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

: Female Genital Mutilation/Cutting (FGM/C) as a form of gender-related violence continues to thrive within communities and across borders, with (under)reported prevalence among communities in the diaspora. Reports of FGM/C among communities in the diaspora speak to the socio-cultural and religious factors which promote its prevalence. Successful interventions offer alternatives such as rites of passage to the socio-cultural-religious prospects offered by FGM/C to practicing communities. This suggests the need for a critical approach to research methods that engage intimately with the worldview of communities practicing FGM/C while inferring implications for designing health-promotion interventions in speciﬁc contexts. This paper draws on the insider and outsider approach to positionality to assess the factors accounting for the prevalence of FGM/C in Pusiga (3.8% nationally and 27.8% in Pusiga) in the Upper East Region of Ghana while inferring lessons for designing health promotion interventions. Applying a phenomenological qualitative design guided by focus groups and interviews, we draw on the insider approach to present a contextually and culturally sensitive report of ﬁve survivors, ﬁve non-survivors, and ten religious leaders on factors that account for the prevalence of FGM/C. Next, we assume an outsider approach to infer implications based on participants’ perspectives for designing health promotion interventions to curb FGM/C. The ﬁndings suggest shifting from socio-cultural-religious factors to economic undertones underpinning FGM/C. Inter-generational differences also vary attitudes toward FGM/C. We recommend a systematic approach to health promotion that addresses FGM/C’s deep socio-cultural and economic, religious underpinnings of FGM/C in Pusiga. 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.


Introduction
Female Genital Mutilation/Cutting (FGM/C) presents as a gender-induced form of violence against young girls and women in developed and developing contexts (Wasige and Jackson 2018, p. 196;Lombard 2018, pp. 1-12).It continues to thrive within communities in Sub-Saharan Africa, the Middle East, Asia, and across borders (Jahangiry et al. 2021(Jahangiry et al. , p. 1184;;Almeer et al. 2021), with (under) reported prevalence among communities in the diaspora (Yaya and Ghose 2018, p. 244;World Health Organization 2022a;Nyashanu and Mguni 2021;Villani et al. 2016, p. 71).It is estimated that 200 million women globally have undergone FGM/C, and 2 million girls are at risk of undergoing the procedure in the future (World Health Organization 2022b).Local socio-cultural and religious norms interrelate with patriarchal and matriarchal gendered notions to believe that FGM prepares a woman socially and culturally to fit within society.These include deep-rooted convictions that uncircumcised women possess sexually enhancing physical characteristics such as the clitoris, making them dangerously sexually motivated, unclean and susceptible to promiscuity within marriages.The prepuce's religious considerations, as is the clitoris are unclean, and its removal makes a woman whole and ready for marriage (Sipsma et al. 2012, pp. 120-27).By inference, a woman's social, religious, and economic prospects in practicing communities are determined by the rite of circumcision; uncircumcised women are accorded no social status in practicing communities.Considering the social capital to be gained, some families within and outside the diaspora employ all means possible, including engaging the services of primary health professionals (Azadi et al. 2021, pp. 1-14;Ogunsiji andUssher 2021, pp. 1253-62) to remove parts of the female genitalia partially or entirely (World Health Organization 2012).Successful interventions include programs that have offered alternatives to the social capital derived from FGM/C (Wakabi 2007(Wakabi , pp. 1069-70)-70), including providing alternative rituals that are non-invasive.For example, a study by Oloo et al. (2011) on alternative rites of passage for circumcision in two districts in Kenya revealed that alternatives to rites of passage are instrumental in replacing the social capital promised by the prospects of FGM/C.
In designing interventions to combat FGM/C, a balanced relationship is required between legal/policy frameworks and the religious-cultural background of practicing communities.However, in the case of Ghana, a strong legal framework has not completely ensured against the FGM/C's prevalence.In 1994 the Criminal Code (Amendment) Act of the Ghanaian Constitution (1992) inserted Article 69A to the Criminal Offences Act (COA) 1960 to prohibit 'female circumcision' (Government of Ghana 1994).In 2007 this was further amended to 'female genital mutilation and increased penalties' (UN Women 2016).Section 69A of the COA 1960 also sets out a clear definition of FGM (Ghana Law Finder 2017) and criminalises the performance of FGM/C and all those who procure or assist in the practice, as follows: Section 69A(1)-'Anyone who carries out FGM and excises, infibulates or otherwise mutilates the whole or any part of the labia minora, labia majora and the clitoris of another person commits an offence and will be subject to punishment . . .' Section 69A(2)-'Anyone who participates in or is concerned with a ritual or customary activity that subjects a person to FGM commits an offence and will be subject to punishment' (Government of Ghana 1994).
Despite the strong legal prohibition of FGM/C, its prevalence remains high in the Upper East Region of Ghana, where advocacy against FGM/C is powerful.Sakeah et al. (2018, pp. 1-10) found that perpetrators of this form of gender-related violence (GRV) cross boundaries to less strict, pro-FGM legal frameworks in communities in Togo and Burkina Faso to perpetuate the violence.Elsewhere, subtle moral support for FGM/C occurs within strong Anti-FGM environments.In this context, the act goes highly underreported.This situation pertains to the UK, where strong advocacy for the fight against FGM/C has been in place for over 30 years.However, no case of FGM has officially been reported to the police (Wasige and Jackson 2018, p. 196).Yet, scholarship highlights varying rates of FGM/C in England, Scotland, and Wales (Wasige and Jackson 2018, p. 196;Nyashanu and Mguni 2021;Connolly 2018).
In a seminal policy review of laws guiding GRV related to young people in Italy, Ireland, Spain, and the UK, Alldred and Biglia (2015, pp. 662-75) explain the misalignment between policy and laws guiding GRV and young people.This may also explain the highly underreported nature of FGM/C in the UK.They proffer that gender-neutral language and a lack of a comprehensive approach to cultural norms work to exclude young people's power dynamics and other realistic needs as they are confronted with forms of GRV such as FGM/C.Given the cultural context within which FGM/C occurs, local socio-cultural and religious norms that shape attitudes and behaviours towards FGM/C are indispensable considerations in program design.In this paper, we, therefore, agree with a joint statement by WHO/UNICEF/UNFPA statement on FGM that "even though cultural practices may appear senseless or destructive from the standpoint of others, they have meaning and fulfil a function for those who practice them" (World Health Organization 1997).Guided by Alldred and Biglia (2015, pp. 662-75), it is crucial to investigate if current policies, laws, and interventions under the concept of gender-related violence speak to the dynamics that underscore FGM/C.
We identify three gaps our study intends to engage with from the discussions above.We place an abject lack of exclusion of practising communities and gatekeepers identified as the major players in FGM/C; see, for example (Wasige and Jackson 2018, p. 196;Nyashanu and Mguni 2021).Next, The exclusion of gatekeepers and practising communities in research has led to a gap in evidence on the power dynamics that interplay leads to the continuous perpetuation of FGM.Additionally, the exclusion of gatekeepers/practising communities from research and advocacy may have resulted in a shortage in scholarship on underpinning socio-cultural or religious factors and their inclusion in health promotion models.
We engage with the gaps above by employing an insider and outsider approach to positionality (further elaborated in Section 2) within the context of a deep appreciation of feminist approaches to research on GRV.This paper draws on a broader study to explore the justification that can be deduced to uphold FGM practice in the Pusiga district.This paper attempts to understand people's attitudes toward the resurgence of FGM practice in the Pusiga district and infer implications on how the practice of Female Genital Mutilation can be minimised or eradicated in the Pusiga District.In this study, we aim to engage with the perspectives of five survivors 1 of FGM, five non-survivors 2 and gatekeepers to understand the socio-cultural and religious factors that motivate the perpetuation of FGM in the Pusiga district (Gap 1), explore the interplays of power between gatekeepers and survivors (Gap 2), and derive evidence for advocating sexuality education as a health-promoting tool based on underpinning factors of FGM and power interplays identified (Gap 3).

