An Insider–Outsider Approach to Understanding the Prevalence of Female Genital Mutilation in Pusiga in the Upper East Region of Ghana

Round 1

Reviewer 1 Report

Dear Authors:

Although I do have a number of fairly significant comments, which I set out below, I first want to comment on my  recommendation of "Reconsider after major revision."  Given the strong potential of this article, my actual recommendation is "Accept after major revision:" however, this was not an option, but it is what I strongly recommend. 

So please read the below with this is mind. In short, although I do think you have a fair amount of work ahead of you, overall, I am really impressed with this study and think it will make a great scholarly contribution to the field.

I will begin with my more minor comments, and then turn to my major recommendation for revision. 

1.  In the methods section, I don't like the word "exciting" —i know this may sound very trivial, but somehow it has a rather elitist/distancing feel to it.  I am sure this was not intended, but I would suggest changing this - maybe a "rich site" or a "valuable site"?  Again, this is pretty minor!!

2.  You need to explain what you mean by survivor and non-survivor of FGM/C.  For instance, is anyone who goes through the cutting process a survivor, including those who "consented" because they "agree" with the practice, as this term usually encompasses non-consensual events. I also know that "consent" is a very charged term, as what does it mean to consent to something of this nature, but I think you may need to address this.  Also, what does a "non-survivor " mean?  Is it someone who actively resisted cutting or is it anyone who isn't cut?  

3. Also in the methods section, it is not entirely clear why the FGM rate is so much higher in the Pusiga district when compared to the country as a whole.

4.  I think you want to say a bit more than you do about your qualitative phenomenological approach.  You don't need a lot here, but I would simply suggest adding a line or two after stating that this is your approach.

5.   You discuss positionality in the "Methods of Analysis" section; however, you really don't carry this through your analysis. By this I mean that while you say a bit about who you are and that one of you is an outsider and the other an insider thus suggesting that these different vantage points are relevant to your analysis, I don't see much evidence of this.  So, this needs some careful attention.  

6.  On lines 273-275, the participant seems to be providing a religious explanation for her views, yet you have it under the moral justifications, rather than in the section on religious views.

7.  I have a structural comment with respect to sections 3.1-3.4.  Specifically, in section 3.4 you discuss the intergenerational dimensions and power dynamics and in doing so you identify the composition of the focus groups.  What is confusing to me is whether or not what you are saying here actually applies to all of the focus groups and the differing views expressed by the participants? 

In other words, did some of the younger participants have different religious views than the elders?  etc. Did these dynamics run through all of the focus groups?  Assuming that was the case, I think you need to restructure this to make that clear.  Perhaps you could do this by introducing these dynamics at the outset of this section and then articulating how they played out in terms of each subsection. Or if you think it is better at the end here, you want to make it clear that these were cross-cutting themes/dynamics. 

However, I think the former would make this clearer - as then your readers would actually know the composition/dynamics of the focus groups.

8.  Now for my most significant, and perhaps controversial comment given the conventions of academic writing.  Your heading for Part 2 is "Inferring implications for Health Practitioners"—you also use the word inferring throughout the paper.  However, underneath the inferring there is a strong and articulate advocacy voice - and I think this needs to come through much clearer and louder from the start of the article.  In other words, I think the aim of the study is to advocate for the development of a sexuality education as a health promotion tool what is based upon the "gleaned insights into how FGM/C's historical, religious, moral and economic dimensions" perpetuate the practice. 

For me, the tension in the article is that this really seems to be your focus and goal, but it is muted.  I think the article would be much stronger, and I would say of real world value, if you made this stance clear.  

However, I understand that this is not always acceptable in academic writing, and so you may opt to disregard this suggestion, but I would love to see you rethink what you say the purpose of your article is and then carry this through out!!

In closing, while I think you have a fair amount of revising to do, I would urge you to move ahead with it. This promises to be a great article that will be of tremendous value to scholars/advocates/health practitioners and others. 

Best of luck. 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

 

This study provides insights into how the historical, religious, moral, and economic dimensions of FGM/C contribute to its prevalence in a particular region of Ghana. It is a remarkable, commendable achievement that this study which required face-to-face in-depth interviews was conducted at all during the COVID pandemic.

 

First, a little about me as a reviewer. I am a human rights scholar without in-depth knowledge of Ghana or its neighbors. I have read many previous articles about FGM/C. I learned a lot from this article, though I am still confused on a few points.

 

First, the author claims the insider-outsider continuum in feminist research provides a powerful approach to producing knowledge on contextual factors that account for FGM/C in particular settings. Please provide a brief explanation of the insider-outsider continuum in feminist research for those of us who are not feminist scholars.  

 

Also, under international human rights laws, national governments have the primary responsibility for protecting the human rights of their citizens. The paper does not discuss the policy of the national government on whether FGM/C is legal/appropriate? By implication, I think Ghana prohibits FGM/C. Is this true? Does Ghana have a policy prohibiting FGM/C? If so, please tell the reader about it. If not, why do women in Ghana have to go to Burkina Faso or other neighboring countries to have FGM/Cutting performed?

