Cognitive behavioral therapy for post-traumatic stress disorder, depression, or anxiety disorders in women and girls living with female genital mutilation: A systematic review

Female genital mutilation and urinary incontinence: an analytical comparison with Sudan's prevalent demography

OBJECTIVE

Female genital mutilation/cutting impacts over 200 million women globally and is linked to obstetric complications as well as long-term urogynecological and psychosexual issues that are frequently overlooked and inadequately addressed. This study aimed to assess the impact of female genital mutilation/cutting on urinary incontinence.

METHODS

This cross-sectional study was conducted in the gynecology department of the Research Hospital located in the Nyala rural region of Sudan. The participants were interviewed to gather socio-demographic and background information. In addition, they received a thorough gynecological examination to evaluate the presence and type of female genital mutilation/cutting. The Incontinence Impact Questionnaire and the Urogenital Distress Inventory were applied to the group with female genital mutilation/cutting and the control group without female genital mutilation/cutting to evaluate urinary incontinence and related discomfort. Subsequently, the scores of both participant groups were compared.

RESULTS

The study compared age, weight, height, BMI, gravida, parity, and sexual intercourse averages between groups. The mean Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7 scores of individuals who underwent mutilation were higher than those of individuals who did not undergo mutilation (p<0.001). Notably, participants subjected to infibulation exhibited significantly higher average scores on both measures in contrast with the other groups (p<0.001).

CONCLUSION

A higher proportion of mutilated participants, specifically those with infibulation, are afflicted with symptoms of incontinence.

Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation

BACKGROUND

Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results.

METHODS

The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin).

RESULTS

Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571).

CONCLUSIONS

A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.

The effect of female circumcision on maternal and neonatal outcomes after childbirth: a cohort study

BACKGROUND

Circumcision has many side effects and complications on women's lives and affects their physical, mental, and social health. The present study aimed to investigate the effect of female circumcision on maternal and neonatal outcomes.

METHODS

Methods: A prospective cohort study was performed with 320 pregnant women by convenience sampling (160 individuals were circumcised and 160 were uncircumcised). Circumcision and its level were confirmed using observation. The data relating to demographic, midwifery history, medical history, maternal and neonatal outcomes were compiled using a questionnaire. All Statistical analyses were conducted by SPSS ver. 16.0. P-values less than 0.05 were considered significant.

RESULTS

The mean age of circumcised women was significantly higher vs. Uncircumcised women (28.92±6.2 vs. 25.42±4.8; P < 0.001). Circumcision was significantly higher in rural compared to urban areas (51.9% vs.18.1%). The level of female education, his parents, spouse, and husband's employment status were significantly associated with circumcision (P < 0.001). 94.4% of uncircumcised nulliparous women and 86.9% of circumcised women experienced Intended Pregnancy (P=0.02). Eighty- five percent of women were circumcision type I. The higher mean duration of the second stage of labor, Second and Third degree of tear, and need for oxytocin in induction were significantly higher among circumcised women (P = 0.03, 0.003, 0.002, respectively). The existence one stage of labor, Second and Third degree of tear, and the need for oxytocin in induction were significantly higher among circumcised women (P = 0.03, 0.003, 0.002, respectively).

CONCLUSION

These findings underscore that Circumcision a prevalent predictor of poor neonatal outcomes and delivery processes, therefore this circumcised women needs intensive care during delivery.

Cognitive-Emotional Aspects of Post-Traumatic Stress Disorder in the Context of Female Genital Mutilation

Around 200 million women and girls worldwide are affected by female genital mutilation/cutting (FGM/C). FGM/C is a procedure that harms or alters the external female genitals for non-medical reasons, and is usually performed on children. Often, this procedure leads to severe consequences for the women's physical and mental health. In a cross-sectional sample of 112 women seeking medical counseling, physical and mental health characteristics associated with FGM/C were examined and possible predictors for the development of post-traumatic stress disorder (PTSD) in women affected by FGM/C were identified. A total of 55.4% (n = 66) of the women reported symptom levels of probable PTSD. Predictors for higher PTSD symptomology were an older age at the time of the FGM/C procedure, feelings of guilt and the centrality of the event in the woman's life. Thus, cognitive-emotional processing was found to play an important role in the emergence of PTSD in women suffering from FGM/C. However, interventions taking into consideration these characteristics are mostly lacking and need to be investigated further in the context of FGM/C.

