the underlying mechanisms and linkages between FGM and other socio-demographic factors, considering that FGM is more likely to be done before marriage (<15yrs). The paper would benefit from some in-depth discussion of the link between FGM and the outcomes as well as link between FGM and socio-demographic factors. Two-thirds of the discussion is on the association between the outcomes and socio-demographic factors, with little focus on FGM (as their main exposure), which is the focus of the paper.

Our response: Thank you very much. The discussion section has been revised to provide more information on FGM and safer sex negotiation, FGM and socio-demographic factors, and safer sex negotiation and socio-demographic factors.

The other concern is on the analysis procedure. Much as it is important to look at the overall association between FGM and the outcomes, the analysis would have benefitted from individual country estimates, considering the wide variation in FGM (6.9% in Togo vs 96.3 % in Guinea) as well as safe sex practices across settings (30% in Mali vs 85% in Liberia). It is not clear if the authors examined the heterogeneity in the both the outcome and main exposure across the countries and how this was accounted for in the pooled analysis. It would important to examine how the risk of unsafe sex varies across the different settings.

Our response: Thank you. We have provided a new result, which examined the association between FGM and safer sex negotiation by country (Table 4).

In the data analysis section, the authors outlined four models they fitted but do not explain to the reader the criteria used in selecting the two models they present in table 3.

Our response: Thank you. We have attached the complete tables containing the four models as supplementary file. We presented the results for only the two models because, the last models were the best-fitted models based on the lowest value of the Akaike’s Information Criterion and the highest value of the log-likelihood. Please refer to the supplementary file for detailed information.

Attachment

Submitted filename: Reviewers comments on FGM & safer sex negotiation (1107).docx

pone.0299034.s002.docx (13.2KB, docx)

Decision Letter 1

Stefano Federici

13 Sep 2023

PONE-D-21-27783R1Female genital mutilation and safer sex negotiation among women in sexual unions in sub-Saharan Africa: Analysis of Demographic and Health Survey dataPLOS ONE

Dear Dr. Adu,

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After reading the revised version of the manuscript and based on the comments provided by Reviewer 2, I believe that the paper is worthy of publication, although it still requires some effort on the part of the authors. I therefore urge the authors to proceed with a revision of the manuscript based on the excellent comments and suggestions provided by Reviewer 2.

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Reviewer #2: (No Response)

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Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This article used data from more than 50,000 currently married and cohabiting women aged 15-49 in 11 countries in SSA from the Demographic and Health Surveys to investigate the relationship between female genital mutilation and safe sex negotiation. The findings are socially relevant given the continuing issue of female genital mutilation in the region. Overall, the paper is well-written and the conclusions are supported by the results presented. However, there are areas where the manuscript can be improved:

1. Some slight errors can be found in the text. For instance, see line 80 and line 170.

2. The improved discussion in the end is helpful. However, it would help the reader to highlight the theorized connection between female genital mutilation and safe sex negotiation in the introduction. Another option could be to have a small theoretical framework after the introduction, which highlights how the two are hypothesized to be related. Again, which mechanisms are at stake?

3. It is argued that the association between female genital mutilation and women’s ability to negotiate for safer sex in sub-Saharan Africa is investigated. However, the focus is just on 11 countries in sub-Saharan Africa. Including the Multiple Indicator Cluster Surveys would make the analysis more robust and accurate to make conclusions about the entire region. This would benefit the cross-validation of the findings. I understand that this could be beyond the scope of this analysis, but I could not refrain from wondering whether the results would hold when including more countries in sub-Saharan Africa. Can the authors explain why they did not use the MICS data and state how many countries were excluded as a result?

4. To the reader, various components of the analysis are unclear. For instance, how is the weighting of the data being taken into account in the analysis? So, what exact weighting procedure was used? If the DHS weights are used, one is given more weight to surveys with more data (nationally representative for each country, but not across countries). See the DHS sampling manual: https://dhsprogram.com/pubs/pdf/DHSM4/DHS6_Sampling_Manual_Sept2012_DHSM4.pdf. The suggested approach is to de-normalize and renormalize according to the relevant measure. Next to that, it is unclear whether multilevel analysis was performed. This is not mentioned in the paper, however, the results (intraclass correlation) suggest that this was performed. Finally, can information regarding multicollinearity be provided?

