Attitudes towards the practice of female genital mutilation/cutting in Somaliland: evidence from the Somali Demographic Health Survey 2020

Abstract

Objectives

To identify key demographic, socio-economic, and cultural determinants influencing the continuation of FGM/C and to evaluate its prevalence and associated factors utilizing the 2020 Somali Demographic and Health Survey (SDHS).

Methodology

A secondary analysis of the Somali Demographic Health Survey (SDHS) in 2020 was conducted, utilizing responses from 6,580 mothers of female children aged 0–14 years. Descriptive statistics, chi-square tests, and multi-nominal logistic regression were employed to analyze the prevalence and associated factors of FGM/C. The analysis incorporated sampling weights to ensure accurate population representation.

Results

The prevalence of FGM/C among respondents was 99.6% (n = 6,553), with Pharaonic circumcision being the most prevalent type (76.7%), followed by Sunni (14.1%) and intermediate forms (8.8%). Demographically, 83.9% of respondents had no formal education, while only 0.99% attained higher education, and the majority resided in nomadic (37.7%) and rural (33.6%) areas. Regional variations were observed, with the highest support for FGM/C continuation in Sanaag (77.2%) and the lowest in Maroodi-jeeh (42.2%). Chi-square analysis revealed significant associations between attitudes toward FGM/C and age (X² = 57.12, p < 0.001), place of residence (X² = 299.45, p < 0.001), education (X² = 140.09, p < 0.001), and wealth (X² = 67.48, p < 0.001). Women in nomadic areas (76.1%) and those with no education (67.6%) were more likely to support continuation, compared to urban residents (53.5%) and those with higher education (24.6%). Multinomial logistic regression indicated that urban residents were 44.7% less likely to support continuation than nomadic residents (Exp(B) = 0.553, p < 0.001), and women with no formal education were 2.3 times more likely to support continuation than those with higher education (Exp(B) = 2.307, p = 0.025). Religious beliefs strongly influenced attitudes, with those considering FGM/C a religious requirement overwhelmingly supporting its continuation (Exp(B) ≈ 0, p < 0.001).

Conclusion

Notwithstanding the near-universal prevalence of FGM/C in Somaliland, attitudes toward its perpetuation are influenced by educational attainment, socioeconomic status, geographical location, and religious convictions. Targeted educational initiatives and culturally appropriate interventions are imperative for altering perceptions and mitigating the practice.

Introduction

Female Genital Mutilation/Cutting (FGM/C) is a non-therapeutic, traditional practice involving the surgical modification of female genitalia, primarily occurring in African nations [1]. The World Health Organization defines female genital mutilation (FGM) as any procedure that partially or completely removes female external genitalia or causes other harm to female genital organs for non-medical purposes [2]. This practice is typically performed on young females from birth to age 15 by traditional practitioners, infringing upon the rights of these children [3]. FGM is globally acknowledged as a human rights violation and a form of violence against women and girls [4].

Female genital mutilation/cutting (FGM/C) is typically carried out on females from birth to adolescence and has been categorized into four distinct types [5]. The first type involves the complete or partial excision of the prepuce and/or clitoral gland. The second type encompasses the complete or partial removal of the clitoral glans and labia minora, leaving the labia majora intact. The third type, known as infibulation, entails constricting the vaginal opening by altering the labia majora and minora, potentially including the removal of the clitoral glans. The fourth type includes any other harmful, non-medical procedures such as burning, piercing, or scraping [6]. The risks associated with FGM/C vary depending on the type performed; the most severe form, infibulation (Type III), poses significant obstetric dangers including the need for infant resuscitation, stillbirth, and neonatal mortality. complete or partial excision of the prepuce (Types I) and complete or partial removal of the clitoral glans and labia minora (Type II) are associated with increased risks of cesarean delivery and postpartum hemorrhage [7].

FGM/C is disturbingly widespread, with global estimates varying significantly. While the exact number is uncertain, projections suggest between 100 and 140 million women and girls in Africa and the Middle East have undergone FGM/C [8]. UNICEF’s global estimate exceeds 200 million affected women and girls [9]. The practice is recognized as a manifestation of deeply ingrained gender inequalities, representing an extreme form of discrimination against females. This issue is addressed in the fifth Agenda of the 2030 Sustainable Development Goal (SDG) [10].

