The Consequences of Female Genital Mutilation on Psycho-Social Well-Being: A Systematic Review of Qualitative Research

Diaspora in high-income context

Studies identified in the review from Sweden, the Netherlands, the United Kingdom, and the United States describe how discourses on FGM affect migrant women and men living in diaspora (Ahlberg et al., 2001; Johnsdotter et al., 2009; Jordal et al., 2018; Kahn, 2016; Parikh et al., 2018; Vloeberghs et al., 2011). Ahlberg et al. (2004) present the views of informants who felt that they often have to lie about their circumcision status to avoid stigmatization or social exclusion in Sweden (Ahlberg et al., 2001). Respondents felt that the way in which “Swedish people” talked about the practice was hurtful and made them feel inferior (i.e., “Here the uncircumcised are the majority . . . they see us as a big thing and you feel inferior”), so they were inhibited to discuss the topic.

Exploring the psycho-social well-being of cut women in diaspora, various studies report on the perceived sense of “feeling different” and shameful (Johansen, 2002; Jordal et al., 2018; Kahn, 2016; Parikh et al., 2018; Vloeberghs et al., 2011). The respondents, who desired clitoral reconstructive surgery, expressed a sense of felt stigma and inferiority that lead them to deny their FGM status in front of others. The majority of women in this study aimed to achieve “normal looking” genitalia through the operation (Jordal et al., 2018).

Reporting a similar sense of “feeling different” and a desire for completeness, Parikh et al. (2018) describe how women react when they feel stigma—some use humor to deflect unease about the topic and others completely avoid discussion about it (Parikh et al., 2018).

Johansen describes school-girls’ sense of shock and bitterness about their condition. “As if it was written on my forehead that I was different down there” (Johansen, 2002). The sense of difference affected socialization with peers such as participating in sports and relationships with boys (Johansen, 2002). Ahlberg et al. (2004) describe how school girls of Somali origin in Sweden exercise social pressure and stigmatizing behavior by “checking each other,” that is, by paying attention to the sound of urinating in the toilets. Some girls felt that negative discourses about the practice affected the relationships between those who had undergone FGM and those who had not, affecting their sense of belonging. The psychological well-being of girls who had undergone some form of FGM was negatively affected by these discourses. For example, one girl stated, “When our teacher talks about circumcision, she dramatizes as if it was a disease . . . students pity you and think you are different.” Some parents had lied to the girl and/or to the family about her FGM status to protect her. This led to uncertainty and insecurity among the girls (Ahlberg et al., 2001) and affected their sense of trust in family members.

Various studies explore migrants’ anxieties regarding pressure from relatives in their countries of origin to have their daughters undergo FGM (Alhassan et al., 2016; Isman et al., 2013; Koukoui et al., 2017; Owojuyigbe et al., 2017; Vloeberghs et al., 2011) as it reflects on their reputation and that of their daughters. In a study on African migrants in Portugal, Spain, and Italy, migrants felt pressure from their mothers-in-law back in their home country regarding the excision of their daughters. In the country of origin, women who had not gone through FGM would be marginalized and would not be able to participate in community activities, ceremonies, and decision-making. “Uncircumcised” women in Guinea Bissau were labeled “solima” (rude, immature, uncivilized) and blufo (stupid, promiscuous). Likewise, in Eritrea uncut, women are called prostitutes. Although such labels were not as extensively used in diaspora, parents were concerned about their daughters’ and their own reputation when returning home. Those who did not have their daughters cut were said to be accused of under-valuing their culture and were stigmatized back home (Alhassan et al., 2016).

Some studies address parents’ concerns regarding their daughters’ reputation and ability to control their sexual appetite if they were left uncut (Alhassan et al., 2016; Koukoui et al., 2017). Looking at migrants from FGM practising communities in Canada and in Ivory Coast, Koukoui et al. (2017) found that parents were concerned that their uncut daughters’ sexual behavior may bring shame not just to themselves and their parents but to the larger family and neighbors. They would thus be shunned and excluded (Koukoui et al., 2017).

Based on interviews with migrants from FGM practising countries living in the United States, Kahn (2016) describes how deviating from the social norm was linked to punishment and banishment by community members. Those who acted upon transgressive beliefs were expelled from the community in an act of cultural silencing

So even when you want to go against [circumcision], you don’t want to open your mouth and say it. You’ll feel scared. Because you don’t want to be lonely in society . . . Even if you don’t like it, you don’t want to say it. (Kahn, 2016)

O’Neill et al. (2017) found that this form of exclusion of women from marriage was reported particularly by older Somali male migrants in Europe when they were speaking of their country of origin. Younger Somali men and other migrants from FGM practising countries living in diaspora said that although the practice was perceived as important, they personally preferred a wife who had not been cut (O’Neill et al., 2017).