Background of Practising Community
The Pusiga district is a relatively new district located in the eastern part of the Bawku municipality of the Upper East Region of Ghana.It shares borders with Burkina Faso and Togo.It has a total population of 57,677, of which 27,516 (47.7%) are male, and 30,161 (52.3%) are female (Ghana Statistical Service 2014, p. 16).The district is faced with several developmental challenges, of which forms of GRV such as FGM/C (Jackson et al. 2003;Sakeah et al. 2018, pp. 1-10;2019, p. e0214923;) and child marriage (Atubiga 2007;Amoah et al. 2021, pp. 455-66) are significant.The demographic factors in Pusiga inform a higher rate of FGM/C which stands at 27.8% compared to the national statistics of 3.8% (Sakeah et al. 2018, pp. 1-10).Again, the demographic characteristics of the district present it as a meaningful site to investigate the high prevalence of FGM/C: Firstly, due to harmful sexual norms such as patriarchal norms, which are arguably stronger in Pusiga as compared to other parts of the country, women are at a power disadvantage in matters of sexuality (Sakeah et al. 2019, p. e0214923).Second, the district is demographically rural.Forty-five thousand nine indigenes live in rural areas with high poverty levels (Ghana Statistical Service 2014).The district also presents a variety of religious affiliations-78.1% are Muslims, followed by a 13.2% affiliation to Christianity and a 7.4% affiliation to the Traditional African Religion (Ghana Statistical Service 2014, p. 30).The poverty levels and religious affiliations of the demography place the reproductive health of 13,159 women between the age of 15 to 49 in the district at risk in the context of challenges presented by FGM/C (Ghana Statistical Service 2014, p. 16).

Selection Criteria, Population and Sampling Technique
The selection of participants and the sampling techniques employed were informed by existing literature on the roles of opinion and religious leaders in promoting FGM/C in Ghana.Traditional leaders are considered stakeholders who uphold the customs that promote FGM in Ghana (Sakeah et al. 2018, pp. 1-10).Religion is also considered a driving force in the prevalence of FGM (Sakeah et al. 2018, pp. 1-10).Therefore, selecting participants representing traditional custodians and religious leaders was essential and reflective of the religious affiliations described above.The researcher used snowball sampling, which is very useful in research involving research networks (Streeton et al. 2004, pp. 35-47).Representatives of all three major religions were selected: a queen-mother, a chief, and two traditional elders (Traditional African Religion), a Christian religious leader and an Islamic religious leader, n = 10.
Additionally, convenience sampling was used in selecting the five (5) non-survivors and five (5) survivors of FGM/C.Circumcised women (survivors) were included due to the supporting roles of FGM in the northern part of Ghana (Akweongo et al. 2021, pp. 1-17) and to describe the factors that led up to their experience as survivors.Young women who had not undergone FGM/C, referred to as non-survivors, were also included to complement the perspectives of peers who had undergone FGM/C.Data from survivors, non-survivors, traditional leaders and the education officer represented major perspectives necessary to understand underscore factors of FFGM/C from the angles of gatekeepers' views as well as survivors' and non-survivors' advocacy and personal experiences.Educational and political considerations and importance to FGM/C were also important, leading to the selection of a Girls' Education Officer and an Assemblyman (community political representative) of the area.Based on this criterion, the sample size was determined to be adequate.The total sample size was 20 (Please see Table 1).