The prevalence of FGM/C varies significantly across regions, with some areas showing a decline in the practice among younger generations. For instance, a survey in Sudan revealed a decrease in FGM/C among young women, with only 20% of girls aged 4 to 9 undergoing the procedure, compared to higher rates among older cohorts [11]. This decline may be attributed to changing attitudes and increased awareness of the health risks associated with FGM/C, which include severe physical and psychological complications [12]. In Egypt, a nationwide survey highlighted that education levels significantly influenced women’s knowledge and attitudes towards FGM/C, indicating that increased education could lead to a reduction in the practice [13].

The 2020 Somali Health and Demographic Survey reveals that 99% of females between 15 and 49 years old have undergone FGM, with the majority experiencing it between ages 5 and 9 [14]. In Somalia, Type III Female Genital Cutting (FGC), the most severe form of genital cutting, is the most commonly practiced [2]. This prevalence suggests that FGM is deeply rooted in religious and social customs, intertwined with psychosexual and personal motivations, making its eradication extremely challenging [15].

The health implications of FGM/C are profound and well-documented. Women who have undergone FGM/C often experience a range of physical complications, including dyspareunia, urinary tract infections, and complications during childbirth [12, 16, 17]. Furthermore, the psychological consequences can be severe, with studies linking FGM/C to increased rates of anxiety, depression, and post-traumatic stress disorder among affected women [18, 19]. Despite these risks, many women in certain communities continue to support the practice, often due to a lack of comprehensive education about its consequences and the perceived social benefits of conforming to cultural norms [20].

The persistence of FGM/C in Somaliland underscores the critical necessity for evidence-based interventions tailored to the local context. Elucidating the attitudes and practices surrounding FGM/C is imperative for developing effective programs to eradicate this harmful practice. This study investigates the attitudes and practices of FGM/C in Somaliland utilizing evidence from the Somali Demographic and Health Survey 2020. The findings aim to contribute to the expanding body of knowledge on FGM/C and inform policymakers, practitioners, and advocates in their endeavors to eliminate this detrimental practice.

Method and materials

Study setting

This investigation was conducted in Somaliland, officially designated as the Republic of Somaliland, an unrecognized de facto sovereign state in the Horn of Africa. The nation comprises six administrative regions: Awdal, Maroodi-jeeh, Sahil, Togdheer, Sanaag, and Sool. Its territory encompasses an area of approximately 176,120 square kilometers, with an estimated population of 5.7 million as of 2021 [21].

Study design and period

This study constitutes a secondary analysis of data derived from the Somali Demographic and Health Survey 2020 (SDHS 2020), the inaugural nationally representative demographic and health survey conducted in Somaliland. The SDHS 2020 utilized a cross-sectional design to collect comprehensive information on demographic, health, and social indicators, including attitudes and practices regarding Female Genital Mutilation/Cutting (FGM/C).

The survey was implemented as a national-level initiative to enhance data systems and support evidence-based planning. Data collection commenced in August 2018 and concluded in December 2019, encompassing urban, rural, and nomadic populations across Somalia and Somaliland. This analysis specifically focuses on FGM/C-related attitudes toward the practices, leveraging the robust and high-quality data from the SDHS 2020 [14]. Particularly focusing on Somaliland.

Data source and sampling

This study used a secondary analysis based on data from the 2020 Somali Health and Demographic Survey (SHDS), which was conducted by the Somalia National Bureau of Statistics [14]. The survey was performed across 16 out of 18 Somalia’s regions. Lower Shabelle and Middle Juba regions were excluded from the survey for security reasons. Each of the 16 pre-war geographical regions in Somalia was stratified into urban, rural, and nomadic areas, except for the Banadir region which was considered completely urban [22]. The variables of interest related to female genital mutilation/cutting were extracted from the child-focused and adolescents’ dataset, KR data, which were extracted from data collected for the female child (age 0 to 14 years), who answered whether the daughter was either circumcised or not questionnaire of the SHDS.

The study population included all women aged 15–49 who were either permanent residents or visitors who stayed in the selected households the night before the survey. A total of 21,218 completed the survey interview. However, for this study, data from mothers of at least one female child (age 0 to 14 years), who answered whether the daughter was either circumcised or not were used. Therefore, data from a total of 6,580 mothers was used for this study. Sampling weights were applied to ensure accurate population representation and only complete cases on all variables of interest were included in the analysis.