Polyvictimization and Psychiatric Sequelae Associated with Female Genital Mutilation/Cutting (FGM/C)

Female Genital mutilation/cutting (FGM/C) is associated with enduring psychiatric complications. In this study, we investigate the rates of co-morbid abuses and polyvictimization experienced by survivors of FGM/C. This is a sub-analysis of a cohort study examining the patient population at the EMPOWER Center for Survivors of Sex Trafficking and Sexual Violence in New York City. A retrospective chart-review of electronic medical records was conducted for all consenting adult patients who had FGM/C and had an intake visit between January 16, 2014 and March 6, 2020. Of the 80 participants, ages ranged from 20 to 62 years with a mean of 37.4 (SD = 9.1) years. In addition to FGM/C, participants were victims of physical abuse (43; 53.8%), emotional abuse (35; 43.8%), sexual abuse (35; 43.8%), forced marriage (20; 25%), child marriage (13; 16.3%), and sex trafficking (1; 1.4%). There was a high degree of polyvictimization, with 41 (51.2%) experiencing 3 or more of the aforementioned abuses. Having FGM/C on or after age 13 or having a higher total abuse score was also found to be strong predictors of depression and PTSD. The high rates of polyvictimization among survivors of FGM/C are associated with development of depression and PTSD. Despite co-morbid abuses, patients still attribute substantial psychiatric symptoms to their FGM/C. Health care providers should understand the high risk of polyvictimization when caring for this patient population.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

Background

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

Objectives

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

Methods

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

Results

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

Conclusion

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Towards characterization of Female Genital Mutilation (FGM) in rural Nigeria

Background

Female genital mutilation (FGM) is a public health challenge and seems to be secretly practiced in some rural communities, despite the ban in Nigeria.

Objectives

The study aimed to identify the activities that are involved in FGM, type(s) of FGM practiced and the knowledge of health implications of FGM among rural community members in Ebonyi State, Nigeria.

Methods

We employed exploratory design using qualitative technique. In-depth interviews were conducted with 44 adult (18 years and older) volunteers in four rural communities in Ebonyi State, Nigeria. After thematic analysis using NVivo 11 Pro software, eight sub-themes emerged, among which are: types of FGM practiced, seasons for FGM, FGM by health workers and community leaders, punishment for refusing FGM and knowledge of health implications of FGM.

Results

Findings show that FGM is more like a process than just an act, and type most practiced in the study area is Type 1. Circumcisers are health workers and women leaders. Knowledge of health implications of FGM was found to be low among those interviewed.

Conclusion

Based on the findings, we concluded that FGM is still practiced in some rural communities in Nigeria, maybe because of poor knowledge of health implications of FGM.

Interventions for reducing violence against children in low- and middle-income countries: An evidence and gap map

Background

More than half of the children in the world experience some form of interpersonal violence every year. As compared with high-income countries, policy responses in low- and middle-income countries (LMICs) are limited due to resource constraints and paucity of evidence for effective interventions to reduce violence against children in their own contexts, amongst other factors.

Objectives

The aim of this evidence and gap map (EGM) is to provide an overview of the existing evidence available and to identify gaps in the evidence base on the effectiveness of interventions to reduce violence against children in LMICs. This report covers evidence published in English; a follow-up study is under preparation focusing on evidence in five additional languages-Arabic, Chinese, French, Portuguese and Spanish.

Methods

The intervention-outcome framework for this EGM is based on INSPIRE-Seven Strategies for Ending Violence against Children, published by WHO and other partners in 2016. The seven strategies include implementation and enforcement of laws; norms and values, safe environment; parent-child and caregiver support; income and economic strengthening; response and support services; education and life skills. The search included both academic and grey literature available online. We included impact evaluations and systematic reviews that assessed the effectiveness of interventions to reduce interpersonal violence against children (0-18 years) in LMICs (World Bank, 2018b). Interventions targeting subpopulation of parents, teachers and caregivers of 0-18 years' age group were also included. A critical appraisal of all included studies was carried out using standardised tools.

Results

The map includes 152 studies published in English of which 55 are systematic reviews and 97 are impact evaluations. Most studies in the map are from Sub-Saharan Africa. Education and life skills are the most widely populated intervention area of the map followed by income and economic strengthening interventions. Very few studies measure impact on economic and social outcomes, and few conduct cost-analysis.

Conclusion

More studies focusing on low-income and fragile and conflict-affected settings (FCS) and studying and reporting on cost-analysis are required to address gaps in the evidence. Most interventions covered in the literature focused on addressing a wide range of forms of violence and harm, which limited understanding of how and for whom the interventions work in a given context, for specific forms of violence. More impact evaluation studies are required that assess specific forms of violence, gendered effects of interventions and on diverse social groups in a given context, utilising mixed methods.