High-prevalence setting where FGM is a social norm

Several studies in this review showed stigmatization of women who have not undergone FGM, with implications on their marriageability. Women who had been cut were thought of as more mature, responsible, trust-worthy, and (sexually) faithful—which are all desirable traits for a bride and wife; in contrast to this, those who had not undergone FGM were not deemed marriageable, were ostracized, and publicly shamed (Abathun et al., 2016; Brown et al., 2016; Isman et al., 2013; O’Neill et al., 2017). Examples were cited of women being returned to their parents after the wedding night because the women had not gone through the practice (Abathun et al., 2016; O’Neill et al., 2017).

Shell-Duncan et al. (2018) found that with the increasing acceptability of interethnic marriages in Senegambia, it was more common for uncut women to marry into families who carry out the practice. Uncut women, however, reported their female kin’s disapproval, which was expressed through verbal abuse, harassment, and exclusion. Uncut women are commonly contemptuously labeled “solema” (meaning rude, ignorant, uncivilized, over-sexed, and unclean), and family members refused to eat food that they prepared and excluded them from family events such as weddings and household decision-making. Parents who do not a girl face judgments about the moral propriety of their daughters and whether they are raised properly—which reflects the social standing of the whole family within the community (Shell-Duncan et al., 2018). Similarly, Abdelshahid and Campbell (2015) showed that parents in Egypt were afraid of their daughters’ social acceptance. Uncut girls were believed to disgrace themselves through their sexual behavior and needed to be “protected” from “wrong-doing” and the humiliation they would bring to themselves if they were left uncut. It was believed that uncut girls would go “astray” and get uncontrollably aroused by anything coming close to her body (Abdelshahid & Campbell, 2015).

Diaspora in high-income context

Three studies set in Sweden, the United States and the Netherlands describe women’s memories of feeling abandoned by the people close to them on the day they were cut, particularly their mothers who did not help them (Berggren et al., 2006; Kahn, 2016; Vloeberghs et al., 2011). Some expressed a sense of betrayal, anger, and frustration, and deplored that nobody had asked them and that the decision to cut had been taken by the elders (Berggren et al., 2006; Kahn, 2016; Vloeberghs et al., 2011). Studies conducted in Canada, the Netherlands, Sweden, and the United States suggest that women who had suffered from the consequences in one way or another were determined to protect their daughters from getting cut (Berggren et al., 2006; Isman et al., 2013; Kahn, 2016; Koukoui et al., 2017; Vloeberghs et al., 2011). Some expressed great relief about having left their country of origin where it was difficult to escape the practice and that they were now living in a place where their daughters were safe (Kahn, 2016; Koukoui et al., 2017; Vloeberghs et al., 2011). One way of protecting the daughters was to not leave them alone with their grandmothers who might cut them without consent of the parents (Isman et al., 2013; Johnsdotter et al., 2009; Kahn, 2016; Koukoui et al., 2017; Vloeberghs et al., 2011).

High-prevalence setting where FGM is a social norm

Schultz and Lien (2014) address how FGM affected relationships between mothers and daughters in the Gambia immediately after the FGM was performed in the ritual initiation context. Negative reactions described were varying degrees of pain, anxiety, disbelief, a sense of betrayal, and anger at the mother. Although the effects on the mother–daughter relationship seemed mostly short-term, as Schulz and Lien suggest, several women experienced emotional challenges in their relationships with their mothers once they lived in exile and were exposed to arguments against FGM. Other women reported pride and described initiation as a bonding experience endowing them with status within the community (Schultz & Lien, 2014).

Diaspora in high-income context

Multiple studies documented the difficulties posed by FGM on intimate relationships and sexual health. Studies set in Belgium, the Netherlands, the United Kingdom, and the United States present the experiences of women and men whose intimate relationships and sexuality are affected by FGM (Johansen, 2002; Kahn, 2016; O’Neill et al., 2017; Vloeberghs et al., 2011). Vloeberghs et al. (2011) and Johansen (2002) present women’s accounts of painful sex due to their FGM, regrets about not experiencing any pleasure or about sex being boring. Johansen describes how sex during marriage was perceived to be a duty for a wife, regardless of how painful (Johansen, 2002). Vloeberghs et al. (2011) describe how some said they pretended to enjoy it to please their husband, or that they came up with excuses not to have sex when their partners showed interest.