The survey utilized a multi-stage probability sampling methodology, stratifying each region into 18 strata based on urban, rural, and nomadic residential areas. Within each stratum, 35 primary sampling units (PSUs) were randomly selected for urban and rural areas and 10 PSUs for nomadic areas. From the enumerated PSUs, 10 secondary sampling units (SSUs) were randomly chosen in urban and rural strata. Subsequently, 30 households were systematically sampled from each selected PSU, and all eligible women aged 15–49 years within these households were invited to participate. A three-stage stratified cluster sampling design was implemented, incorporating probability proportional to size for PSUs and SSUs and systematic sampling at the household level. Data was collected through face-to-face interviews using a structured questionnaire designed for ever-married women.

Measurements of variables

Dependent variable

The outcome variable for the study was focused on attitudes toward FGM/C and can be derived from questions such as “Should female circumcision continue or stop?” with potential responses including Continued, Stopped, Depends, and Don’t Know. These responses were recoded as categorical variables where 1 = Continued, 0 = Stopped, 2 = Depends, and 3 = Don’t Know, representing varying degrees of support or opposition to the practice.

Predictor variables

The primary predictor in this study was the question in the women’s questionnaire asking “Is your daughter circumcised?”. The variable was coded as 0 “No” and 1 “Yes”. and beliefs regarding whether circumcision is required by religion, with responses classified as “Yes,” “No,” or “Don’t Know.” These variables provide critical insight into the personal and cultural beliefs influencing FGM/C practices.

Additional predictors include key socio-demographic and contextual factors such as age, educational level (No Education, Primary, Secondary, or Higher), and wealth index (Lowest, Second, Middle, Fourth, and Highest). Marital status was also examined and grouped into Married, Divorced, or Widowed. Place of residence was classified as urban, rural, or nomadic, while regional variations were assessed across Awdal, Maroodi-Jeeh, Saahil, Togdheer, Sool, and Sanaag. Furthermore, the type of circumcision (Sunni, Intermediate, Pharaonic, or Don’t Know), the individual who performed the circumcision (Traditional Circumciser, Traditional Birth Attendant, Other Traditional, Doctor, Clinical Officer, Nurse/Midwife, Other Health Professional, or Don’t Know), and the age at which FGM/C was performed were included as significant contextual and procedural factors.

Data analysis

Data analyses were conducted using STATA version 17. Descriptive statistics were performed for all selected variables and presented as frequencies, percentages, means, and standard deviations. Subsequently, a bivariate analysis, specifically a chi-square test, was conducted to examine the relationship between the dependent variable (Attitude towards FGM/C) and categorical variables. Logistic regression models were employed to investigate the strength and direction of relationships between predictor variables and the outcome variable (Attitude towards FGM/C). To adjust for the effect of confounders, an odds ratio with 95% confidence intervals was computed to identify the presence and strength of association, and a p-value < 0.05 was considered statistically significant. The sample weight calculated for the SDHS 2020 was incorporated into the analysis to ensure accurate population representation.

Ethical consideration

The study used secondary data obtained in accordance with the National Data Sharing and Accessibility Policy (NDSAP) implemented by the Government of Somalia. The dataset utilized in the study did not contain any personally identifiable information about the survey participants, thus eliminating the need for ethical approval for this study.

SDHS 2020 adhered to stringent ethical protocols to ensure participant protection. Informed consent was obtained after participants received comprehensive information regarding the study’s objectives, methodologies, and potential risks, with written consent procured before participation. Confidentiality was maintained through the anonymization of all data and the dissemination of solely aggregated results.

Results

Prevalence of Female Genital Mutilation /Cutting (FGM/C) and demographic characteristics

The prevalence of FGM/C among the surveyed population is high, with 6,553 (99.6%) respondents reporting they have undergone the practice. Among these individuals, 5,024 (76.7%) underwent Pharaonic circumcision, which constitutes the most prevalent type, followed by Sunni circumcision at 923 (14.1%) and Intermediate circumcision at 579 (8.8%). A small proportion, 27 (0.4%), were unable to identify the specific type of circumcision they underwent (Table 1).

Table 1.

