Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for nonmedical reasons.
The adverse physical consequences of female genital mutilation/cutting have been documented. Yet, we know little about the adverse mental health consequences of the practice.
The aim of this article is to undertake a comprehensive review of the literature pertaining to the psychological consequences of female genital mutilation.
Regarding positive experiences, women have reported sensations of happiness, relief from embarrassment and shame, and a sense of feeling honored.
Negative psychosocial consequences of FGM include posttraumatic stress disorder, anxiety disorders, panic disorders, depression and suppression of feeling and thinking, and sometimes attempted suicide, difficulties in sexual and marital life.
Clinicians are encouraged not to pathologize the consequences of FGM but to focus on the urgent psychological, social and psychosexual needs identified among a significant number of women.
Female genital mutilation, Culture Mental health
EU: Europe; FGM: Female Genital Mutilation; FGM/C: Female Genital Mutilation/Cutting; PTSD: Posttraumatic Stress Disorder; UK: United Kingdom; WHO: World Health Organisation
Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for nonmedical reasons [1].
According to the definition of the World Health Organisation (WHO), FGM means partial or complete non-therapeutic removal or injury of each of the external female genitals for religious or cultural reasons [2]. FGM has been classified into 4 types: Type I (clitoridectomy) involves the partial or total removal of the prepuce and/or the clitoral gland; type II involves the partial or total removal of the labia minora and clitoral glans without the excision of the labia majora; type III (infibulation) involves narrowing the vaginal canal by modifying the labia majora and minora and may also include the removal of the clitoral glans; type IV involves any other nonmedical, harmful procedure, such as cauterization, pricking, and scraping [3].
Regarding prevalence studies, in Sudan, 96.6% of girls are mutilated before the age of 6 years. In general, Africa, Middle East, and Asia have the highest prevalence globally. Hotspots such as Egypt, Ethiopia, Tanzania, Somalia, Mali, Burkina Faso, Gambia, Guinea, Nigeria, Sierra Leone, Iraq, Iran, Yemen, India, Malaysia, and Indonesia have been documented by various authors. More than 200 million girls and women have been mutilated all over the world [2].
In 2011 over half a million first-generation women and girls in the EU, Norway and Switzerland had undergone FGM before immigration. One in two was living in the UK or France, one in two was born in East-Africa [4].
In countries where FGM is performed, people use the term ‘circumcision’ to talk about a ‘open’ or ‘closed’ woman. Internationally, the term ‘female genital mutilation’ (FGM) should be used. ‘Circumcision’ means only the excision of the clitoral foreskin and plays down the procedure. The term ‘female genital mutilation’ describes better the irreversibility and heaviness of the operation. On the other hand, in contact with the patient, the word ‘mutilation’ can be an unfavourable choice of word because it causes a stigmatisation [5].
The complex reasons for which the practice is performed and its meaning within the social context have also been largely discussed [1]. The perpetrators gave many reasons to justify their involvement in this dehumanizing acts, which includes satisfying religion obligations in Christianity and Islamic injunction/teachings, prevention of early neonatal deaths during delivery by preventing the fetal head from touching the clitoris, the rites of passage from girl to womanhood, prevention of promiscuity, enhancement of the girls femininity by excision of the clitoris which make female more of a male, and hygiene and aesthetic reasons, to make marriage an effortless process and to prevent recurrent genital infections. Other reasons given are family honour and increasing sexual pleasure of the husband [2].
The adverse physical consequences of female genital mutilation/cutting (FGM/C) have been thoroughly investigated and documented: Obstetric, gynaecological and genitourinary consequences such as haemorrhages, perineal tears, caesarean delivery, risk of infection, dysmenorrhea, urinary tract infections and dysuria; consequences for sexuality, mainly, dyspareunia, loss of sexual interest and decreased quality of sexual intercourse [6].
Yet, we know little about the adverse mental health consequences of the practice [7]. Exposure to trauma in childhood or adolescence has been shown to be associated with a variety of deleterious mental health outcomes. Specifically, meta-analyses have shown that those exposed to any form of childhood maltreatment are much more likely to report recurrent and chronic mental health conditions [8].
The aim of this article is to undertake a comprehensive review of the literature pertaining to the psychological consequences of female genital mutilation.
The authors conducted a search using electronic databases including PubMed, Scopus, Web of Science, and Google Scholar. The search was performed using a combination of relevant keywords: ‘Female genital mutilation’, ‘mental health’, ‘psychological consequences. The search was limited to articles published from 2010 to the present date, written in the English language.
Additional sources, such as reference lists of included articles and relevant review papers, were also hand-searched to ensure comprehensive coverage of the literature.