Data Collection Instruments
A qualitative phenomenological approach was used to utilise the experiences of the authors and participants to inform the data collection process and derive findings (Finlay 2013, pp. 172-201;2014, pp. 121-41;Marshall et al. 2012Marshall et al. , pp. 2664-73)-73).The phenomenological approach, per its definition, allowed us-first author (BEO) and second author (GAA), to draw on our personal experiences as an indigene (language knowledge and familiarity with the local Kusasi culture) and a sexual health educator and researcher while remaining sensitive to the need to prevent experiences from forming judgements or any form of bias while collecting and analysing data.A structured interview guide and a focus group discussion guide were used in collecting data.The in-depth interview guide was designed so that opinion leaders who are stakeholders in the fight and upholders of the practice could contribute to the discussion on FGM on the study site.Through in-depth interviews, perspectives were derived on background, knowledge, experience/behaviour, opinion, feelings, and sensory experiences regarding FGM/C.
The focus group discussion elicited varying views from survivors and non-survivors about their individual and collective knowledge of FGM/C.In-depth interviews were conducted for all participants except survivors and non-survivors.There were two focus group discussions.One each with survivors and another with non-survivors.Focus groups consisted of five participants each.In-depth interviews lasted an hour, while focus group discussions lasted between an hour and a half and two hours.Data was collected between July to September 2021.Focus groups were conducted in the home of participants, while interviews were conducted in schools after the close of school hours to allow for a quiet and conducive atmosphere.Drawing on the background of GAA as an indigene, participants were offered the option to engage in interviews and focus groups in either English or the Kusasi language to allow for accurate discussions around the interview questions and to avoid linguistic challenges that may occur as a result of attempts to translate from the local language to English and vice versa (Alldred and Foradada-Villar 2018, pp. 237-49).

Methods of Analysis
The broader study's data from focus groups and in-depth interviews were transcribed and coded, and themes were analysed through content analysis.Under data collection, it has been shown how utilising the phenomenological approach, the second author harnessed his knowledge of the culture and language of the area to facilitate data collection.We extended these qualities of the phenomenological approach to the insider and outsider continuum of positionality to analyse the themes from the more comprehensive analysis.Positionality is a method of inquiry employed in social science research such as psychology, nursing and health promotion and feminist studies to highlight subtle, underpinning political, social and religious factors that shape the research process (Gruenbaum 2005, pp. 429-41;Caretta and Jokinen 2017, pp. 275-83;Manohar et al. 2017, pp. 1-15;Nyashanu 2021;Merriam et al. 2001, pp. 405-16).Positionality is usually associated with autoethnographic studies to situate the researcher's personal experiences in the context of a research problem (Ngunjiri et al. 2010, pp. 1-17); we associate positionality with phenomenology as a way of drawing on the experience of GAA to show how differences in social position and power shape attitudes towards FGM/C in the Pusiga society.
Graduate researchers have also encouraged positionality to '. . .describe an individual's world view and the position they adopt about a research task and its social and political context' (Holmes 2020, pp. 1-10).As postgraduate researchers, we tapped into these prospects offered by positionality under the insider-outsider continuum of positionality.
An insider in research shares identities such as race, ethnicity and culture, religion and language with the people researched.The insider, as a researcher, is also recognised as a member of the community engaged in research (McCutcheon 1999).The researcher, as an insider, delves into the research process with first-hand knowledge, experience and in most cases, cultural insights into the research problem.When properly managed, therefore, common identities of the researcher and the researched could be tapped into to enhance rather than mar the research process.For example, a body of literature has suggested that the insider dimension of indigene positions one better to study the religious and cultural practices of one's religion (Chryssides and Gregg 2019;McCutcheon 1999).GAA is a native of the practicing community and shares the same language and culture as the people.
Additionally, GAA has undergone an appreciable level of studies in religion.Additionally, therefore, an insider.Just as his background in the language and culture aided in data collection procedures, it further shaped the data analysis process, allowing a religiocultural interpretation of the data from the more extensive study.His knowledge of the practicing community's culture and advanced research methods informs a massive gap in the literature-the lack of inclusion of practicing communities in FGM/C-related research.
In stark contrast, outsiders are researchers who are unrelated to the researched community across any of the characteristics discussed under the insider continuum, i.e., race, culture, language, ethnicity, etc. Simply put, the outsider is not a member of the researched community.The outsider dimension of positionality is not always negative.For example, it has been explored in social sciences such as religion to facilitate positive power dynamics between 'outsiders' and research communities, as opposed to insiders and relevant communities.In this study, BEO assumes the position of an outsider-an experienced sexual health researcher and a Ghanaian by nationality, but having a different upbringing, ethnicity, culture and religion to the practicing community of Pusiga.With this background, BEO worked together with GAA to infer the implications of the findings for health promotion.This was intended to suggest localised models of sexual health which engaged with community-level motivations for FGM/C and suggest non-invasive alternatives thereof.

