Research blog by Serene Chung.
This study investigates the psychological effects of female genital mutilation (FGM) within migrant communities in the United Kingdom. Firstly, it will analyse the psychological disorders suffered by the individual, considering their migrant cultural identity. Secondly, it will consider the psychological impact of FGM in the context of relationships between the women and their spouses or families.
For the purposes of this study, interviews with experts together with the existing body of literature were used.
Background – FGM in the UK
FGM refers to the process of partial or complete removal of the external female genitalia or other injury to the female genital organs for non-medical purposes. The World Health Organization (2008, p.4) has classified FGM into four types:
In 2011, about 137,000 women and girls with FGM, born in countries where FGM is practised, were permanent residents in England and Wales (Equality Now and City University London, 2014, p.3). The number of women with FGM living in England and Wales has increased since 2001, and this is largely attributable to migration (Equality Now and City University London, 2014, p.21). The main groups in the UK who experience FGM are from Egypt, Eritrea, Ethiopia, Gambia, Iraq, Kenya, Kurdistan, Liberia, Mali, Nigeria, Northern Sudan, Sierra Leone, and Somalia (British Medical Association, 2011, p.3). In 2011, there were 170,000 women aged 15 and over in England and Wales with FGM and 63,000 girls aged 0-13 were at risk of FGM (Equality Now and City University London, 2014, p.20).
Given the increased prevalence of FGM within diasporas in the UK, an increasing number of doctors may come across women with FGM. As many health professionals in the UK are unlikely to be familiar with the psychological consequences of FGM, there is an ever-increasing need to examine the psychological impact of FGM to aid the treatment of these women.
Psychological Effects of FGM
a) Psychological Disorders Suffered by the Individual
The World Health Organization (2008, Annex 5) reported that immediate psychological trauma may stem from the pain, shock and the use of physical force by those performing FGM. In the long term, post-traumatic stress disorder (PTSD), anxiety, depression and memory loss may occur (Behrendt and Moritz, 2005). A study in practising African communities found that women who have undergone FGM have the same levels of Post Traumatic Stress Disorder (PTSD) as adults who have been subjected to early childhood abuse, and that the majority of the women (80 per cent) suffer from affective (mood) or anxiety disorders (Keel, 2014, p.6).
Women who have undergone FGM may also be affected by chronic pain syndrome, and [a]s with other causes of chronic pain there is an increased risk of depressed mood, with reduced social functioning, worthlessness, guilt, and even suicidal ideation. Limited mobility also increases social isolation and role loss in society (Whitehorn, Ayonrinde and Maingay, 2002, p.166).
Burrage (2015, p.99) writes that women who have experienced FGM tend to develop psychological conditions which make them withdrawn and uncommunicative or distrustful. There are anecdotal reports of teenage girls ‘returning to the UK from “holidays” abroad who were well adjusted to school before they went, but who fail to thrive in the learning environment after they return’ (p.99). Other psychological effects include emotional distance, flashbacks, sleep disorders, social isolation, and somatization.
It has also been found that the psychological trauma that women experience through FGM ‘often stays with them for the rest of their lives’ (Equality Now and City University London, 2014, p.8). A study of a sample of newly married women in Benha city found that the psychological complications resulting from FGM ‘may be submerged deep in the child’s subconscious and may trigger behavioural disturbances’ (Elnashar, Abdelhady, 2007, p.243). Dr Brenda Kelly, Consultant Obstetrician from Oxford Rose Clinic, mentions a case of one of her patients who had undergone FGM about 30 years ago, but still recalls the trauma of the procedure (Chung, 2015).
It is necessary to take into account other circumstances that affect the development of psychological disorders in women who have undergone FGM. In 2012, Vloeberghs et al (2012) examined the consequences of FGM in the Netherlands. The sample was 66 women who had migrated from Somalia, Sudan, Eritrea, Ethiopia and Sierra Leone. One-sixth suffered from PTSD and a third had symptoms related to depression and anxiety (p.677). Women who were infibulated and who clearly remembered the event, and women who had received education concerning FGM reported more PTSD symptoms as well as greater anxiety and depression. Women who were older at the time and with whom FGM was discussed also reported more PTSD symptoms. Memon (2014, pp.5-6) points out that both the severity of the procedure and the age at which it occurred appear to be related to the psychological effects; nevertheless, all the women in the study reported some negative effects of stress, such as recurrent bad memories and nightmares.