Demographic characteristics

Variables	Categories	Frequency	Percentage	Cum
Age in 5-year groups
	15—19	217	3.30	3.30
	20—24	1081	16.43	19.73
	25—29	1848	28.09	47.82
	30—34	1543	23.45	71.27
	35—39	1233	18.74	90.01
	40—44	486	7.39	97.40
	45—49	171	2.60	100.00
Current marital status
	Married	6203	94.27	94.27
	Divorced	227	3.45	97.72
	Widowed	150	2.28	100.00
Type of place of residence
	Rural	2210	33.59	33.59
	Urban	1889	28.71	62.29
	Nomadic	2481	37.71	100.00
Region
	Awdal	850	12.92	12.92
	Maroodi-jeeh	897	13.63	26.55
	Saahil	905	13.75	40.30
	Togdheer	1295	19.68	59.98
	Sool	1553	23.60	83.59
	Sanaag	1080	16.41	100.00
Highest educational level
	No Education	5521	83.91	83.91
	Primary	857	13.02	96.93
	Secondary	137	2.08	99.01
	Higher	65	0.99	100.00
Wealth index combined
	Lowest	915	13.91	13.91
	Second	1446	21.98	35.88
	Middle	1589	24.15	60.03
	Fourth	1452	22.07	82.10
	Highest	1178	17.90	100.00
Respondent circumcised
	Yes	6553	99.59	99.59
	No	27	0.41	100.00
The type of circumcision the respondent underwent	Sunni	923	14.09	14.09
	Intermediate	579	8.84	22.92
	Pharaonic	5024	76.67	99.59
	Don’t Know	27	0.41	100.00
Who performed circumcision
	Trad circumcizer	5347	81.60	81.60
	Trad Birth attendant	1089	16.62	98.21
	Other Trad	18	0.27	98.49
	Doctor	6	0.09	98.58
	Clinical officer	8	0.12	98.70
	Nurse/midwife	55	0.84	99.54
	Other Healt Professional	2	0.03	99.57
	Don’t Know	28	0.43	100.00

The age distribution indicates a predominance of females in the 25–29 (28.09%) and 30–34 (23.45%) age cohorts, with the youngest age group (15–19) constituting 3.30% of the total sample. Regarding marital status, the majority (94.27%) of respondents are married, with a smaller proportion being divorced (3.45%) or widowed (2.28%). Concerning place of residence, the most of the respondents reside in nomadic areas (37.71%), followed by rural (33.59%) and urban (28.71%) settings. Geographically, the largest proportion of respondents originates from Sool (23.60%), followed by Togdheer (19.68%) and Sanaag (16.41%). For educational attainment, the majority have no formal education (83.91%), with only a small proportion having completed primary (13.02%), secondary (2.08%), or higher education (0.99%). The wealth distribution demonstrates a significant proportion in the lower wealth categories, with 13.91% in the lowest quintile and 21.98% in the second quintile Table 1.

Socio-demographic factors associated with attitude toward the practice of Female Genital Mutilation (FGM)

Age groups demonstrated a strong association with attitudes towards FGM/C (X2 = 57.1158, p < 0.001), with younger individuals (15–19 years) exhibiting a higher likelihood of supporting its continuation. Similarly, place of residence exhibited a significant impact (X2 = 299.4507, p < 0.001), with nomadic populations displaying the highest support (76.06%), followed by rural (63.53%) and urban (53.45%) residents. The region also significantly influenced attitudes (X2 = 654.42, p < 0.001), with Sanaag demonstrating the highest support (77.22%) and Maroodi-jeeh the lowest (42.25%). Educational level (X2 = 140.0932, p < 0.001) and wealth index (X2 = 67.4757, p < 0.001) were also strongly associated with FGM/C attitudes. Individuals with no education were more likely to support its continuation (67.63%), while those with higher education were less supportive (24.62%). Wealthier individuals exhibited a slight preference for continuation, and (69.14%) in the middle wealth index. Finally, religion was a significant factor (X2 = 3.3e + 03, p < 0.001), with those who believed circumcision was required by religion overwhelmingly supporting its continuation (86.68%) Table 2.

Table 2.

