Long-term consequences of female genital mutilation in a European context: self perceived health of FGM women compared to non-FGM women

Effect of type III female genital mutilation on obstetric outcomes: A systematic review and meta-analysis

Background

Controversial evidence suggests a potential association between female genital mutilation (FGM/C) and adverse obstetric outcomes, with type III FGM/C (infibulation) carrying the greatest risk. The aim of this systematic review and meta-analysis was to assess current rate of adverse obstetric outcomes in women with type III female genital mutilation and cutting (FGM/C; infibulation) delivering across different settings worldwide.

Methods

We searched PubMed, Scopus, Embase, and ClinicalTrials.gov databases from inception to Jan 1, 2023. Studies were selected if they included the main outcome of postpartum haemorrhage (PPH) or secondary outcomes, which included major conditions affecting maternal-neonatal health during labour and delivery. DerSimonian-Laird random effects meta-analysis including pooled effect estimates with corresponding 95 % confidence intervals was performed. Heterogeneity was assessed using the I2 statistic. Meta regression for relevant covariates was performed when data on relevant confounders were available. The Newcastle-Ottawa scale (NOS) was used to assess quality of observational studies. The level of evidence was assessed with the GRADE method.

Results

14 observational studies including 15,320 type III FGM/C women and 59,347 controls were eligible. The risk for postpartum haemorrhage was significantly increased in type III FGM/C, in the main analysis (OR 1.83, 95 % CI 1.03 to 3.24, I2 = 93 %), in pooling of data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I2 = 0 %), and in sensitivity analysis of higher quality studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I2 = 95 %). Meta-regression showed that nulliparity was significantly and positively associated with postpartum haemorrhage. Similarly, analysis of data adjusted for confounders showed an increased risk of episiotomy in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I2 = 52 %). Sensitivity analysis of studies with NOS≥7 revealed a significant increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I2 = 96 %), perineal tears (OR 4.24, CI 1.09 to 16.46, I2 = 66 %), prolonged second stage of labour (OR 5.19, 95 % CI 1.00 to 26.85, I2 = 66 %), and Apgar score less than 7 (OR 4.19, CI 1.64 to 10.70, I2 = 0 %). No difference was found regarding obstetric anal sphincter injuries and mode of delivery in these women. Deinfibulation achieved similar obstetric and neonatal outcomes to women who never had type III FGM. The overall quality of the studies was adequate (median NOS score: 7; IQR: 6-8), the level of evidence, according to the GRADE assessment, was low.

Conclusions

These results consistently show an increased risk of adverse obstetric outcomes in women with FGM/C type III. Infibulation substantially increases the risk for PPH, particularly in nulliparae. Systematic Review registration: PROSPERO CRD42023421993.

The need for and acceptability of a curriculum to train nursing and medical students in the sexual healthcare of clients with female genital mutilation/cutting in Tanzania

BACKGROUND

Female genital mutilation/cutting (FGM/C) is tied to one of the most conservative cultures in the Mediterranean and Sub-Saharan Africa. More than 200 million girls and women in 30 African, Asian and the middle Eastern countries have undergone FGM/C. However, healthcare professionals are not adequately trained to prevent and manage FGM/C-related complications including sexual health problems. This study aimed to assess the need and acceptability of a curriculum to train nursing and medical students in the sexual healthcare of clients with FGM/C in Tanzania.

METHODS

We used a descriptive and cross sectional study design to collect and analyse information from 271 medical and 137 nursing students in Tanzania. A Qualtrics online survey was used to obtain quantitative data on training interest, previous training received, and the curriculum delivery method. Open-ended questions were used to explore their insights on significance to obtain the necessary competencies to treat and prevent FGM/C. Descriptive statistics were used to analyze quantitative data while qualitative data were analyzed using a thematic approach.

RESULTS

Almost half of the participants reported they had little to no training in sexual healthcare for women with FGM/C (47%). In all, 82.4% reported the training to be acceptable. Following thematic analysis of open-ended questions, participants expressed a desire to improve their competencies to meet the current and future sexual and psychological health needs of women and girls who have undergone FGM/C.

CONCLUSION

It is a necessary and acceptable to develop a curriculum to train healthcare students to diagnose, treat and prevent sexual health complications related to FGM/C. In our study, designing a culturally sensitive curriculum and its delivery method, that includes practical sessions with simulated patients, was considered the most beneficial and favorable.