5. Regarding Table 4, I am wondering why models 1 and 2 are being shown. Before, it was argued that model 3 was the best estimation. So, why is this not used to perform the country analysis? Also, look at PLOS ONE guidelines for statistical reporting, https://journals.plos.org/plosone/s/submission-guidelines.#loc-statistical-reporting. This suggests including the complete estimations with particular format requirements in the appendix.

6. In the discussion, it is argued that both female genital mutilation and safe sex negotiation are related to social norms. Could the authors take this into account in the statistical analysis?

7. The results in ‘prevalence of female genital mutilation and safer sex negotiation among women in sub-Saharan Africa’ do not align with the results mentioned in the abstract.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #2: No

**********

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PLoS One. 2024 May 17;19(5):e0299034. doi: 10.1371/journal.pone.0299034.r004

Author response to Decision Letter 1

31 Oct 2023

Reviewer #2: This article used data from more than 50,000 currently married and cohabiting women aged 15-49 in 11 countries in SSA from the Demographic and Health Surveys to investigate the relationship between female genital mutilation and safe sex negotiation. The findings are socially relevant given the continuing issue of female genital mutilation in the region. Overall, the paper is well-written and the conclusions are supported by the results presented. However, there are areas where the manuscript can be improved:

Response: Thank you.

1. Some slight errors can be found in the text. For instance, see line 80 and line 170.

Response: We have corrected these errors.

2. The improved discussion in the end is helpful. However, it would help the reader to highlight the theorized connection between female genital mutilation and safe sex negotiation in the introduction. Another option could be to have a small theoretical framework after the introduction, which highlights how the two are hypothesized to be related. Again, which mechanisms are at stake?

Response: Thank you for this observation. A theoretical perspective has been provided.

3. It is argued that the association between female genital mutilation and women’s ability to negotiate for safer sex in sub-Saharan Africa is investigated. However, the focus is just on 11 countries in sub-Saharan Africa. Including the Multiple Indicator Cluster Surveys would make the analysis more robust and accurate to make conclusions about the entire region. This would benefit the cross-validation of the findings. I understand that this could be beyond the scope of this analysis, but I could not refrain from wondering whether the results would hold when including more countries in sub-Saharan Africa. Can the authors explain why they did not use the MICS data and state how many countries were excluded as a result?

Response: Thank you. We understand that data on FGM is available in the MICS. However, the focus of this study is to use the standard DHS to ascertain the association between FGM and safe sex negotiation. Also, there were variations in the surveys years for the MICS and DHS, which we think could have affected the study. Hence the decision to use only the DHS. As at the time of this study, all the countries that had data on both FGM and safe sex negotiation as well as the covariates.

4. To the reader, various components of the analysis are unclear. For instance, how is the weighting of the data being taken into account in the analysis? So, what exact weighting procedure was used? If the DHS weights are used, one is given more weight to surveys with more data (nationally representative for each country, but not across countries). See the DHS sampling manual: https://dhsprogram.com/pubs/pdf/DHSM4/DHS6_Sampling_Manual_Sept2012_DHSM4.pdf. The suggested approach is to de-normalize and renormalize according to the relevant measure. Next to that, it is unclear whether multilevel analysis was performed. This is not mentioned in the paper, however, the results (intraclass correlation) suggest that this was performed. Finally, can information regarding multicollinearity be provided?

Response: We took into account weighting at the country and pooled levels. Thus, we de-normalised and renormalised the dataset before the final analysis. Multilevel regression analysis was used to examine the association between FGM and safer sex negotiation. We also checked for evidence of collinearity and there was no evidence of high collinearity among the variables. The minimum, maximum, and mean variance inflation factor were 1.00, 3.74, and 1.84, respectively.

5. Regarding Table 4, I am wondering why models 1 and 2 are being shown. Before, it was argued that model 3 was the best estimation. So, why is this not used to perform the country analysis? Also, look at PLOS ONE guidelines for statistical reporting, https://journals.plos.org/plosone/s/submission-guidelines.#loc-statistical-reporting. This suggests including the complete estimations with particular format requirements in the appendix.

Response: Thank you. We have attached the complete table indicating Model O, I, II, and III as a supplementary file.