Ethical Considerations
FGM/C is a sensitive topic many would ordinarily not be willing to be identified with openly.Ethics approval was sought from the Ethics Review Committee of the University of Cape Coast.Reviewers and PhD supervisors had to be convinced that the intended fieldwork remained sensitive to the anonymity, privacy and confidentially of all participants.Written consent was obtained from participants to allow the recording and taking of meeting notes.GAA also remained emotionally sensitive to the participants, especially survivors of FGM/C, so the intended fieldwork did not evolve as another form of gender-induced violence.A distress protocol was developed, characterised by pre-and post-assessment questions to evaluate the temperament of participants during in-depth interviews and focus group discussions.GAA assessed the emotional character of participants, especially survivors of FGM/C, to evaluate signs of emotional distress.The contingent plan following the identification of any emotional pain was to end interviews and focus group discussions.However, no forms of emotional distress were recorded.The implementation of the distress protocol also increased trust between GAA and the participants, and also among participants during focus group discussions.
Fieldwork was conducted during the COVID-19 pandemic.All local protocols were observed, including wearing nose masks, staying apart a distance of 1 m in school classrooms and homes of interview participants, and using hand sanitisers before and after each focus group discussion and in-depth interview.Official permission was also obtained from the Municipal Education Office of the Bawku Municipality to obtain special permission to conduct school interviews during the pandemic.

Findings
An analysis of the perspectives of survivors, non-survivors, and traditional leaders and education officers highlighted the following themes: historical and religious justification, moral justification and gendered dimensions of FGM, economic dimensions of FGM, and intergenerational dimensions or power dynamics underpinning FGM.It is important to note here that the analysis highlighted similar views from participants in both focus groups and in-depth interviews on historical and religious justification, moral justification and gendered dimensions of FGM, and economic dimensions of FGM.However, there were some differences in perspectives between participants engaged in focus groups (survivors and non-survivors) and older participants (gatekeepers) engaged in in-depth interviews under the "intergenerational dimensions or power dynamics underpinning FGM" theme.These findings are presented through "insider-contextualised interpretations" of themes by GAA as a native of the practicing community.

Historical and Religious Justifications
Participants consider FGM/C to have long-standing historical and religious undertones.The religious character provides a strong mandate for which gatekeepers of the act are motivated to uphold.Embedded within this historical-religious construct, FGM/C has been applied for various reasons outside its original aim to "tame women sexually".
Firstly, it is believed to have served as a tool for differentiating between women from surrounding communities in Togo and Burkina Faso and women from the local community.A traditional elder from the community gave this evidence in support: ". . .Female Genital Mutilation started very long ago and is practised in Burkina Faso.Our ancestors used circumcision as a way of differentiating women who were from Burkina Faso from that those from Ghana.So it was a sign of identi-fication between citizens of Burkina Faso and those who were not" Source (IDI with an Elder, Pusiga-June 2019).
The suggestion that women had to undergo genital cutting just for identification speaks to the humiliating methods of gendered violence women had been subjected to over the ages.Some participants also moved away from FGM/s purpose of identification to a more religiously justified basis for FGM/C.Several respondents reported that both Islam and the Indigenous Traditional religion identify the clitoris as a form of dirt which must be cleared for religious purity.For the indigenous Religion: ". . .Female Genital Mutilation was started by Adam and Eve in the Bible and subsequently Abraham over 2000 years ago.So, female Genital Mutilation did not begin from Pusiga.It was created by our forefathers, who passed the practice to our fathers and passed it to us.You see, the resemblance of the clitoris to that of the penis was something that needed to be curbed.I think this is one reason why our ancestors and the Bible are against it (IDI with a Christian religious leader, Pusiga-June, 2019).
It is important to note that this view above, so put forward by a Christian, is representative of the sentiments of many believers and non-believers of the traditional Indigenous Religion.For example, in the Presbyterian church of Pusiga, where I, GAA, am a presbyter, there have been discussions with fellow church members in support of FGM/C based on its resemblance to the penis but also its association with impurity.
So it is not surprising that during focus group discussions, an Islamic cleric also links the clitoris to impurity and pushes for its proliferation: ". . .FGM cannot be stopped among Muslims as our previous Muslim leaders practise it in the past; therefore, we cannot stop practising it.We Muslims believe that if you are a female Muslim and are not circumcised, Allah will not accept your prayer.This uncircumcised Muslim woman is considered unclean and dirty; hence, every Muslim woman must undergo circumcision.If non-Muslims decide not to circumcise their females, we do not bother about that, but for us Muslims, we must do it."(IDI with Islamic Leader, Pusiga-June, 2019).
Underpinned by the solid historical antecedents described and motivated by a confluence of Islam and Traditional religious values, the members of the community, irrespective of religious affiliation, seem strongly encouraged to subject their daughters to FGM/C.It is with this motivation that a gatekeeper of FGM/C during a focus group discussion notes that: ". . .In my clan, it is taboo if any feminine child born is not circumcised, for it is something we grew to see.I have gone through it and do not see why young girls should not be circumcised source: (IDI with Queen Mother of Pusiga-June, 2019).