Associated factors Attitude toward FGM/C practice

Variables	Categories		Female Genital Mutation (FGM)			X2	P-value
		Continued	Stopped	Depends	Don’t Know
Age in 5-year groups						57.1158	0.000*
	15—19	150 (69.44%)	45 (20.83%)	45 (20.83%)	45 (20.83%)
	20—24	771 (71.32%)	771 (71.32%)	771 (71.32%)	771 (71.32%)
	25—29	1212 (65.73%)	1212 (65.73%)	1212 (65.73%)	1212(65.73%)
	30—34	987 (63.97%)	987 (63.97%)	987 (63.97%)	987 (63.97%)
	35—39	756 (61.31%)	756 (61.31%)	756 (61.31%)	756 (61.31%)
	40—44	303 (62.35%)	303 (62.35%)	303 (62.35%)	303 (62.35%)
	45—49	118 (69.01%)	118 (69.01%)	118 (69.01%)	118 (69.01%)
Current marital status						3.5449	0.738
	Married	4,052 (65.38%)	4,052(65.38%)	4,052 (65.38%)	4,052(65.38%)
	Divorced	142 (62.56%)	142 (62.56%)	142 (62.56%)	142 (62.56%)
	Widowed	104 (69.33%)	104 (69.33%)	104 (69.33%)	104 (69.33%)
Place of residence						299.4507	0.000*
	Rural	1,404 (63.53%)	1,404 (63.53%)	1,404 (63.53%)	1,404 (63.53%)
	Urban	1,007 (53.45%)	1,007 (53.45%)	1,007 (53.45%)	1,007 (53.45%)
	Nomadic	1,887 (76.06%)	1,887 (76.06%)	1,887 (76.06%)	1,887 (76.06%)
Region						654.42	0.000*
	Awdal	552 (65.33%)	552 (65.33%)	552 (65.33%)	552 (65.33%)
	Maroodi-jeeh	379 (42.25%)	379 (42.25%)	379 (42.25%)	379 (42.25%)
	Saahil	615 (67.96%)	615 (67.96%)	615 (67.96%)	615 (67.96%)
	Togdheer	834 (64.40%)	834 (64.40%)	834 (64.40%)	834 (64.40%)
	Sool	1,084 (69.80%)	1,084 (69.80%)	1,084 (69.80%)	1,084 (69.80%)
	Sanaag	834 (77.22%)	834 (77.22%)	834 (77.22%)	834 (77.22%)
Highest educational level						140.0932	0.000*
	No Education	3,734 (67.63%)	3,734 (67.63%)	3,734 (67.63%)	3,734 (67.63%)
	Primary	495 (58.10%)	495 (58.10%)	495 (58.10%)	495 (58.10%)
	Secondary	53 (38.69%)	53 (38.69%)	53 (38.69%)	53 (38.69%)
	Higher	16 (24.62%)	16 (24.62%)	16 (24.62%)	16 (24.62%)
Wealth index combined						67.4757	0.000
	Lowest	588 (64.26%)	588 (64.26%)	588 (64.26%)	588 (64.26%)
	Second	964 (66.85%)	964 (66.85%)	964 (66.85%)	964 (66.85%)
	Middle	1,098 (69.14%)	1,098 (69.14%)	1,098 (69.14%)	1,098 (69.14%)
	Fourth	936 (64.46%)	936 (64.46%)	936 (64.46%)	936 (64.46%)
	Highest	712 (60.44%)	712 (60.44%)	712 (60.44%)	712 (60.44%)
Religion is Required Circumcision						3.3e + 03	0.000*
	Yes	3,808 (86.68%)	3,808 (86.68%)	3,808 (86.68%)	3,808 (86.68%)
	No	424 (20.58%)	424 (20.58%)	424 (20.58%)	424 (20.58%)
	Don’t know	66 (54.10%)	66 (54.10%)	66 (54.10%)	66 (54.10%)

*Significant association p < 0.05

Factors influence the attitudes towards the practice of Female Genital Mutilation (FGM)

In terms of age, the reference group is the 45–49 age group. The odds of supporting circumcision continuation versus cessation do not significantly differ across the other age groups, with p-values exceeding 0.05 in all comparisons. For instance, the 20–24 age group (Exp(B) = 0.761, p = 0.371), the 25–29 age group (Exp(B) = 0.887, p = 0.617), and other age groups exhibit similar odds, indicating no significant association between age and the likelihood of supporting circumcision continuation.

Place of residence demonstrates a significant influence on the decision. Individuals residing in rural areas (Exp(B) = 0.653, p = 0.000) exhibit lower odds of supporting circumcision continuation compared to those in nomadic areas, whereas those in urban areas (Exp(B) = 0.841, p = 0.057) demonstrate marginally lower odds, although this result approaches the threshold of statistical significance. This suggests that geographic location influences attitudes toward circumcision, with urban and rural residents being less inclined to support its continuation than those in nomadic settings. Regarding education level, individuals with no formal education (Exp(B) = 2.307, p = 0.025) are more likely to support circumcision continuation compared to those with higher education. Although the association for primary education is marginal (p = 0.083), the odds are significantly higher for those without formal education, highlighting the potential impact of education on attitudes toward circumcision.