Prevalence of female genital mutilation among women in Ethiopia: A systematic review and meta-analysis

Background

Female genital mutilation affects the social, psychological, spiritual and physical well-being of women. In Ethiopia, studies regarding the female genital mutilation were conducted in various settings and years.

Objective

This systematic review and meta-analysis was aimed to summarize the prevalence of female Genital Mutilation in Ethiopia.

Methods

A systematic search of articles was conducted in PubMed, African Journals Online (AJOL), Excerpta Medica database (EMBASE), SCOPUS, Web of Science, and JSTOR. Data were extracted using a standardized data extraction format prepared in Microsoft Excel. The data were analyzed using STATA version 11 software. Cochrane Q statistic was used to assess the presence of significant between-study heterogeneity. I² was used to quantify between-study heterogeneity. A leave-one-out sensitivity analysis and subgroup analysis based on a study period and setting were done. The funnel plot and Egger's regression tests were used to measure the presence of substantial publication bias. The pooled estimated prevalence of female genital mutilation was conducted using a DerSimonian and Laird random effects model.

Results

The pooled prevalence estimate of FGM was 77.28% (95% CI: 55.81, 98.76). The pooled prevalence was higher in studies conducted from 2013-2017 (78.39%, 95%CI: 48.24, 108.54) and studies conducted in Hospital (92.02: 95%CI: 55.81, 98.76).

Conclusion

The prevalence of Female Genital Mutilation is high. Therefore, interventions that are focused on health education, social support and advocacy are recommended.

The impact of female genital mutilation/cutting on obstetric outcomes and its management

Objectives: Female genital mutilation/cutting (FGM/C) is a surgical intervention that is still widely performed around the world with serious obstetric and neonatal outcomes. We aimed to determine the obstetric and neonatal effects of FGM/C in pregnant women in a hospital with high standards of care in Sudan, where this is a common case, using a homogenous patient group.Methods: This is a retrospective cohort study in pregnant women with FGM/C, conducted at Nyala, Sudan-Turkey Training and Research Hospital. The inclusion criteria were: >18 years of age, history of FGM/C, vertex presentation, full-term birth, and single pregnancy. FGM/C group was compared with women without FGM/C (control group) who were monitored for the same period of 8 months in terms of age, parity, gestational age, and obstetric and neonatal outcomes.Results: A total of 220 eligible pregnant women were included in the study. Each group consisted of 110 pregnant women (FGM/C and control groups). We noticed that in the FGM/C group more emergency C-sections occurred, the second stage of the delivery was prolonged significantly, and episiotomy and periclitoral injuries were higher. Also, it was seen that postpartum blood loss and hospitalization of the mother lasted longer in the FGM/C group. No significant differences were found between the two groups with regard to newborns.Conclusions: FGM/C is definitely associated with poor obstetric outcomes. These patients should be diagnosed during the antenatal period, and the delivery processes should be managed by experienced healthcare professionals according to the type of FGM/C.

Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews

Background

In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.

Objectives

To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).

Review methods

The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.

Results

Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.

Limitations

Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.

Conclusions

The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.

Future work

Future research should evaluate the most-effective models of training and of service delivery.

Study registration

This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Female genital mutilation: implications for clinical practice

Female genital mutilation (FGM) is an established cultural practice in over 30 countries. It has no health benefits, carries a high risk of physical and psychological harm, and is illegal in many countries including the UK. A sensitive approach is required, both in the management of complications and prevention of this practice. This article discusses the prevalence and classification of FGM, and offers practical advice to nurses and midwives involved in general and obstetric care. Legal aspects, including safeguarding responsibilities and the mandatory duty to report FGM in England and Wales, are outlined.

Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting

OBJECTIVE

To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C.

DESIGN

A systematic review of qualitative research studies using a thematic synthesis approach.

METHODS

Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified.

CONCLUSIONS

This review has highlighted key knowledge gaps, especially around (1) girls'/unmarried women's experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training.

PROSPERO REGISTRATION NUMBER

CRD420150300012015.

It is a problem and it is not a problem: Dilemmatic talk of the psychological effects of female genital cutting

This qualitative study aimed to explore the psychological effects of female genital cutting in the United Kingdom within a systemic psychological framework. Semi-structured interviews were carried out with 13 women who had experienced female genital cutting. Four key themes emerged from thematic analysis of the data: (1) wholeness contested, (2) sexuality milestones and female genital cutting awareness, (3) salvaging family relationships and (4) for our own good. Findings highlight the importance of recognising the relational nature of how women perceive the psychological effects of female genital cutting and how these reactions are negotiated in their social sphere.