Moral Justifications and the Gendered Dimension
Participants also expressed a moral dimension to FGM/C in the Pusiga Community.Under the previous theme, a religious antecedent has been discussed, promoting the removal of the clitoris based on uncleanliness.Here, a moral dimension is presented on two fronts: a moral motivation to uphold the long-standing (religious) traditions associated with FGM/C as gatekeepers and the moral need to maintain the ritual to perpetuate chastity among women.Over here, chastity is presented separately to make it distinct from the religious piety shown by FGM/C.Thirdly, it follows that women are made pure for the gendered reason of remaining chaste for marriage.
As an indigene of Pusiga, I recognize that in our worldview, sexual promiscuity (and adultery in marriage) is a vice that defiles the perpetrator's body and spirit and the community's moral fibre.The general belief is that the clitoris, as a sexual enhancing feature of a woman, promotes infidelity to one man and increases promiscuity among married women.Therefore, adultery/sexual promiscuity in marriage can be repaired by removing the feature that provides sexual feelings to the woman.The following statements by the Queen-mother of Pusiga, who is a gatekeeper who had herself undergone FGM/C and a political leader, speak to the moral responsibility attached to FGM/C in Pusiga: "Yeah, it is a tradition in our country and supported by God.I believe it because I fear punishment from God.I do not have good memories of it because I felt bad pain, and I still get pain during my menstruation, but you know this is what God wants us to do".". . .Families from the traditional religion choose to circumcise their girls with the belief that it is a religious requirement".Source: (FGD with Sugidi Assemblyman, Pusiga-June, 2019).
The second moral dimension is that FGM/C instils the moral virtue of chastity in young women.A survivor of FGM/C explains this moral reason for having undergone FGM/C: ". . .The reason why my fellow girls and I got circumcised, and it will continue with other girls, because they told us that if we are not circumcised, our desire for sex will be too strong to the extent that we cannot control ourselves hence leading us to immoral acts such as promiscuity and adultery in marriage.So, because we do not want to bring disgrace to our families and ourselves, we went through the show-source: (FGDs with survivors of FGM, Pusiga-July 2019).
Per this perspective, FGM/C seems to provide psychological assurance against promiscuity.My culturally contextualised understanding of this community perspective is essential to show that the benefits to women go beyond mere removal of the clitoris and prevention of sexual promiscuity.Removing the clitoris psychologically assures both the gatekeeper and the survivors of chastity in marriage.
However, it is essential to note that the patriarchally and matriarchal underlying reason for FGM/C is to make a woman chaste for marriage.In the long run, the individual and community expectations of a marriageable bride are determined based on FGM/C.In a patriarchal society such as Pusiga, part of the Kusasi traditional area, sexual intimacy, such as foreplay, plays no role in marriage.Marriage is mainly seen as an institution through which procreation continues.Moreso, sexual intimacy holds no significance to the subjective feelings of women.Therefore, removing the clitoris ensures families and, most importantly, husbands, of chastity even within marriage.In short: ". . .when a man wants to marry, he will first investigate to know if the lady is circumcised or not before he finalised the marriage arrangements" (FGDs with Survivors of FGM, Pusiga, July 2017).

Socio-Economic Benefits and Justifications
According to most participants, FGM/C also presents socio-economic benefits to survivors and families, ensuring its perpetuation.The strong moral, cultural and religious justifications have rendered the practice of FGM/C a means of gaining social and economic status.The socio-economic benefits can be better understood as I link the spiritual and moral benefits of what FGM/C offers socio-economically to the fears of what it fails to provide when one does not undergo it.
Firstly, participants linked the social benefit of FGM/C to respect and recognition accrued from being made pure.It was discussed that a religious justification of FGM/C is to remove impurities in the form of the clitoris (as well as the prepuce).In the Pusiga community, uncircumcised women are stigmatised to the extent that local songs and statements are composed to ridicule them.An example of such words is "o site pieli ne la'ad" meaning "her store is full of provisions".The above information means the clitoris is unwanted in the human body because it is seen as filthy.This means that in close-knit communities, such as the one in which I reside, it is well known that families fail to take their daughters through the rite of genital cutting.Indeed, such women are avoided and dissociated within social programs: "Hmmmmm, if you refuse to undergo circumcision, you will be considered somebody who does not properly belong to your people and the society as well.Even if there is a funeral or a social gathering and you appear there, those who know you try to avoid your company because you are uncircumcised.They say when you are not circumcised, it is unholy to pray as a Muslim, and because of that, we young girls undergo the practice of praying and also feel comfortable among our people (FGDs with Survivors, Pusiga-July, 2019).
Uncircumcised women are also hardly shortlisted as brides for marriage.One of the mothers of a survivor contends that "circumcision is seen as proof of chastity and virginity before marriage and that it increases her daughter's marriage prospect" (IDI with the queen mother of Ninkogo, July 2019).Motivated by the fear of remaining a spinster for life, survivors of FGM/C argue that: "It is shameful not to circumcise, and we will not find husbands if we do not circumcise as it increases our chances of getting a peaceful married life (FGDs with survivors)".
Some men also go to the extent of rejecting brides who have remained uncircumcised until marriage.". . .Uncircumcised women are ridiculed and put to shame by their husbands.They are usually pushed back to their father's house to undertake the practice even if they do not like it.Men described such women as having a padlock on the door.So, when a man wants to marry, he will first investigate to know if the lady is circumcised or not before he finalised the marriage arrangements" (Survivors of FGM in an FGD, Pusiga-July, 2017).
It is the custom of my area that a woman's bride price is five cows.Still, men who detect that their newly married wives were virgins pay extra cows as compensation for the parents of the lady, to also demonstrate the ability to take good care of their daughters.
Pusiga is a largely rural geographical area characterised by high levels of poverty.Marriage is seen as a way for families to derive honour and a decent standard of living through the office of traditional marriage.Furthermore, to go through rejection by potential husbands and the community, as exemplified above, indicates failure and damnation in the eyes of society.In other words, FGM/C is equally seen in its rite of passage that marks the end of childhood and the beginning of adulthood and, for that matter, marriage life, with which chances of marriage and a better life are assured.A queen mother and a gatekeeper aptly summarise the economic prospects of FGM/C: "A woman has to undergo FGM or else she may not live in the society, get a job, marry or get a husband; the tradition may be seen as bad, but it is valued by our society and brings honour to families" (IDI with Queen Mother, Pusiga-June, 2019).