Wealth also influences attitudes toward circumcision. Individuals in the lowest wealth index (Exp(B) = 1.351, p = 0.021) and second wealth index (Exp(B) = 1.308, p = 0.021) are more likely to support circumcision continuation compared to those in the highest wealth index. However, no significant relationship is observed for those in the middle and fourth wealth categories (Exp(B) = 1.167, p = 0.185 and Exp(B) = 1.189, p = 0.134, respectively), suggesting that wealth disparities may affect attitudes toward circumcision.

Religion plays a critical role in shaping these attitudes. Respondents who consider circumcision a religious requirement (Exp(B) = 0.000, p < 0.001) are overwhelmingly likely to support its continuation, with the odds ratio being virtually zero for both those who believe circumcision is required by religion and those who do not. This finding underscores the importance of religious beliefs in influencing decisions about circumcision. Regional variations also demonstrate significant associations. Respondents from certain regions, such as Maroodi-Jeh (Exp(B) = 0.360, p = 0.000), Saahil (Exp(B) = 0.754, p = 0.048), and Togdheer (Exp(B) = 0.699, p = 0.006), are less likely to support circumcision continuation compared to those from Sanaag, which serves as the reference region. These results indicate regional differences in attitudes toward circumcision, with individuals from certain regions being less inclined to favor its continuation Table 3.

Table 3.

Factors influence the attitudes towards the practice of Female Genital Mutilation (FGM)