6. In the discussion, it is argued that both female genital mutilation and safe sex negotiation are related to social norms. Could the authors take this into account in the statistical analysis?

Response: Thank you for your observation. This was beyond the scope of the study, hence, it has been captured as a limitation.

7. The results in ‘prevalence of female genital mutilation and safer sex negotiation among women in sub-Saharan Africa’ do not align with the results mentioned in the abstract.

Response: We have corrected this error.

Attachment

Submitted filename: Reviewers comment.docx

pone.0299034.s003.docx (14.5KB, docx)

Decision Letter 2

Stefano Federici

16 Nov 2023

PONE-D-21-27783R2Female genital mutilation and safer sex negotiation among women in sexual unions in sub-Saharan Africa: Analysis of Demographic and Health Survey dataPLOS ONE

Dear Dr. Adu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Just one more small effort to make the manuscript suitable for publication. I invite the authors to address the issues raised by the Reviewer.

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Academic Editor

PLOS ONE

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Additional Editor Comments :

Just one more small effort to make the manuscript suitable for publication. I invite the authors to address the issues raised by the Reviewer.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for the response to the comments that were made. The paper is well-written and conclusions are supported by the results presented. Many of the comments made were addressed appropriately! Some additional minor remarks:

- One more minor error in line 215

- Regarding the MICS surveys, I am not sure whether I understand the arguments made. So, why was the DHS chosen in particular? And what do you mean by variations in the survey years for the MICS? Anyhow, explaining why the MICS were not used and the possible downslides of this could be discussed in the limitation parts of the article.

- Thank you for responding to several of the questions regarding to the analysis and adjustments made to the paper. However, the information about the weighting is still not included in the article itself. I think it would be good for transparency and potential reproducibility of the methods and results to add these to the article as well.

- The statement in line 247 is only true for particular countries as well.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 May 17;19(5):e0299034. doi: 10.1371/journal.pone.0299034.r006

Author response to Decision Letter 2

14 Jan 2024

Reviewer #2:

Thank you for the response to the comments that were made. The paper is well-written and conclusions are supported by the results presented. Many of the comments made were addressed appropriately! Some additional minor remarks:

- One more minor error in line 215

Response: We have corrected this error.

- Regarding the MICS surveys, I am not sure whether I understand the arguments made. So, why was the DHS chosen in particular? And what do you mean by variations in the survey years for the MICS? Anyhow, explaining why the MICS were not used and the possible downslides of this could be discussed in the limitation parts of the article.

Response: Thank you. We used the standard DHS because tot all the countries have the MICS dataset. Additionally, the data collection process for the MICS and the variable measurement except for the sociodemographic characteristics differs from the standard DHS. Hence, our decision to use the standard DHS dataset. However, we have acknowledged this as a limitation.

- Thank you for responding to several of the questions regarding to the analysis and adjustments made to the paper. However, the information about the weighting is still not included in the article itself. I think it would be good for transparency and potential reproducibility of the methods and results to add these to the article as well.

Response: Thank you. We have described how the weighting methodology used in the study.

- The statement in line 247 is only true for particular countries as well.

Response: We have corrected this by adding the countries.

Attachment

Submitted filename: Reviewers Comment_R2.docx

pone.0299034.s004.docx (12.9KB, docx)

Decision Letter 3

Stefano Federici

5 Feb 2024

Female genital mutilation and safer sex negotiation among women in sexual unions in sub-Saharan Africa: Analysis of Demographic and Health Survey data

PONE-D-21-27783R3

Dear Dr. Adu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Stefano Federici, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

Acceptance letter

Stefano Federici

21 Mar 2024

PONE-D-21-27783R3

PLOS ONE

Dear Dr. Adu,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Stefano Federici

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Supporting information containing S1 and S2 Tables.

    (DOCX)

    pone.0299034.s001.docx (25KB, docx)
    Attachment

    Submitted filename: Reviewers comments on FGM & safer sex negotiation (1107).docx

    pone.0299034.s002.docx (13.2KB, docx)
    Attachment

    Submitted filename: Reviewers comment.docx

    pone.0299034.s003.docx (14.5KB, docx)
    Attachment

    Submitted filename: Reviewers Comment_R2.docx

    pone.0299034.s004.docx (12.9KB, docx)

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    https://dhsprogram.com/data/available-datasets.cfm.

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