Intergenerational Dimensions and Power Dynamics Underpinning FGM
Despite the broad agreements between participants on the multi-layered socio-religioeconomic benefits of FGM/C, there seem to be some variations in attitudes introduced by intergenerational differences between gatekeepers, families and survivors.These variations, as indicated earlier in the introduction to the findings, consist of a difference in perspectives of younger participants-survivors and non-survivors who took part in focus groups rooting for a stop of the act, and relatively older gatekeepers who were engaged in in-depth interviews, advocating for its perpetuation.The widely held notion is that FGM/C is widely perpetrated by women against women, with grandmothers and mothers facilitating FGM/C so that daughters are made ritually clean, socially accepted, and socially vetted for marriage.However, in this study, self-reports of some participants suggest otherwise; some families, including mothers, speak against it and protect daughters from being circumcised.
I first look at the older generation who, due to the deep knowledge of FGM/C's historic, religious and moral benefits of FGM/C, promote the act despite broad advocacy against it in the district.First is the role of Mothers as gatekeepers: ". . .The burden for the girls to go through circumcision usually comes from their mothers; men do little in that regard.Mothers think that their prospective in-laws and society will respect them if their daughters are circumcised, so they take all the necessary steps to ensure their daughters get circumcised."Source: (IDI with a father, Pusiga-July, 2019).
Secondly, grandmothers also facilitate the act within Pusiga and neighbouring communities such as Burkina Faso to ensure that granddaughters are circumcised: "The day I got circumcised, my grandmother told me that today would be a memorable day for me.She told me we have to adhere and that I should be happy and proud because I am now going to become a woman.Finally, she took me to the place (Burkina Faso), and I was asked to lie down.Then, one woman, in addition to my grandmother, held me, and another woman cut my clitoris.Hmm, it was really a painful experience.I was made to stay in that house for one week without any of my relatives, and the woman kept dressing my wound hot until it healed, and I went back home."(FGDs with Survivors, Pusiga-July, 2019).
The act is also widely accepted among grandmothers because they have less knowledge about the sexual and reproductive health challenges it presents to women.This was confirmed by the Gender Education Officer, who is also deeply involved in Advocacy programs for FGM/C: ". . .From my observation, the older people, especially our grandmothers, still strongly support the practice.The only thing I can say apart from the fact that they consider it a tradition, they also lack the knowledge of the harm FGM causes to the survivors."(IDI with Gender Education Officer, Pusiga-July, 2019).
In contrast, due to better education and the conscious awareness of the sexual health challenges posed by FGM/C, the younger generation of survivors and non-survivors of FGM/C expressed similar views to show disagreements with the tenets of FGM/C as well as the older generation of mothers and grandmothers who enforce these social norms.Some survivors of FGM/C proposed that the consequences of remaining uncircumcised were untrue if they compared themselves to friends in the community who had not been circumcised: "To be honest with you, if I am asked today to under the practice, I will not submit myself to it.I will run away from my father's house to go live somewhere.The process from cutting to dressing the wound until it gets healed is painful and unbearable.My grandmother told me that if I did not do it, I would not grow to be a responsible woman.However, I see many colleagues who did not do it, living comfortable lives.So, I will not advise anybody to do it" (FGD with survivors of FGM, July 2019).
There were also non-survivors of FGM/C who had been protected from the act by disagreeing parents who prevented grandmothers from taking advantage of the crossborder system to carry out the act: "My grandmother wanted me to undergo circumcision far away in Burkina Faso, but my father and mother disagreed.My grandmother told me that if I did not do it, I would not grow to become a responsible woman, but that has proven to be untrue.Today, I am married with three children, and all my children are doing well contrary to their claim that I will lose my first born if I do not get circumcised."(FGDs with Non-survivors, July 2019).
The comments above suggest that advocacy against FGM/C and the difference in reception levels of the older generation (grandmothers) and survivors (and parents) underpin negative and positive attitudes towards FGM/C.

Discussion
Advocacy and research against FGM/C in Pusiga has been intensive, but with continuous reports of prevalence in the district.This study set out to address three identified gaps: the absence of FGM/C research drawing on the direct contribution of gatekeepers of the act in Pusiga, a lack of scholarship on the power dynamics that interplay between gatekeepers and survivors in the research site, and localised health promotion models derived from the inputs of practising communities, and the power dynamics thereof.The discussion of the findings is in two parts.The first part involves a seamless debate of the major themes alongside reviewed literature and its implications for program design.In the second part, we put forward our claim for sexuality education as a health promotion practice to address the contextual issues.