Vloeberghs et al (2012, pp.689-690) classified the women into three types :
ii) Considering the Migrant Cultural Identity
A study undertaken in Senegal found that women who had experienced FGM were significantly more likely to suffer from PTSD and other psychiatric syndromes when compared to women who had not been subjected to FGM. PTSD was also accompanied by memory problems. All but one woman surveyed ‘remembered the day of her circumcision as extremely appalling and traumatizing’, and ‘[o]ver 90% of the women described feelings of intense fear, helplessness, horror, and severe pain, and over 80% were still suffering from intrusive re-experiences of their circumcision’ (Behrendt and Moritz, 2005, pp.1,000-1,002). This study indicates that FGM is likely to cause various ‘emotional disturbances, forging the way to psychiatric disorders, especially PTSD’ (pp.1,001).
However, the study makes it clear that one must be cautious when interpreting these results because the results do not give rise to general conclusions about the occurrence of psychological problems after FGM. Firstly, it suggests that the composition characteristics of those surveyed (low age and high level of education) might have influenced the results (pp.1,001-1,002). Secondly, the ‘low prevalence of female genital mutilation in Senegal may be important for the occurrence of psychiatric disorders, possibly representing another risk factor for the establishment of PTSD’ – since only 20% of the female population have undergone FGM, the survivors are ‘often aware that their status is not generally accepted in society’. Furthermore, people are increasingly taught about the negative effects of FGM, ‘creating an atmosphere against female genital mutilation’ (p.1,002).
It is therefore important to consider the psychological effects of FGM in conjunction with the migrant cultural identity of the women. The psychological impact of FGM in countries where FGM is culturally acceptable or prevalent is thought to be minimal (Whitehorn, Ayonrinde, Maingay, 2002, p.165). In fact, Whitehorn, Ayonrinde and Maingay (2002, p.165) note that not undergoing FGM in certain communities has a greater psychological impact than the trauma caused by FGM itself, as a woman without FGM may ‘become a social pariah’. The authors note that Black and Debelle have suggested that the psychological effects of FGM are less likely to occur among societies in which FGM is the norm, ‘as experiences are normalized’ (p.166). On the other hand, FGM is illegal in the UK and is therefore clearly not considered ‘the norm’. It is, however, still practised in some immigrant communities within the UK, and girls may be sent overseas for the procedure (p.165). The prohibition of FGM in most Western countries may have a significant impact on migrant women with FGM, since what was once regarded as normal is now considered deviant and unacceptable (Johnsdotter, 2007). Therefore, migrant women may find their racial and ethnic identity challenged by the migration process (Whitehorn, Ayonrinde, Maingay, 2002, p.165).
Whitehorn, Ayonrinde and Maingay also note that migrants may arrive in a society built on a value system quite different from his or her own. The process of assimilating into a different culture may cause further stress and affect health and well-being. Migration-related stress may also lead to the high prevalence of mental health problems among migrants (Whitehorn, Ayonrinde, Maingay, 2002, p.165). In a recent interview, Dr Brenda Kelly also stated that it is sometimes difficult to work out if the depression is due to the general difficulties of arriving in the UK, or due to the consequences of FGM (Chung, 2015).
Women and girls may experience cognitive dissonance where the norms of FGM are not shared (Burrage, 2015, p.99). According to Festinger’s (1957) theory, cognitive dissonance arises when one holds conflicting beliefs, causing one to feel uncomfortable. Festinger suggests that people strive to maintain consistency in their beliefs. For women who have undergone FGM, the ‘desire to gain social status, please parents, and comply with peer pressure is in conflict with the fear, trauma, and after-effects of the operation’ (Toubia, 1994, p.714). As Sarajane Rodgers, author of the FGM and Initiation Rituals article for 28 Too Many (2015), argues, women who have undergone FGM may have experienced pain and other negative consequences, and may not have wished to go through FGM. However, many were forced to undergo this procedure, and here cognitive dissonance arises because of their conflicting beliefs and actions. In an attempt to resolve the inconsistency, it may be easier for women to say that ‘it wasn’t so bad’ rather than, ‘It was terrible and I can’t change the fact that it was done to me’ (Rodgers, 2015).