Multinomial logistic regression					Number of obs =   6,574 LR chi2(66)   = 3831.86 Prob > chi2   =  0.0000
Log likelihood = −3613.0593					Pseudo R2     =  0.3465
Attitude	Coefficient	Std. err	z	P > z	[95% conf. interval]
Continued
Age
20 - 24	.234539	.2484226	0.94	0.345	-0.2523603-0.7214382
25 - 29	.2502341	.2405344	1.04	0.298	-0.2212046-0.7216728
30 - 34	.2482707	.2426176	1.02	0.306	-0.2272511-0.7237925
35 - 39	-.0012977	.2456182	-0.01	0.996	-0.4827006-0.4801052
40 - 44	-.28062	.2708354	-1.04	0.3	-0.8114476-0.2502076
45 - 49	.423852	.3353267	1.26	0.206	-0.2333762-1.08108
Residence					-
Urban	-.4469963	.1002002	-4.46	0	-0.643385--0.2506076
Nomadic	.3278247	.102775	3.19	0.001	0.1263894-0.5292601
Region					-
Maroodi-jeeh	-1.175078	.1483576	-7.92	0	-1.465854--0.8843027
Saahil	-.1002623	.1499592	-0.67	0.504	-0.3941768-0.1936523
Togdheer	-.2069457	.1454676	-1.42	0.155	-0.492057-0.0781655
Sool	-.04292	.1403083	-0.31	0.76	-0.3179193-0.2320792
Sanaag	.5745789	.1668199	3.44	0.001	0.2476179-0.9015399
Education					-
Primary	-.3209963	.1214589	-2.64	0.008	-0.5590513--0.0829413
Secondary	-.6171519	.2711363	-2.28	0.023	-1.148569--0.0857346
Higher	-1.46518	.4045112	-3.62	0	-2.258008--0.672353
Wealth					-
Second	-.0461024	.1396324	-0.33	0.741	-0.3197769-0.2275721
Middle	-.3093336	.1426951	-2.17	0.03	-0.5890109--0.0296563
Fourth	-.2727185	.1396153	-1.95	0.051	-0.5463596-0.0009225
Highest	-.5538552	.1429594	-3.87	0	-0.8340505--0.2736598
Religion_FGM					-
No	-3.711872	.0861427	-43.09	0	-3.880709--3.543036
Don't Know	-1.554475	.2570386	-6.05	0	-2.058261--1.050689
					-
_cons	2.912818	.2823713	10.32	0	2.35938-3.466256
Stopped	(base outcome)				-
Depends					-
Age					-
20 - 24	-.3757049	.3280683	-1.15	0.252	-1.018707-0.2672971
25 - 29	-.0233295	.3118617	-0.07	0.94	-0.6345671-0.5879081
30 - 34	-.0137762	.3149218	-0.04	0.965	-0.6310117-0.6034592
35 - 39	-.3097572	.323784	-0.96	0.339	-0.9443621-0.3248478
40 - 44	-.3090599	.3644437	-0.85	0.396	-1.023357-0.4052366
45 - 49	-.2764887	.4886838	-0.57	0.572	-1.234291-0.681314
Residence					-
Urban	-.4053755	.1461762	-2.77	0.006	-0.6918756--0.1188755
Nomadic	.2010058	.1474043	1.36	0.173	-0.0879013-0.489913
Region					-
Maroodi-jeeh	-1.183327	.3265864	-3.62	0	-1.823425--0.5432295
Saahil	-.0042586	.2902132	-0.01	0.988	-0.5730661-0.5645489
Togdheer	1.438912	.2392995	6.01	0	0.9698938-1.907931
Sool	.9892022	.2426903	4.08	0	0.513538-1.464866
Sanaag	1.860014	.2593193	7.17	0	1.351757-2.36827
Education					-
Primary	.030857	.1663359	0.19	0.853	-0.2951554-0.3568694
Secondary	-.0830703	.4010025	-0.21	0.836	-0.8690208-0.7028803
Higher	.1469441	.4795436	0.31	0.759	-0.7929442-1.086832
Wealth					-
Second	-.0427741	.1946729	-0.22	0.826	-0.424326-0.3387778
Middle	-.5309944	.1996907	-2.66	0.008	-0.9223809--0.139608
Fourth	-.5795577	.2018251	-2.87	0.004	-0.9751276--0.1839878
Highest	-.6698959	.2147921	-3.12	0.002	-1.090881--0.2489112
Religion_FGM					-
No	-2.153241	.1264913	-17.02	0	-2.401159--1.905322
Don't Know	.1875985	.3268871	0.57	0.566	-0.4530884-0.8282855
_cons	-.2519804 .399026		-0.63	0.528	-1.034057-0.5300962
Don_t_Know					-
Age					-
20 - 24	15.0681	3361.992	0	0.996	-6574.315-6604.451
25 - 29	16.71213	3361.992	0	0.996	-6572.671-6606.095
30 - 34	16.6098	3361.992	0	0.996	-6572.773-6605.992
35 - 39	-.8109867	3620.202	0	1	-7096.276-7094.654
40 - 44	16.35311	3361.992	0	0.996	-6573.03-6605.736
45 - 49	-.6511064	7409.572	0	1	-14523.15-14521.84
Residence					-
Urban	1.013921	.7073423	1.43	0.152	-0.3724447-2.400286
Nomadic	.8473229	.6717982	1.26	0.207	-0.4693774-2.164023
Region					-
Maroodi-jeeh	-.0639418	1.417964	-0.05	0.964	-2.843099-2.715216
Saahil	1.783697	1.271864	1.4	0.161	-0.70911-4.276504
Togdheer	1.670225	1.362089	1.23	0.22	-0.99942-4.33987
Sool	-.2791927	1.403817	-0.2	0.842	-3.030624-2.472238
Sanaag	4.484433	1.313643	3.41	0.001	1.909741-7.059125
Education					-
Primary	-.5486407	.8381219	-0.65	0.513	-2.191329-1.094048
Secondary	-19.27287	5283.288	0	0.997	-10374.33-10335.78
Higher	-19.14901	12283.97	0	0.999	-24095.28-24056.98
Wealth					-
Second	-1.601531	1.111942	-1.44	0.15	-3.780897-0.5778341
Middle	.1645436	.9039978	0.18	0.856	-1.607259-1.936347
Fourth	.8005543	.8989291	0.89	0.373	-0.9613143-2.562423
Highest	-1.190823	1.25615	-0.95	0.343	-3.652832-1.271186
Religion_FGM					-
No	16.16109	1221.548	0.01	0.989	-2378.029-2410.351
Don't Know	21.50635	1221.548	0.02	0.986	-2372.684-2415.697
_cons	-39.30623	3577.034	-0.01	0.991	-7050.165-6971.552

Discussion

This study highlights the pervasive nature of Female Genital Mutilation/Cutting (FGM/C) in Somaliland, with a prevalence of 99.6% among the respondents, consistent with findings from the 2020 Somali Health and Demographic Survey (SHDS) [14]. The high prevalence aligns with reports from other regions in Somalia and neighboring countries where FGM/C is culturally entrenched [9]. For instance, Sudan’s prevalence is slightly lower but remains substantial, with 88% of women affected [11]. The dominant type of FGM/C reported in Somaliland is Pharaonic circumcision (76.7%), which is significantly more invasive than other forms, posing severe health risks [4].

Educational attainment strongly influenced attitudes toward FGM/C. Women with no formal education were significantly more likely to support its continuation. This finding corroborates studies from Egypt, where higher education levels were associated with reduced support for FGM/C [13]. Education likely increases awareness of the health risks and human rights violations associated with the practice, highlighting the importance of integrating anti-FGM/C messaging into educational curricula.