Effect of Female Genital Mutilation on Sexual Function in Ibadan, Nigeria

Objective: Female genital mutilation, which harms women physically and psychologically, also causes serious problems in sexual life that continue throughout life. This study aimed to determine the impact of female genital mutilation on sexual outcomes in Ibadan, Nigeria. Method: This is a cross-sectional descriptive study. A self-administered questionnaire was used to obtain data from 161 women who agreed to participate in the study. After the data were collected, the sample group was divided into two groups those with female genital mutilation (84) and those without (77), and they were compared in terms of sexual outcomes. Results: Type I (77.3%) and type II (22.7%) mutilations were found in women with female genital mutilation. It was determined that women with FGM experienced statistically significantly more pain and bleeding during vaginal penetration than uncircumcised women. At the same time, the orgasm rate was found to be statistically significantly lower in this group. Conclusions: Our study revealed that female genital mutilation and enlargement of the incision area negatively affect sexual health.

Our Body Our Health (Jirkeena, Caafimaadkeena): Somali Women's Narratives on Sexual Health

Women across the globe have been subject to female genital cutting (FGC), with the highest rates in Somalia. FGC can result in sexual concerns, especially sexual pain and lower pleasure. Due to ongoing civil war and climate disasters, there is a large number of Somali immigrants and refugees living in countries where healthcare providers may be unfamiliar with the impact of FGC. In this qualitative study, sixty Somali women between the ages 20 and 45 and living in the U.S. shared their perspectives on how FGC has affected their sexual lives, including how they have coped with any complications attributed to FGC. Participants were recruited through convenience sampling and interviewed by a bilingual community researcher in either Somali or English. Data were analyzed through a participatory analysis process by academic and community researchers. Themes included sexual desire, arousal, and pleasure; sexual satisfaction; sexual pain at first intercourse; coping with sexual pain at first intercourse; long-term sexual pain, coping with long-term sexual pain. Results are discussed with a focus on agency of the participants, role of partners, and implications for healthcare professionals.

Female genital mutilation in the Canary Islands: A qualitative study on the perspectives of women and healthcare professionals

Introduction

Migration to Western countries is associated with social and health challenges that are difficult to manage. Female genital mutilation (FGM) is a harmful practice that still occurs in the 21st century. According to the World Health Organization, FGM is a ritual procedure involving the partial or total removal of the external female genitalia for non-therapeutic reasons.

Objectives

(I) To explore the experiences of women residing in the Canary Islands, in Spain, who had suffered FGM, and their assessment of the healthcare received. (II) To explore the perspectives of healthcare professionals who had attended to these cases, care pathways, and prevention.

Methods

A qualitative study, phenomenologically oriented based on a pragmatic perspective, was conducted. We conducted open in-person interviews, and written documents were sent via email for data collection. Purposeful and snowball sampling methods were used to select women who had undergone FGM and healthcare providers who had attended to such patients. Nine participants were recruited, five health professionals and four women. Although the sample size was not very large, the data had enough depth and richness to meet the goals of the study. The data were analyzed using the thematic analysis technique.

Results

Six main themes emerged, including the "meaning of FGM," "health consequences," "benefits of treatments," "knowledge about FGM," "experiences of professionals and with professionals," and "recommendations of professionals in improving care."

Conclusions

Professionals and women identified the lack of training to address this problem, and both parties perceived FGM as a negative practice. The women lack knowledge about the relationship between some health problems they suffer and FGM, which poses a challenge for accurate diagnosis and treatment. Therefore, professionals need to know in detail all health conditions related to FGM to diagnose and treat these women more accurately. When affected women arrive in Western countries and receive correct information on the consequences of FGM, they are more likely to reject this practice. The identification of cases of FGM in women born in the Canary Islands urges the need to develop strategies to avoid such situations.

Understanding the consequences of Female Genital Mutilation: a phenomenological study in sub-Saharan women living in Spain

BACKGROUND

Female Genital Mutilation (FGM), which is culturally accepted in some African communities, has serious consequences on the physical, psychological, urogynecological, obstetrical and sexual health of girls and women. It is therefore important to understand women's experiences of the consequences of FGM.

OBJECTIVE

to understand the experiences of the consequences of female genital mutilation in sub-Saharan female survivors living in Spain.

DESIGN

a qualitative study based on Merleau-Ponty's hermeneutic phenomenology.

