Abdu Mohmed, a native of Djibouti's northern town of Tadjourah who now lives in the capital, Djibouti city, still remembers his sister screaming from pain as she was circumcised years ago.
"How many women have been destroyed?" he asked, referring to the widespread practice of female genital mutilation (FGM), in this tiny Horn of Africa country of 600,000 people.
A harmful cultural practise that often results in pain, trauma, haemorrhage, infection, reduced sexual pleasure and later in life, difficulties with urination, menstruation, infertility and abscesses, FGM is common in Djibouti. Experts say it is a major contributor to maternal mortality in the country.
A survey carried out by the health ministry in 2002, involving 1,000 women who gave birth at the Peltier Hospital in Djibouti City, concluded that 98 percent of them had been circumcised. However, experts say nobody knows for sure whether the rates are lower for younger girls and women. Another survey is planned for the near future.
FGM takes different forms, but it is the most severe one, infibulation that is prevalent in Djibouti. It involves cutting away the inner labia and clitoris then tying the remaining lips together, leaving a tiny hole for urine and menstrual blood to pass. In rural areas a higher rate of infibulation is likely, says Miriam Martinelli, an experienced Italian nurse and research student.
Experts in the country worry that since FGM causes blood to be present in sexual encounters, it could also lead to a dramatic rise in the speed of HIV transmission. According to the 2002 study, Djibouti's estimated HIV prevalence is, by African standards, still low at 2.9 percent.
Martinelli noted, however, that the FGM taboo was slowly being broken. "At least now, we can talk about it," she told IRIN. "It was not like this 10 years ago and it is not like this in [other countries]. So this is a change."
Among some Djiboutians, however, the practise is part of cultural norms. Sitting in the director's busy office, with its air-conditioning and bare, white walls at the College d'Enseignement Moyen in Tadjourah, Madina Houmed, mother of five, was irritated when asked about female circumcision.
"Every country has its own traditions and culture," she told IRIN.
The practise has remained prevalent despite repeated efforts by the government, United Nations agencies and various NGOs to eradicate it. Article 333 of Djibouti's Penal Code, for example, outlaws the practice, but few people have ever been arrested.
Over the next few months, the health ministry - in conjunction with various UN agencies - is planning a regional conference to discuss female rights in the country. Already, though, agencies like the UN Children's fund (UNICEF) are supporting sensitisation and social mobilisation against the practise by training religious and community leaders, and through the media.
According to the UN, Djibouti is among at least 28 African countries where FGM is practised. The total number of living women who have been subjected to it on the continent is estimated at 100-130 million, of whom some 26 million have undergone infibulation.
In Tadjourah, where nomads lead camels with their loads of firewood along windy seaside streets illiteracy and religious misconceptions have contributed to the FGM prevalence.
Last August, an aid group supported a workshop in the town at which it thought beliefs by some Djiboutians that FGM was supported by their faith could be disproved. Two months later, confusion exists in Tadjourah: does Islam forbid, tolerate, recommend or even oblige the different forms of circumcision?
"As a Muslim, I prefer it when there is circumcision," says Ahmed Houmed, an authoritative religious figure with a thin and wispy beard.
Medical arguments fare little better. Mohmed, 32, an unemployed father of 10 who declined to give his second name, does not see the link between female circumcision and Djibouti's high rates of maternal mortality. Many circumcised women give birth without dying, he said.
"Death is decided by God," he told IRIN.
"If she is not excised [circumcised], she will become a prostitute," Aicha Youssouf, a midwife in Tadjourah's maternity ward told IRIN. "She cannot stay in the house. If she is not [circumcised], she has a complex because she believes herself to be different from others. She will think that the man will reject her."
According to Martinelli: "Quite a lot of well-educated and quite high-level people say, 'I don't want to mutilate my daughters', meaning, 'there is such a strong pressure on me, my women and my family that most probably I will'." She added: "Maybe the next generation will say, 'I don't want to and I won't'."