In a study looking at African migrants from FGM practising communities in Belgium, the Netherlands, and the United Kingdom, O’Neill et al. (2017) found that although some women reported no sexual problems linked to FGM, other women complained that they did not enjoy sex very much but did it to please their partners or because they perceived it to be a duty (O’Neill et al. 2017). Similarly, some men had not noticed any difference during sexual relations between women who had been through the practice and those who had not. However, others felt emotionally affected by their partners’ lack of pleasure and difficulty in having orgasms. Some respondents stated that their divorces were caused by the ways that FGM had affected their intimate relationships. Many older Somali and Ethiopian men in the study suggested that although casual sexual relations with uncut women were enjoyable, uncut women were not for marriage and that such relationships would not last. Their younger counterparts residing in Europe who participated in the study felt that love was a more important criteria for marriage than FGM status. A study based in Norway found that uncut women were preferred as marriage partners among Norwegian Somalis (Gele et al., 2012).

Ahlberg et al. (2004) present Swedish Somali’s conflicting views on different types of FGM, virginity, and trust. Some men believed that infibulation was not proof of a woman’s virginity because even women who had a child could have been re-infibulated and married as virgins afterwards. Women on the other hand thought that men were more suspicious of un-infibulated women, who had undergone Type I, II, or IV FGM, and cases were reported of un-infibulated virgin brides being sent back to their parents because the husband and in-laws doubted the girl’s virginity status (Ahlberg et al., 2001). Two studies show how sexual pain had a negative impact on experiences in finding a committed partner (Kahn, 2016; Vloeberghs et al., 2011). Kahn (2016) presents women’s experiences of disliking sex and having pain during intercourse, which led to a chain of short-term relationships with men rather than long-lasting committed and supportive relationships. Other research set in Sweden suggests that the diminished enjoyment of sex is a result of cultural discourses according to which sex, for women, should not be enjoyable because it is dirty. Thus their reduced pleasure may also be linked to the embodiment of such cultural discourses (Johnsdotter et al., 2009).

High-prevalence setting where FGM is a social norm

Looking at the effects of FGM on sexuality in southern Ethiopia, Battle et al. (2017) report on men and women’s descriptions of pain and pleasure among newly wedded couples. Women with type-III FGM described traumatic experiences of first sex including extreme pain, bleeding, fear, fainting, becoming ill, and fleeing forced first sex. The husbands of infibulated women also reported pain and abrasions on their penis after prolonged unsuccessful attempts at penetration. This painful and traumatic process was, however, culturally endorsed and positively associated with masculinity. Men described this experience with pleasure and pride, which was particularly linked to a sense of feeling reassured that no other man had ever penetrated their wife. In this study, this process is thus believed to create a bond of trust and confidence between man and wife—a reassurance that she would remain faithful to him (Battle et al., 2017).

Battle et al. (2017) also describe the breakdown of relationships between women and men as being linked to women’s dislike of sex, pain, and trauma. Three major strategies for avoiding sex emerged in their research in southern Ethiopia; these included direct refusal of sex, physical, and psychological distancing, and the promotion of other sex partners. For instance, leaving a husband’s bed in the middle of the night, sleeping with children and pretending to be sick were mentioned as ways of avoiding sexual contact with one’s husband. Battle describes that violence toward a wife was a culturally endorsed response to resistance to sexual intercourse among her Somali study participants in Ethiopia.

Men also avoided sex in marriage as a result of sexual difficulties with their wives but used different tactics, such as engaging in extra-marital affairs, polygamy, or divorce. Commonly mentioned reasons for leaving a wife were related to her “bad behavior”—such as fighting, being too demanding, and infertility. The distinct marriage patterns of polygamy and divorce suggest dissatisfaction and tensions in marriages to infibulated women (Battle et al., 2017). A study set in Southern Nigeria also shows that although FGM contributes to a woman’s respectability and reputation as a wife, almost all men with excised wives admitted to regularly having sex outside marriage with multiple partners. Nevertheless sex with their excised wives was perceived as a duty, and they continued to have sexual relations with their wives (Owojuyigbe et al., 2017).