PARTICIPANTS AND SETTING

13 sub-Saharan female survivors of female genital mutilation participated. The study was carried out in two south-eastern Spanish provinces where many jobs in the agricultural and service industry are done by African immigrants originating from ethnic groups in which FGM is still prevalent.

FINDINGS

In-depth interviews were carried out for data collection. ATLAS.ti was used for inductive analysis, from which two main themes were developed that represent the experiences of the consequences of FGM: (a) The impact of FGM: Hijacked sexual health and (b) The difficult process of genital reconstruction: overcoming the aftereffects and regaining integrity.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The mutilated women experienced serious consequences in their sexual, psychological and obstetrical health. Genital reconstruction was a difficult decision but contributed to regaining their sexual health and identity. The professionals involved play an important role in the care provided for the associated consequences of FGM, in identifying risk groups and in providing advice that allows the women to regain their sexual and reproductive health.

Experiences of Primary Healthcare Workers in Australia towards Women and Girls Living with Female Genital Mutilation/Cutting (FGM/C): A Qualitative Study

Female genital mutilation/cutting (FGM/C) is a harmful cultural practice with significant health consequences for affected women and girls. Due to migration and human mobility, an increasing number of women with FGM/C are presenting to healthcare facilities of western countries (including Australia) where the practice is non-prevalent. Despite this increase in presentation, the experiences of primary healthcare providers in Australia engaging and caring for women/girls with FGM/C are yet to be explored. The aim of this research was to report on the Australian primary healthcare providers' experiences of caring for women living with FGM/C. A qualitative interpretative phenomenological approach was utilised and convenience sampling was used to recruit 19 participants. Australian primary healthcare providers were engaged in face-to-face or telephone interviews, which were transcribed verbatim and thematically analysed. Three major themes emerged, which were: exploring knowledge of FGM/C and training needs, understanding participants' experience of caring for women living with FGM/C, and mapping the best practice in working with women. The study shows that primary healthcare professionals had basic knowledge of FGM/C with little or no experience with the management, support, and care of affected women in Australia. This impacted their attitude and confidence to promote, protect, and restore the target population's overall FGM/C-related health and wellbeing issues. Hence, this study highlights the importance of primary healthcare practitioners being skilled and well-equipped with information and knowledge to care for girls and women living with FGM/C in Australia.

A prospective cohort study of the relationship of female genital mutilation with birth outcomes in Somalia

Background

Female genital mutilation (FGM) is defined as the partial or complete removal of the external female genitalia for non-medical reasons. There are some complications related to childbirth that concern both the mother and the baby. In this study, we aimed to evaluate the birth outcomes of FGM, which is widely applied in Somalia.

Methods

The study included 268 women who gave birth at 37–42 weeks of gestation with a cephalic singleton, 134 with FGM and 134 without FGM. This study was designed a prospective cohort study and conducted between January 2019 and December 2020. Patients’ ages, duration of delivery, FGM types, caesarean section requirements, before and after birth hemoglobin levels, birth weeks, baby birth weights and perineal tear data were recorded. In addition, we analyzed neonatal intensive care needs and APGAR scores for infants.

Results

In patients with FGM, it was determined that the outlet obstruction increased 2.33 times, perineal tears increased 2.48 times, the need for caesarean section increased 2.11 times compared to the control group, and the APGAR score below 7 at the 5th minute in the children increased 2 times and the need for neonatal intensive care increased 1.87 times.

Conclusions

FGM causes increased risk of perineal tear, prolongation in the second stage of labour, increased need for emergency caesarean section, and increased need for NICU for infants. Prevention of FGM will help reduce both obstetric and neonatal complications.

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.

Women who have undergone female genital mutilation/cutting's perceptions and experiences with healthcare providers in Paris

Female genital mutilation/cutting (FGM/C) is a health and human rights issue and a dangerous form of gender-based violence. Given migratory flows from the countries in which it is practised, FGM/C concerns a substantial number of women living in Western countries. In this study, we looked at women who had undergone FGM/C experiences with French medical practitioners. We also discussed with them the desirability of screening for, and prevention of, FGM/C in international travel medicine centres. A qualitative approach was used to collect and analyse the data. Focus groups and semi-structured interviews were held with 26 women (24 participants in focus groups and 2 individual interviews). Transcriptions were coded and analysed thematically. All the participants came from sub-Saharan Africa. Their median age was 32.9 years. Persistent silence about FGM/C in the host society following immigration resulted in dissatisfaction with healthcare providers. Participants expected professionals to address the subject of FGM/C, feeling professionals should bring up the subject first so as to put women at ease. International travel medicine centres were discussed by some as a possible means of prevention.