Place of residence also played a critical role. Women in urban areas were less likely to support FGM/C continuation compared to their nomadic counterparts. Similar patterns have been observed in Nigeria, where urbanization correlates with declining FGM/C prevalence due to increased exposure to anti-FGM/C campaigns and access to healthcare services [12]. This urban–rural divide underscores the need for targeted interventions in rural and nomadic communities.

Religious beliefs emerged as a key determinant of attitudes. Among respondents who perceived FGM/C as a religious requirement. This aligns with findings from Ethiopia, where religious justification was a significant predictor of FGM/C support [15]. Efforts to counteract this perception should involve religious leaders and culturally sensitive dialogues to challenge the association between FGM/C and religious piety.

Wealthier women were less likely to support FGM/C continuation, with those in the highest wealth quintile less likely to favor its perpetuation compared to the lowest. These findings are consistent with research in Kenya, which identified economic empowerment as a protective factor against FGM/C [8]. Wealthier individuals often have greater access to information and healthcare, enabling them to make informed decisions against harmful practices.

Significant regional differences were observed. Support for FGM/C continuation was highest in Sanaag and lowest in Maroodi-Jeeh. This regional disparity reflects cultural and socioeconomic heterogeneity, as seen in similar studies in Sudan and Ethiopia, where regions with stronger cultural ties to FGM/C showed higher prevalence and support [11, 15].

The health risks associated with FGM/C, particularly Type III (Pharaonic circumcision), are profound, including obstructed labor, postpartum hemorrhage, and neonatal mortality [7]. Despite these risks, the practice persists due to entrenched cultural norms and limited access to accurate health information. Community-based education campaigns, combined with healthcare provider training, are essential to mitigate these risks.

The findings underscore the importance of integrating FGM/C eradication efforts into broader health and development programs. The involvement of policymakers, educators, and community leaders is crucial. Programs should focus on economic empowerment, educational outreach, and culturally sensitive advocacy to dismantle the socio-cultural structures sustaining FGM/C.

Conclusion

The study demonstrates that FGM/C remains a pervasive practice in Somaliland, driven by socio-cultural and religious norms. Educational attainment, wealth, geographic location, and religious beliefs significantly influence attitudes toward its continuation. Addressing these factors necessitates comprehensive, community-based interventions that prioritize education, economic empowerment, and cultural sensitivity. Religious leaders and influencers should play a pivotal role in reshaping narratives that perpetuate FGM/C as a moral or religious imperative.

Reducing FGM/C in Somaliland will require coordinated efforts involving policymakers, health practitioners, educators, and community leaders. Supported by robust data, sustained advocacy campaigns are essential to dismantle the entrenched socio-cultural structures sustaining this practice. Future research should explore ongoing interventions’ impact and further investigate socio-political frameworks’ role in perpetuating or mitigating FGM/C.

Abbreviations

GBV

Gender-Based Violence

LGA

Local Government Area

PSU

Primary Sampling Unit

SDG

Sustainable Development Goal

SHDS

Somali Health and Demographic Survey

SSU

Secondary Sampling Unit

UNICEF

United Nations International Children’s Emergency Fund

WHO

World Health Organization

Author’s contributions

The author, A.Y., solely conceptualized the study, performed the data analysis using the Somali Demographic Health Survey 2020 dataset, and drafted the manuscript. A.Y. interpreted the results, prepared all figures and tables, and critically revised the manuscript for intellectual content. The author approves the final version of the manuscript and is accountable for all aspects of the work.

Funding

There is no funding.

Data availability

https://microdata.nbs.gov.so/index.php/catalog/50/get-microdata.

Declarations

Ethics approval and consent to participate

The Somali Demographic and Health Survey 2020 (SDHS 2020) was approved by the Somali National Bureau of Statistics (SNBS) and the Ministry of Health, Somalia. The study adhered to the SNBS’s ethical data collection and participant protection guidelines.

This study utilized secondary data from the Somali Demographic and Health Survey 2020 (SDHS 2020), which adheres to ethical guidelines for data collection and participant protection. Informed consent was obtained from all participants by the Somali National Bureau of Statistics before data collection. No additional ethical approval was required for this secondary data analysis, as the dataset was anonymized and did not contain personally identifiable information.

Consent for publication

The author declared this manuscript have not been published elsewhere.

Competing interests

The authors declare no competing interests.