In the literature, psychological consequences of female genital mutilation encompass both positive and negative aspects.
Regarding positive experiences, individuals who have undergone female genital mutilation (FGM) have reported sensations of happiness, relief from embarrassment and shame, as well as a sense of feeling honored [9].
Being among their peers and being allowed to participate in social activities was retrospectively particularly important for the women who underwent this procedure. They described the need to be ‘among’ or ‘belong’ as a reason for deciding to go for the FGM [10]. Connection and belonging are crucial components of human life, such that broad indicators of social integration have been linked to improved physical and mental health [11].
Some of the women recounted experiencing emotional elevation once the decision to be cut was made and as they were approaching the date of their cutting.
They also described a sense of liberation, relief and rise in social status after being cut, which was seen as a rite of passage to womanhood and respectability. The procedure made them thereafter eligible for marriage or it meant they would be receiving special attention from family and friends such as having a special meal cooked for them [10].
Parents, influenced by social norms and community expectations, believe that cutting secures social and economic security for their daughters.
In this view, the social harm of not cutting outweighs any physical, psychological, or legal risk [12]. The shame and stigma often associated with a girl who does not undergo the ceremony is usually unbearable and many parents understandably want to avoid this stigma for their children [13].
Negative psychosocial consequences of FGM include posttraumatic stress disorder (PTSD), anxiety disorders, panic disorders, depression and suppression of feeling and thinking, and sometimes attempted suicide. These effects are due to psychological trauma of the painful procedure, sense of humiliation and being cheated by parents, use of physical force by those performing the procedure, negative genital image, lack of sense of ownership of their bodies, destructive sexual life, and infertility [14].
To date, only a few scientific studies have investigated the relationship between FGM and PTSD. In fact, Mulongo, et al. reviewed more than 1 thousand articles on FGM, of which only ten reported psychological outcomes and only two original studies met high scientific standards. Behrendt and Moritz compared 23 Senegalese women with FGM to 24 in the no FGM group. Compared to the no FGM group, the FGM group presented a higher prevalence of PTSD (30% vs. 0%). Moreover, Knipscheer, et al. recently investigated a sample of 66 immigrant women in the Netherlands. More than one third of this group presented with clinically relevant symptoms of PTSD [9].
Mutilating injuries following a physical trauma have been linked to acute stress and post-traumatic stress as well as anxiety and depressive symptoms in children and adolescents [15].
Only a limited number of studies assessing the psychopathological consequences of Female Genital Mutilation (FGM) exhibit statistically significant results.
A recent systematic review [2] found six studies [16-21] that reported a higher burden of anxiety among women who underwent FGM/C compared with the control group of women who did not undergo FGM/C.
Also, six studies [16,19-23] reported a higher burden of depression among women who underwent FGM compared with the control group of women who did not undergo FGM.
Specific factors, associated partly with FGM and partly with current life stressors, influence the severity of psychopathology. Immigrant women who have a vivid recollection of the circumcision, who do not have a paid job, and who cope with their problems mainly in an avoidant way (substance misuse), may form a group at risk of severe psychological problems [24].
FGM (female genital mutilation) results in sexual problems and contributes to unhappiness in marriages. Extensive research has demonstrated that there is a significant disparity in marital satisfaction between females who have undergone genital mutilation and those who have not. A specific study examined various aspects of marital life, including personal subjects, the quality of the marital relationship, problem-solving skills, financial management, leisure activities, sexual relationships, relationships with relatives and friends, and overall marital satisfaction. The findings of this study indicate that genital mutilation serves as a fundamental factor leading to marital dissatisfaction [23]. Similar results were found in other studies [25,26].
Extensive research and literature consistently indicate that the psychological consequences of female genital mutilation (FGM) are predominantly negative. Numerous studies have shed light on the profound and long-lasting psychological impacts experienced by girls and women who have undergone this harmful practice.
Prevention and clinical efforts should focus on the individual within its context and should be aware of potential hesitation among some women to seek psychological help. Clinicians are encouraged not to pathologise the consequences of FGM but to focus on the urgent psychological, social and psychosexual needs identified among a significant number of circumcised women [24].
Awareness campaign and education about the medical, social, and psychosexual complications involved in FGM, the abuse of the rights of the girls or the women and that FGM has no medical, sociocultural or religion benefit is a potent tool in the abandonment of FGM. Education gives the vulnerable group the power to take a firm decision for themselves or for their female children based on the information received and not relying on taboos or beliefs that will endanger their reproductive lives or that of their girl child or send them to early and untimely deaths [27].
None to declare.
The author contributed equally to the development of this paper.
No sources of support were used to fund this paper.