As to whether the psychological effects are the same in the UK as in Africa, Dr Brenda Kelly (Chung, 2015) noted that psychological distress is something Westerners do talk about and is acceptable to talk about in the UK. In Africa, there is a stigma associated with talking about anything outside the marriage. Hence, the psychological consequences of FGM are not necessarily more prevalent in Western society, but it can be easier to talk about them.
b) Effect of FGM on Relationships
i) Spousal Relationships
Women who have undergone FGM are more likely than women without FGM to experience painful intercourse, reduced sexual satisfaction and reduced sexual desire (Berg, Denision, 2012, pp.41-56). FGM may lead to sexual phobia (El-Defrawi et al, 2001, p.472). Women may also experience more difficulty reaching orgasm, and shame or embarrassment about intimacy (Burrage, 2015, p.115). Narrowing of the vaginal opening may make intercourse painful for both partners (British Medical Association, 2011, p.6). A study (Elnashar, Abdelhady, 2007, p.241) carried out on a sample of newly married women in Benha city found that 40.5% of women who had undergone FGM experienced dyspareunia (difficult or painful sexual intercourse), while only 18.8% of uncut women experienced it. 17.5% of the women who had undergone FGM felt their husband’s dissatisfaction, while only 4.7% of those uncut felt that way.
Lack of sexual pleasure for both parties can lead to husbands having extramarital affairs with women who have not undergone FGM (FORWARD, 2002, p.6). Emotional or physical pain during sexual intercourse reduces enjoyment for both the woman and her partner, thus affecting the intimacy in the relationship (Whitehorn, Ayonrinde, Maingay, 2002, p.167). An interview with Dr Brenda Kelly (Chung, 2015) revealed that when intercourse is painful, the vaginal muscles contract, making intercourse even more difficult, thus perpetuating a vicious cycle. As a result, these women avoid sex, which could lead to marital dissatisfaction.
In addition, immigrant females may have ‘altered expectations’ of sexuality due to the ‘new sexual culture, media or new peers’ (Whitehorn, Ayonrinde, Maingay, 2002, p.166). A woman who has undergone FGM may become aware of differences in the appearance of her genitalia and may feel embarrassed during clinical examination or sexual intercourse. Furthermore, women who are aware of a lack of sexual enjoyment may feel anger, guilt, shame or inadequacy (p.166).
Furthermore, being unable to have sexual intercourse may lead to a woman not being able to fulfil her childbearing role, and this may be a major role in certain communities. In some societies, the failure to produce children is blamed on women, and may even be attributed to a curse, which can result in the woman being rejected by her husband and even by her extended family, causing ‘further social isolation’ (Whitehorn, Ayonrinde, Maingay, 2002, p.167).
However, the assumption that all circumcised women have sexual problems or are unable to achieve orgasm is not substantiated by research or anecdotal evidence. The relation between the degree of anatomical damage and the ability of women to compensate for it through other sensory areas or emotions and fantasy is not well understood (Toubia, 1994, p.714).
ii) Familial Relationships
Traditionally, a female member of the community performs the FGM procedure. She may be closely related or a total stranger. Some survivors experience a sense of betrayal by someone emotionally close to them (Whitehorn, Ayonrinde, Maingay, 2002, p.165). In many cases, girls are held down by their female relatives while FGM is carried out (British Medical Association, 2011, p.5).
In the long term, there may be ‘behavioural disturbances as a result of the childhood trauma and possible loss of trust and confidence in carers who have permitted, or been involved in, a painful and distressing procedure’ (British Medical Association, 2011, p.6).