 

Finally, after reading this article, I was not clear about how the authors view the role of patriarchy in perpetuating this practice. There are places where the authors blame prospective husbands and other places where they praise some fathers for opposing the procedures being performed on their daughters. I know its complicated, but I urge the author to be clearer.

 

This is important because the policy implications discussed at the end of the article focus on sex education mostly for women and girls. I don’t see how this would have much effect on religious leaders, prospective husbands, and fathers, who are the main culprits in this story.

 

Small points. The writing is clear. However, two small corrections:

 

Line 164, position should be positions

 

Please rewrite Line 340, It is the custom in the area that the bride price (dowry) of a woman is five cows, but men who detect that their newly married wives were virgins and that they were those who broke their virginity paid extra cows as compensation for the parents of the lady be able to take good care of their daughters.

 

 

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

Thank you for the opportunity to review your paper entitled “An Insider-Outsider Approach to Understanding The Prevalence of Female Genital Mutilation in Pusiga in The Upper East Region of Ghana Submitted to section” which aims to examine justifications for FGM/C as a means of informing public health interventions. I read your paper with great interest.

Below are my recommendations/concerns-

·       I struggled to see the relevance of the Insider/Outsider framework as that lens is not consistently threaded through the entire paper. How did the Insider/Outsider data analysis and data collection? Though not explicitly stated in most papers, all researcher studies have Insider/Outsider Positionality dynamics. If those dynamics are explicitly highlighted in the paper, then a more robust discussion about how the authors were intentional about dynamics is warranted.

·       When providing background information for Pusiga, I recommend that the author include information about gender disparities in social outcomes and access to power. What is missing for me in this discussion in a stronger emphasis on the role of patriarchy in perpetuating FGM. How are patriarchy, gendered-power dynamic and FGM/C interrelated in Pusiga?

·       The authors should provide more background information about the phenomenological approach employed.

·       The eligibility criteria for inclusion in the study is not well described. What were the inclusion criteria for “non-survivors” and “survivors”? For the purposes of the study, how did the author define non-survivors and survivors?

·       How did the researchers determine that the sample size was enough? How did the researchers enhance Trustworthiness in the study?

·       Pg 4, line 153. The author defines Positionality as “a method of inquiry”. This definition is a bit odd given the design of the study. Positionality as a form of inquiry is more commonly associated with autoethnography.

·       The definitions of insider vs. outsider provider is too simplistic and could be further developed.

·       The interview and data collection process are not quite clear. Did focus groups include both survivors and non-survivors?

·       The author briefly discusses the role of gender and patriarchy in propagating FGM/C but does not address it in the discussion/recommendation. Are the recommendations made by the author contextually and culturally appropriate? Is education about sexuality culturally appropriate given the cultural and religious values of member of the Pusiga community? Given the structure of the community, who determines what education community members can access? What potential conflicts could arise between the proposed implications and cultural context in Pusiga? What is role of women empowerment interventions in this discussion?

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Dear Authors:

I greatly appreciate the care by which you responded to comments, and the manuscript is greatly improved - very nicely done!! In particular, I think making your advocacy tone stronger really enhances the focus of this paper.

I have ticked the box "accept after minor revision;" however, imagine that I am inserting the word "very" before minor!  Here are my comments regarding a few clean-up points that I think will enhance the clarity of your paper:

1.  While I appreciate your comment on p. 4 that you recognize the "charged nature of the term consent," I think perhaps you duck that by your statement that you are aligning it with the terms survivor and non-survivor.  Is it that you think true consent to FMG/C is impossible given the contextual variables such that there really is no distinction to speak of between those who consent and those who don't?  I am not sure you want or need to wade into this deeply contested terrain, which, of course punctuates other feminist debates, such as over sex work, but if you raise it, I believe you need to do a bit more than you have done here. For instance,  if you are saying that the distinction isn't important for purposes of your study because consent really is an impossibility, then articulate this.  Or perhaps you can avoid this heady debate, if this issue really is not pertinent to your work - and so you are not distinguishing between the groups, without explicating your views on the (im)possibility of true consent.

2.   On p. 5, lines 96-98 are a bit unclear as it sounds as if the differential rates can be explained by "harmful sexual norms," but there is nothing that says they are stronger in Puisga District compared to the country as a whole - I think perhaps the posited link is the demographic characteristics, but this isn't clear.   

3. On p. 13  I think the use of the first person is a tad confusing. If i read p. 13 correctly, I believe the author is saying that as a native of Pusiga s/he recognizes that this is the world view of the community, but as written it reads as if it is their  personal world view. Also, on that page lines 312-313, it again reads as if the author is saying that s/he personally believes these are the benefits of FGM/C as distinct from saying that as an insider they understand the community perspective. 

4.  I didn't pick this up the first time through, but on p. 15, line 359, the suggestion is that bride price is interchangeable with dowry, however, I think they are quite distinct https://theconversation.com/how-bride-price-reinforces-negative-stereotypes-a-ghanaian-case-study-120337, so this perhaps should be double-checked. 

So, these are all quite minor!  Great job. 

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

All concerns raised have been addressed.

Author Response

Thank you very much for the review of our manuscript!