Economic burden of female genital mutilation in 27 high-prevalence countries

Background

Female genital mutilation (FGM) is a traditional harmful practice affecting 200 million women and girls globally. Health complications of FGM occur immediately and over time, and are associated with healthcare costs that are poorly understood. Quantifying the global FGM-related burden is essential for supporting programmes and policies for prevention and mitigation.

Methods

Health complications of FGM are derived from a meta-analysis and stratified by acute, uro-gynaecological, obstetric and psychological/sexual. Treatment costs are calculated from national cohort models of 27 high-burden countries over 30 years. Savings associated with full/partial abandonment are compared with a current incidence reference scenario, assuming no changes in FGM practices.

Results

Our model projects an increasing burden of FGM due to population growth. As a reference scenario assuming no change in practices, prevalent cases in 27 countries will rise from 119.4 million (2018) to 205.8 million (2047). Full abandonment could reduce this to 80.0 million (2047), while partial abandonment is insufficient to reduce cases. Current incidence economic burden is US$1.4 billion/year, rising to US$2.1 billion/year in 2047. Full abandonment would reduce the future burden to US$0.8 billion/year by 2047.

Conclusion

FGM is a human rights violation, a public health issue and a substantial economic burden that can be avoided through effective prevention strategies. While decreasing trends are observed in some countries, these trends are variable and not consistently observed across settings. Additional resources are needed to prevent FGM to avoid human suffering and growing costs. The findings of this study warrant increased political commitment and investment in the abandonment of FGM.

Female genital mutilation/cutting in sudan and subsequent pelvic floor dysfunction

Background

We aimed to evaluate the socio-demographic characteristics of women with female genital mutilation/cutting (FGM/C) and the results of FGM/C due to pelvic floor dysfunction.

Results

The prevalence of FGM/C was 87.2% in Sudan and Type 3 (50.4%) was the most prevalent, followed by Type 2 (35%) and Type 1 (8.5%). In the multinominal logistic regression analysis performed to show the effect of FGM/C on pelvic organ prolapse (POP), it was observed that FGM/C frequency in POP group 2 was statistically similar when POP group 1 was taken as reference category. In the evaluation for symptomatic POP (POP group 3), risk of developing POP in patients without FGM/C was significantly lower than patients with type 3 FGM/C with a rate of 82.9% (OR(odds ratio): 0.171 (p: 0.002), (Confidence Interval (CI) %95; 0.058–0.511). Risk of developing POP rate in patients with type 1 FGM/C was 75% (OR:0.250 (p: 0.005), CI %95; 0.094–0.666) and in patients with type 2 FGM/C was 78.4% (OR:0.216 (p: 0.0001), CI%95; 0.115–0.406). In the multinominal logistic regression analysis including other variables affecting POP, when group 1 was taken as the reference category, it was found that the possibility of developing mild POP (group 2) decreased in FGM/C type 1 and 2 compared to FGM/C type 3 but it was not statistically significant. However, the evaluation for the symptomatic POP group showed up a significantly lower risk of developing POP in patients with type 2 FGM/C compared to patients with type 3 FGM/C, with a rate of 58.4%. (OR:0.419 (p: 0.016), CI%95; 0.206–0.851) (Table 3). In addition, older age was found to be significant risk factor for increasing symptomatic POP (p: 0.003).

Conclusions

Type 2 and 3 FGM/C continues to be an important health problem in terms of complications that may develop in advanced ages as well as many short-term complications as a result of mechanical or physiological deterioration of the female genital anatomy.

Female Genital Mutilation: Knowledge and Skills of Health Professionals

BACKGROUND

Female genital mutilation (FGM) is any process that injures female genitals for non-medical reasons and is a violation of women's human rights. An important number of women from countries where FGM is performed are arriving to Western countries. Health professionals are important for detecting cases of FGM. No surveys to assess knowledge, attitudes and practices on FGM among healthcare professionals has been conducted in Castilla la Mancha (Spain) until now.

METHODS

The main goal of the study is assessing knowledge, attitudes and perceptions of healthcare professionals in relation to FGM. A cross-sectional descriptive study was conducted based on self-administered online surveys to nurses, midwives, family doctors, pediatricians, obstetrics and gynecologists.