In 1999, FORWARD conducted a study of 15 Somali women in Manchester, asking about their experience of and attitudes towards FGM. Many women were distressed and hurt. One woman stated, ‘My mother has now died but I can never forgive her for what she did to me[;] she ruined my life’ (FORWARD, 2002, p.21).
c) Protective Factors
Firstly, age can be a protective factor against the negative psychological effects of FGM. As Dr Brenda Kelly states (Chung, 2015), if the survivor is younger than two years old, she is unlikely to remember it and is unlikely to experience PTSD. Those most at risk of PTSD are children older than the age of five who recall being forcibly held down and who experienced great pain and/or complications afterwards.
Secondly, a variety of other circumstances may mitigate the negative consequences of FGM. A 2015 study by Knipscheer et al (2015) found that almost 64% of the participants ‘did not report scores above the cut-off on indicators for PTSD, anxiety or depression’ (p.275). It was found that the type of FGM, country of origin, source of income, vividness of recollection and coping style were significant factors affecting the mental health outcome. For example, infibulation, a ‘vivid recollection’ and a substance-misuse coping style were associated with higher PTSD scores (p.275). Survivors may also be able to recover without developing mental health problems (p.276) – for example, Lockhat in 2004 showed that women who had undergone Type 4 FGM did not report PTSD-related problems. Alternatively, women could underreport symptoms because of different perceptions (for example, that other factors than FGM were responsible for the symptoms) or taboos (making them embarrassed to share these problems). A reluctance to report symptoms may also be due to the fact that thinking or talking about their FGM experience may cause the pain experienced at that time to reappear (p.276). The study also suggested that if women assess the event less negatively, there is lower likelihood of development of PTSD (p.276). The study therefore highlights the importance of assigning different weights to different factors in each particular case.
It is, however, argued by many authors (Behrendt and Mortiz, 2005; Lockhat, 2006; Elnashar and Abdelhady, 2007) that the cultural significance of FGM might not be a protective factor against the development of psychological problems. The World Health Organization in 2008 (pp.5-7) found that the following reasons have been given for FGM: custom and tradition, religious requirement, purification, family honour, hygiene, aesthetics, protection of virginity, increasing sexual pleasure for the husband, providing a sense of belonging to a group, enhancing fertility and increasing matrimonial opportunities. However, these reasons do not necessarily mitigate the negative effects of FGM.
A variety of factors will affect the psychological outcome of FGM; for example ‘coping style, other traumatic experiences, information before circumcision, and sexual experiences’ (Behrendt and Moritz, 2005, p.1,002). Furthermore, when researching about the psychological effects of FGM, one must also be cautious that one may be dealing with ‘a culture which demands modesty and reluctance to discuss intimate matters, especially in the presence of men who are strangers’ (Burrage, 2015, p.131). Some women who have undergone FGM say that experiencing it is a ‘source of pride and belonging’. It is consequently difficult to make generalisations about the psychological effects of FGM (Epstein, Graham, Rimsza, 2001, p.279).
It is therefore suggested that more investment should be put into research, to build an evidence base to support the movement to end FGM, and also to inform the development of psychological support for survivors.
Supporting survivors is an important component in the move towards ending FGM. As psychotherapist and anti-FGM activist Leyla Hussein (2015) argues, safe houses often do not provide counselling services for those women and girls who desperately need them, after having traumatic experiences and fleeing from their families. Hussein has thus founded a therapy group and counselling service for FGM survivors called the Dahlia Project, which is the only one of its kind in the EU. It is submitted that more effort could be made by governmental and non-governmental organisations to create more such services within the UK, to provide psychological support for survivors.
In addition, the stigma of mental illness must be challenged in order to place a higher priority on psychological support for survivors. As Hussein (2015) notes, mental health is still a taboo in the developing and developed worlds. For survivors to be willing to speak about their mental health issues, it is necessary to create a more accepting environment. This can be done by raising awareness within the health, education and judicial sectors. Hussein (2015) also suggests ‘implementing FGM into health plans so that professionals are adequately trained’.
In conclusion, addressing the psychological impact of FGM can expedite the process of eradicating FGM and also deal with the difficulties that survivors currently face.
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