Increased beta power in the bereaved families of the Sewol ferry disaster: A paradoxical compensatory phenomenon? A two-channel electroencephalography study

AIM

The Sewol ferry capsizing accident on South Korea's southern coast resulted in the death of 304 people, and serious bereavement problems for their families. Electroencephalography (EEG) beta frequency is associated with psychiatric symptoms, such as insomnia. The aim of this study was to investigate the relation between frontal beta power, psychological symptoms, and insomnia in the bereaved families.

METHODS

Eighty-four family members of the Sewol ferry victims (32 men and 52 women) were recruited and their EEG was compared with that of 25 (13 men and 12 women) healthy controls. A two-channel EEG device was used to measure cortical activity in the frontal lobe. Symptom severity of insomnia, post-traumatic stress disorder, complicated grief, and anxiety were evaluated.

RESULTS

The bereaved families showed a higher frontal beta power than healthy controls. Subgroup analysis showed that frontal beta power was lower in the individuals with severe insomnia than in those with normal sleep. There was a significant inverse correlation between frontal beta power and insomnia symptom in the bereaved families.

CONCLUSION

This study suggests that increased beta power, reflecting the psychopathology in the bereaved families of the Sewol ferry disaster, may be a compensatory mechanism that follows complex trauma. Frontal beta power could be a potential marker indicating the severity of sleep disturbances. Our results suggest that sleep disturbance is an important symptom in family members of the Sewol ferry disaster's victims, which may be screened by EEG beta power.

Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review

BACKGROUND

Because female genital mutilation/cutting (FGM/C) leads to changes in normal genital anatomy and functionality, women are increasingly seeking surgical interventions for their FGM/C-related concerns.

AIM

To conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications.

METHODS

We conducted systematic searches up to May 2016 in 16 databases to obtain references from different disciplines. We accepted all study designs consisting of girls and women who had been subjected to FGM/C and that examined a reparative intervention for a FGM/C-related concern. We screened the titles, abstracts, and full texts of retrieved records for relevance. Then, we assessed the methodologic quality of the included studies and extracted and synthesized the study data.

OUTCOMES

All outcomes were included.

RESULTS

Of 3,726 retrieved references, 71 studies including 7,291 women were eligible for inclusion. We identified three different types of surgical intervention: defibulation or surgical separation of fused labia, excision of a cyst with or without some form of reconstruction, and clitoral or clitoral-labial reconstruction. Reasons for seeking surgical interventions consisted of functional complaints, sexual aspirations, esthetic aspirations, and identity recovery. The most common reasons for defibulation were a desire for improved sexual pleasure, vaginal appearance, and functioning. For cyst excision, cystic swelling was the main reason for seeking excision; for reconstruction, the main reason was to recover identity. Data on women's experiences with a surgical intervention are sparse, but we found that women reported easier births after defibulation. Our findings also suggested that most women were satisfied with defibulation (overall satisfaction = 50-100%), typically because of improvements in their sexual lives. Conversely, the results suggested that defibulation had low social acceptance and that the procedure created distress in some women who disliked the new appearance of their genitalia. Most women were satisfied with clitoral reconstruction, but approximately one third were dissatisfied with or perceived a worsening in the esthetic look.

CLINICAL TRANSLATION

The information health care professionals give to women who seek surgical interventions for FGM/C should detail the intervention options available and what women can realistically expect from such interventions.

STRENGTHS AND LIMITATIONS

The systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed.

CONCLUSION

There are some data on women's motivations for surgery for FGM/C-related concerns, but little is known about whether women are satisfied with the surgery, and experiences appear mixed. Berg RC, Taraldsen S, Said MA, et al. Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review. J Sex Med 2017;14:977-990.

Psychological and counselling interventions for female genital mutilation

Women and girls living with female genital mutilation (FGM) are more likely to experience psychological problems than women without FGM. As well as psychological support, this population may need additional care when seeking surgical interventions to correct complications of FGM. Recent WHO guidelines recommend cognitive behavioral therapy for women and girls experiencing anxiety disorders, depression, or post-traumatic stress disorder. The guidelines also suggest that preoperative counselling for deinfibulation, and psychological support alongside surgical interventions, can help women manage the physiological and psychological changes following surgery. This synthesis summarizes evidence on women's values and preferences, and the context and conditions that may be required to provide psychological and counselling interventions. Understanding women's views, their own ways of coping, as well social and cultural factors that influence women's mental well-being, may help identify the types of interventions this population needs at different times and stages of their lives.