Studies set in Egypt, Kenya, Nigeria, and Ethiopia have explored men’s feelings about their wives’ FGM status. A study in Egypt explored how women and men experience conflict as a result of lack of sexual satisfaction and pain (Abdelshahid & Campbell, 2015). Some women stated that it was not possible for them to share their feelings of rejection, the physical pain during intercourse, or arguments within the couple with other community members due to the private nature of the issue. It was considered taboo for women to speak of sexuality. Although married men regretted their wives’ lack of sexual response and desire, they felt reassured that their wives did not enjoy sex enough to go and seek it elsewhere. That is,

When I sleep with my wife, I’d like her to have a desire for me . . . lack of response, of course, doesn’t appeal to any man . . . it doesn’t satisfy any man . . . but when I feel that my wife has no sexual drives, I feel reassured, but, when we sleep together I feel bad because she doesn’t have a desire for me. (Abdelshahid & Campbell, 2015)

Various studies show that men’s feelings about the effect of the FGM on women’s sexuality are ambivalent (Abathun et al., 2016; Abdelshahid & Campbell, 2015; Brown et al., 2016). Studies set in Ethiopia and in Kenya describe how young men felt enormous social pressure to marry women with FGM but feared being socially outcast and denied social status and political influence in local governance structures. Nevertheless, these young men did not embrace the idea that marriage to a cut woman as they were aware of the negative health consequences of the practice and felt that they should oppose this custom in spite of their family’s expectations; however, this was not always easy to negotiate (Abathun et al., 2016; Brown et al., 2016).

Graamans et al.’s (2018) study on Maasai and Samburu in Kenya suggests that negative conceptions of women’s sexuality have given way to positive associations regarding women’s desire of wanting to love their husbands, their indulgence in pleasure, and the “sweetness of love,” which were thought to be absent in women with FGM. It was suggested that this might affect the intimacy which bonds husband and wife and holds the family together. Having undergone FGM thus led to insecurities and anxieties about a husband looking for new partners and wives (Graamans et al. 2018).

Diaspora setting in high-income context

In a study among women who were seeking clitoral re-constructive surgery in Sweden, Jordal et al. (2018) explored women’s conceptions of how FGM affected their sex-life and intimate relationships. They found that they perceived their inability to enjoy sex as a handicap because they were living within a context in which women’s sexual pleasure and indeed mutual pleasure was viewed as important for closeness and intimacy. Although some of them were able to enjoy sex and reach orgasm with the right partner or when masturbating alone, there was a general sense of inadequacy among the informants who perceived their genitalia as ugly and dysfunctional, which caused shame and uneasiness in sexual relations as well as negative effects on their self-esteem. This negative self-image led some of them to avoid certain sexual practices associated with pleasure or avoid sex and intimacy altogether. These women hoped that reconstructive surgery would improve their self-esteem and likewise their sexual relations (Jordal et al., 2018).

Studies set in the Netherlands and the United States described how anxiety, trauma, and anger related to FGM affected women’s social lives, behavior, and relationships with others. Vloeberghs et al. (2011) describe the experiences of women who were troubled by unpleasant memories when confronted with particular situations or reminders, such as razor blades, knives, blood, sexual intercourse, including on their wedding night, and child-birth (Kahn, 2016; Vloeberghs et al., 2011). These reminders could trigger a range of profound emotional reactions such as crying, feeling “sick and like throwing-up” (Kahn, 2016; Vloeberghs et al., 2011) as well as a sense of powerlessness (Kahn, 2016).

In response to negative discourses about FGM or personal experiences where women felt stigmatized, studies describe avoidance and deflection (Parikh et al., 2018; Vloeberghs et al., 2011) as well as anger about media images that depict the practice as barbaric and incite pity among the audience (Johnsdotter et al., 2009). Studies suggested that women do not want to be pitied or seen as victims because of the practice (Jordal et al., 2018; Vloeberghs et al., 2011). Vloeberghs et al. (2011) also describe their respondents’ anger and frustration when they realize that FGM is not necessary, that it was not a religious requirement, and that not all women were cut. Anger was provoked by a sense of injustice that they had been cut and others had not and sometimes anger with relatives who allowed the practice to happen. Others expressed their anger more generally toward what they called the “backward” traditions and “ignorance” that made women perform the practice (Vloeberghs et al., 2011).

High-prevalence setting where FGM is a social norm

There is lack of qualitative research describing psychological consequences such as posttraumatic stress disorder (PTSD), anxiety, and low self-esteem related to FGM in high-prevalence settings. Multiple studies comparing women with and without FGM on clinical outcomes have found that women with FGM have higher rates of these psychological complications, such as depression, anxiety, and posttraumatic stress disorder, as compared to women without FGM (M. R. Ahmed et al., 2017; Behrendt & Moritz, 2005; Kizilhan et al., 2017; Köbach et al., 2018).

These studies did not meet the inclusion criteria of this review, which summarizes the qualitative research in this area and complements these clinical findings.