Part I: Inferring Implications for General Advocacy/Research
The evidence suggests deep historical and religious antecedents connecting practising communities in Burkina Faso and Togo to Pusiga.We also drew on the insider experience of GAA as an indigene of Pusiga to show that underpinning this historical-religio-cultural framework is a high sense of moral authority motivating gatekeepers such as Islamic and Christian leaders and traditional leaders (queens and chiefs) to remove the clitoris for purity and render the circumcised woman chaste for marriage.This aligns with other studies in Nigeria and Ghana, which show that women are circumcised based on religio-cultural beliefs associated with purity and chastity (Sakeah et al. 2019, p. e0214923;Yaya and Ghose 2018, p. 244).Allowing features such as the clitoris and prepuce to remain on young girls implies allowing a religious and impure sacrilege to fester.Age may not be a consideration when it comes to FGM/C.Considering the link between FGM/C and marriage, more research, such as Ahinkorah et al. (2022, pp. 1-12) is required to investigate the association between FGM/C and child marriage in Pusiga of high prevalence in the district (Jackson et al. 2003;Atubiga 2007).
This same historical-religio-moral link shared by practising communities in Togo and Burkina Faso and Pusiga may explain the transmigration of daughters from the more robust anti-FGM/C environment in Pusiga to less monitored areas in Togo and Burkina Faso.The transfer of daughters from Pusiga to Burkina Faso and Togo for circumcision is well documented (Sakeah et al. 2018, pp. 1-10;2019, p. e0214923).The second author, as an indigene from Pusiga, also corroborates evidence given by Sakeah on the transmigration of daughters for cutting.This study adds to this existing knowledge by showing that the historical-religio-moral link shared by these communities may underpin the continuous transfer of women from Pusiga to outside communities despite massive advocacy against FGM/C in Pusiga.As a sexual health educator, with a deep appreciation of the local context for researching, designing and implementing health promotion programs, this finding is essential for understanding the cultural context in program design involving cross-border, practising communities such as Pusiga.
The insider experience of the second author has also helped to highlight the purityenhancing and chastity-enabling functions of FGM/C in marriage.As a precursor for marriage, the contextualised interpretation of participants' views shows that FGM/C also vets a woman for social acceptance or otherwise in the community.As noted in the background and confirmed in the findings, patriarchal (and matriarchal) norms put forward marriage as a critical institution in the Pusiga community and a gateway to a good and comfortable life for women and their children.Additionally, patriarchal norms position FGM/C as the yardstick for attaining the social status of marriage.For this economic benefit, families make arrangements to escape the solid legal frameworks in Pusiga to surrounding communities for the rite to be performed on their daughters.The economic benefits of FGM/C are replicated in other studies on the relevance of FGM/C for marriage (Sakeah et al. 2018, pp. 1-10;2019, p. e0214923;Akweongo et al. 2021, pp. 1-17).The economic dimension requires consideration in programs aimed at curbing FGM/C in Pusiga.
Notwithstanding the overwhelming alignment with the ideals of FGM/C by participants, some voices were calling for a stop to the act.Interestingly mothers, as well as survivors who have been sentenced to be custodians of circumcision in Pusiga (Sakeah et al. 2019, p. e0214923), argued the porosity of some of the promises such as chastity and automatic good life offered by FGM/C.However, the mothers in arms against FGM/C are the younger generation who have a better understanding of the sexual and reproductive health implications of FGM/C compared to the older generation of grandmothers who are equally informed by the historical, religious and moral dimensions of FGM/C discussed earlier.This is what this study identifies as a power dynamic between gatekeepers and (would-be) survivors of FGM/C.This finding and others discussed in part one offers the basics for inferring implications for health promotion practice and FGM/C in the municipality.

Part 2: Advocating Sexuality Education for Health Promotion
So far, the study, through the vantage points of GAA as an insider and BEO as an outsider, has gleaned insights into how FGM/C's historical, religious, moral, and economic dimensions contribute to its prevalence in Bawku.The discussions that ensue in this second part draw more specifically on the position of BEO as an outsider and a sexual health educator to advocate for sexuality education as a health promotion intervention, still drawing on the contextual presentation of the data.

Sexuality Education as a Health Promotion Tool
Sexuality education in and out of school could provide a good starting point for addressing some of the challenges and gaps identified in the study.A bit of background is required in the structure of sexuality education in the Ghanaian context.Ghanaian research shows that the sexuality education curriculum officially teaches abstinence-an approach to sexuality education which is argued to be culturally limiting (Ocran 2021, pp. 153-66).However, my (Ocran 2021, pp. 153-66), andother Ghanaians' research (Amo-Adjei 2022, pp. 941-56) have shown that the policy framework allows for pro-omprehensive sexuality education approaches (CSE), which are culturally sensitive.Therefore, suggestions could be made of some of the contextual issues discussed here for integration into a sexuality education program.Secondly, in-school sexuality education interventions in Ghana requiring an intersectoral approach involve Education Officers such as the Girls' Education Officer (included in the study) and community gatekeepers such as traditional leaders (queen mothers and chiefs, also included in the study) (Awusabo-Asare et al. 2017).Based on the evidence in the literature and my experience as a sexual health educator, I argue that the suggestions made forthwith on sexuality education to curb FGM/C in Pusiga stand to be culturally relevant and can be assessed by the relevant constituencies in this study (gatekeepers, survivors and non-survivors).I also acknowledge the potential conflicts at stake, particularly the tension between negative patriarchal norms fuelling FGM/C and the anti-FGM/C agenda.Notwithstanding, advocacy, including women empowerment interventions, has made a huge impact in the context of prevailing social patriarchal norms (Sakeah et al. 2019, p. e0214923;Akweongo et al. 2021, pp. 1-17), and this background provides hope for the prospects offered by my proposed sexuality education intervention discussed at the more general community level to the individual/personal level.

Sexual and Reproductive Challenges versus Moral Mandate
As part of the second objective of this study, we identified power dynamics between gatekeepers and survivors, with the younger generation advocating for a stop to the act based on the sexual health challenges it poses and the older generation pushing for its perpetuation based on a moral mandate.The support against the act could be attributed partly to ongoing women empowerment programs against FGM/C in the district reported in the literature (El-Dirani et al. 2022;Sakeah et al. 2019, p. e0214923) and confirmed by the Girls Education Officer.As part of health promotion, women empowerment strategies, the sexual and reproductive health challenges of FGM/C should be systematically designed into in and out-of-school sex education programs to involve different age groups to ensure that the older generation gains a better understanding of the dangers (Villani et al. 2016, p. 71;World Health Organization 2022a, 2022b;Azadi et al. 2021, pp. 1-14) FGM/C poses to the health of women.

