Background Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that has been prevalent in Egypt for many years. The medicalization of FGM/C has been increasing significantly in Egypt making it the country with the highest rate of medicalization. In this qualitative study, we explored the drivers and motives behind why healthcare professionals perform FGM/C and why mothers rely on them to perform the practice on their daughters. Methods The study drew on a “mystery client” approach, coupled with in-depth interviews (IDIs) and focus group discussions (FGDs) with health care providers (i.e. physicians and nurses) and mothers. It was conducted in three geographic areas in Egypt: Cairo, Assiut and Al Gharbeya. Results Study findings suggest that parents who seek medicalized cutting often do so to minimize health risks while conforming to social expectations. Thus, the factors that support FGM/C overlap with the factors that support medicalization. For many mothers and healthcare providers, adherence to community customs and traditions was the most important motive to practice FGM/C. Also, the social construction of girls’ well-being and bodily beauty makes FGM/C a perceived necessity which lays the ground for stigmatization against uncut girls. Finally, the language around FGM/C is being reframed by many healthcare providers as a cosmetic surgery. Such reframing may be one way for providers to overcome the law against FGM/C and market the operation to the clients. Conclusion These contradictions and contestations highlighted in this study among mothers and healthcare providers suggest that legal, moral and social norms that underpin FGM/C practice are not harmonized and would thus lead to a further rise in the medicalization of FGM/C. This also highlights the critical role that health providers can play in efforts to drive the abandonment of FGM/C in Egypt. Electronic supplementary material The online version of this article (10.1186/s12914-019-0202-x) contains supplementary material, which is available to authorized users.

Background Child marriage is a human rights violation disproportionately impacting girls in low- and middle-income countries. In the Middle East region, conflict and displacement have prompted concerns that families are increasingly resorting to child marriage to cope with economic insecurity and fears from sexual violence. This study set out to examine child marriage among Syrian refugees residing in Egypt with the aim of understanding drivers of child marriage in this context of displacement as well as how child marriage affects refugee girls’ wellbeing. Methods This analysis draws from 15 focus group discussions (FGD) conducted with married and unmarried girls, as well as parents of adolescent girls in three governorates in Egypt. FGDs included a participatory ranking exercise and photo-elicitation. Additionally, we conducted 29 in-depth interviews with girls and mothers, as well as 28 key informant interviews with health providers, community leaders, and humanitarian actors. The data was thematically analyzed using a combination of inductive and deductive coding. Results A prevalent phenomenon in pre-war Syria, child marriage has been sustained after the influx of Syrian refugees into Egypt by pre-existing cultural traditions and gender norms that prioritize the role of girls as wives and mothers. However, displacement into Egypt engendered different responses. For some families, displacement-specific challenges such as disruptions to girls’ education, protection concerns, and livelihood insecurity were found to exacerbate girls’ vulnerability to child marriage. For others, however, displacement into urban areas in Egypt may have contributed to the erosion of social norms that favored child marriage, leading to marriage postponement. Among girls who were married early, we identified a range of negative health and social consequences, including lack of family planning use, disruption to schooling and curtailment of girls’ mobility as well as challenges with marriage and birth registration which accentuated their vulnerability. Conclusion Efforts to address child marriage among Syrian refugees must acknowledge the different ways in which displacement can influence child marriage attitudes and practices and should capitalize on positive changes that have the potential to catalyze social norm change. Moreover, targeted, focused and contextualized interventions should not only focus on preventing child marriage but also on mitigating its impacts.

IntroductIon Despite the presence of a law banning female genital mutilation/cutting (FGM/C), the practice continues to be widespread in Egypt. According to 2014, Egypt Demographic and Health Survey (EDHS), the prevalence of FGM/C is 93% among ever-married women aged 15-49 (MOHP, El-Zantay and Associates, and ICF International, 2015). Type I (i.e. partial or total removal of the clitoris and/or the prepuce) and type II (i.e. partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora) are the most common types of FGM/C in Egypt (WHO, 2008; Tag-Eldin et al., 2008). Reasons underlying the practice of FGM/C include believing it is a religious requirement; it protects a girl's chastity/ prevents against adultery or husbands prefer women who are circumcised (MOHP, El-Zanaty and Associates and, ICF International, 2015; Tag-Eldin et al., 2008). According to the 2014 Survey of Young People in Egypt (SYPE) 1 , the prevalence of FGM/C tends to be declining among younger generations of women (73.9% amongst females age 13-17 compared to 85.7% amongst those age 30-35). However, more parents are relying on medical personnel to circumcise their daughters (Ismail, Abdel-Tawab & Sheira, 2015). It is noteworthy that rates of FGM/C medicalization (i.e. performance of the practice by medical personnel) in Egypt are more extensive than in any other country where FGM/C is practiced (UNICEF, 2013). Medicalization of a harmful practice such as FGM/C institutionalizes and normalizes it, making the process of complete abandonment more difficult (Askew et al., 2016). A global strategy to stop health-care providers from performing FGM/C was developed by the World Health Organization (WHO) and in collaboration with multiple governments, health-care professional bodies, UN agencies and non-governmental organizations (NGOs) after recognizing the magnitude of the problem (WHO, 2010). It is a call to action by which supportive legal and educational frameworks are created and implemented, monitoring and accountability channels are strengthened and capacities of healthcare providers are improved. 1 SYPE was conducted by the Population Council in collaboration with the Central Agency for Public Mobilization and Statistics (CAPMAS). It is a nationally representative survey conducted with more than 10,000 young people in 2009 and 2014. It provides a comprehensive profile of Egyptian adolescents and youth before and after the 2011 and 2013 political events.

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