The Female Sexual and Reproductive Health System
As identified by the reports of participants, the clitoris and the prepuce's religious considerations as impure and unclean is a solid cultural foundation for FGM/C.Barring any attempts to negate these religious interpretations, health promotion programs could gradually and systematically educate the community on the importance of the clitoris as well as any other religiously considered feature and the role it plays in sexual intimacy, marriage and childbirth.One of the critical discussions that could be included is sexual pleasure.

Pleasure as a Theme in Sexuality Education
Sexual pleasure could form an expanded sub-topic for discussion under the biological features of the female reproductive system.Sexual pleasure has increasingly evolved as a topic of interest in discussions on sexual rights and sexual health.International NGOs interested in women's sexual health, such as the World Association of Sexual Health (WAS), of which I am a member, have long advocated for sexual pleasure to be part of sexual health programs to eliminate all forms of gender-based violence against women (Ford et al. 2021, pp. 612-42).A gap, however, exists across the literature, and that is the lack of a practical example of how a lack of consideration of sexual pleasure contributes to forms of GRV (Ford et al. 2019, pp. 217-30;Gruskin et al. 2019, pp. 29-40).This study offers an excellent empirical instance by showing that due to harmful patriarchal, gender and religious norms associated with the clitoris, the community of Pusiga are inclined to consider women only as children-producing tools and nothing beyond that.In short, due to the absence of sexual pleasure in the sexual considerations of the Pusiga community, women are not considered sexual beings with sexual feelings just as men do.Sexual pleasure could therefore be an essential component of the functions of the female reproductive system in sex education programs in the municipality.

Chastity as a Non-Invasive Theme in Sexuality Education
The aim of FGM/C, as shown in the findings, is to make women chaste for marriage.However, the impression created by the participants that, per the act of circumcision itself, chastity, as a virtue is assured, could be very erroneous.As a non-invasive approach to addressing this myth, chastity can be promoted as a 'delay in sexual activity of young women to allow for educational and bio-physical development'.The paper, therefore, agrees to some extent with advocates of FGM/C in Pusiga on the need for a delay in sexual activity but disagrees that it should be enforced through FGM/C.I also disagree that abstinence before marriage should be the approach to ensuring chastity, as abstinence has been shown to implement inequitable sexual norms such as the lack of sexual pleasure in the sexual worldview of the Pusiga community (Ford et al. 2019, pp. 217-30).Instead, sexual delay, which is part of sexuality education programs, allows for other priorities such as educational attainment before marriage and systematic child spacing (Potvin 2019, pp. 118-33;Stout and Kirby 1993, pp. 120-26;Rotz et al. 2021), and could be part of health promotion programs to curb the prevalence of FGM/C in Pusiga.

Role Modelling
The data shows that non-survivors and survivors show varying forms of support against FGM/C.Survivors gave evidence of peers who had not undergone circumcision but had led chaste and successful marriage/social lives.At the same time, non-survivors explained how their parents had supported them against being circumcised.These two scenarios provide the basics to tap into the health promotion model of role modelling, used in health promotion as a behaviour-change model (Morgenroth et al. 2015, pp. 465-83).Role modelling could be used as a women empowerment strategy to show that FGM/C does not psychologically and certainly assure chastity.However, sexual delay and educational attainment are the ingredients for eliminating poverty and successful life.This can be done by using models of women who have not undergone circumcision yet have made it in life, socially and economically, as a way to underscore this point.Survivors of FGM/C who have long been known to support the act in Pusiga (Akweongo et al. 2021, pp. 1-17) could also be engaged to show the sexual and reproductive health challenges they experience.

Conclusions
This paper has engaged with the perspectives of religious leaders, political leaders, opinion leaders, survivors and non-survivors of FGM/C on the factors fuelling the prevalence of FGM/C in the Upper East Region of Ghana, despite broad advocacy against the practice.We drew on the insider and outsider approach to positionality to glean deeper insights which are contextually and culturally sound to the culture and situation in the practicing community.The findings suggest a shift from socio-cultural-religious factors to economic undertones underpinning FGM/C.Inter-generational differences between the older generation of grandmothers and the young generation of mothers and parents also vary in attitudes toward FGM/C.We recommend a systematic approach to health promotion that addresses FGM/C's deep socio-cultural, economic and religious underpinnings of FGM/C in Pusiga.These include the integration of chastity, sexual pleasure, sexual delay and role modelling into sex education programs in the municipality.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.

Limitations
The cultural assumptions made of the worldview of Pusiga and the cultural interpretations given to the participants' perspectives limit the recommendations for general advocacy, research and health promotion in that area.Notwithstanding, Pusiga represents a hybrid, practicing community where advocacy is vital, so survivors migrate across borders for circumcision.Therefore, the findings derived from the discussions here are relevant for further research on FGM/C among communities in the diaspora and the factors that shape the transfer of young girls and women across borders for the act.
Next, the implications for health promotion are only starting points to help think about valuable topics to be used in health promotion programs in Pusiga, not health programs themselves.These topics, however, draw on contextual findings and are highly relevant to the Pusiga community.

4. 3 .
Implications for Healthcare Professionals Engaged with Survivors of FGM/C Healthcare professionals in the Pusiga community who engage with survivors of FGM/C should be encouraged to move beyond their field on the dangers posed by FGM/C to understand the underlying norms that this study has identified to motivate and promote FGM/C in Pusiga.Armed with this knowledge, they can counsel survivors of FGM/C along the trajectories of what survivors expect before and after FGM/C.