RESULTS

In total, 1168 professionals answered the surveys. Just 13.9% indicated that they had received training in FGM, however just 10.7% correctly identified the three types of FGM, 10.7% the countries where it is usually practiced, 33.9% knew the legislation in Spain and only 4.4% found a case of FGM during their professional practice. Regarding the knowledge about protocols, 8.64% of the sample indicated to know one of them.

CONCLUSION

The present study demonstrate that it is necessary to improve the training and awareness of healthcare professionals related to FGM in Castilla la Mancha.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

"You have to be clean:" a qualitative study of pubic hair grooming behaviours among women living in Italy

The majority of pubic hair and genital self-image research describes women living in the USA, UK and Australia. This may leave attitudes and behaviours across other cultures and geographic regions ambiguous. The purpose of this study was to describe pubic hair removal attitudes and behaviours among reproductive-age women living in Italy. Individual interviews were conducted with 46 women aged 18-45 years between June and July 2017, living in Florence, Italy and currently utilising the Italian healthcare system. Pubic hair removal was popular among participants. Women mainly removed pubic hair by waxing. Sexual partners influenced removal, as did cultural norms and the desire for cleanliness. Most participants indicated pubic hair removal onset during adolescence, often upon puberty. However, most participants had never discussed removal complications with providers. Pubic hair removal often related to a more positive genital self-image because of social norms surrounding hairlessness. Removal among this sample appears to differ from the literature in other contexts, with women living in Italy engaging in more frequent and earlier waxing. Findings offer opportunities for clinicians to proactively address safe pubic hair practices and women's genital concerns during consultations.

Are you in pain if you say you are not? Accounts of pain in Somali-Canadian women with female genital cutting

ABSTRACT

As a rite of passage to womanhood, 2 million girls undergo female genital circumcision (FGC)-the tradition of cutting, and often removing parts of the vulva-every year. The current study is the first to focus on the connection between peripheral nerve damage and chronic neuropathic pain in women with FGC. We used mixed methods-quantitative, qualitative, and physiological-to study chronic pain in Somali-Canadian women (N = 14). These women have the most extensive form of FGC, which includes removal of the glans clitoris, labia minora, medial portion of the labia majora, and stitching together the remaining parts of the labia majora. Our results indicate a multifaceted pain experience in women with FGC. Although they report good overall health and very low pain levels on the short form of the McGill Pain Questionnaire, pressure-pain quantitative sensory testing of the vulvar region applied through vulvalgesiometers shows pain thresholds consistent with those reported by women with chronic vulvar pain. Furthermore, qualitative interviews reveal a considerable amount of often debilitating pain in daily life. These results challenge the use of assessment tools offering elicited verbal pain language and highlight the importance of culturally sensitive ways of conceptualizing, measuring, and managing pain.

A systematic review and meta-analysis of the consequences of female genital mutilation on maternal and perinatal health outcomes in European and African countries

INTRODUCTION

Key knowledge gaps remain to improve reproductive health outcomes for millions of women living with female genital mutilation (FGM). We aimed to update previous reviews and quantify more rigorously maternal and perinatal complications related to FGM across different settings.

METHODS

In this systematic review and meta-analysis, we searched 15 electronic databases for studies published between 1 August 1995 and 15 March 2020, reporting on maternal and perinatal complications related to FGM. We included studies comparing women with and without FGM while accounting for confounders. Pooled relative risks (RR) were calculated, using fixed-effects and random-effects models, for a range of maternal and perinatal outcomes, adjusting for individual characteristics and according to delivery settings and study design.

RESULTS

We identified 106 unique references, assessed 72 full-text articles and included 11 studies. We found non-significant elevated risks of instrumental delivery, caesarean delivery, episiotomy, postpartum haemorrhage, perineal laceration, low Apgar score and miscarriage/stillbirth related to FGM. Heterogeneity was present for most outcomes when combining all studies but reduced in subgroup analyses. The risk of caesarean delivery was increased among primiparous women (1.79, 95% CI 1.04 to 3.07) such as the risk of episiotomy in European specialised settings for women with FGM (1.88, 1.14 to 3.09). In Africa, subgroup analyses revealed elevated risks of postpartum haemorrhage (2.59, 1.28 to 5.25). The most common reported type was FGM II. However, few studies provided stratified analyses by type of FGM, which did not allow an assessment of the impact of the severity of typology on studied outcomes.

CONCLUSION

This review suggests maternal and perinatal morbidity related to FGM vary by study design, context and by subgroup of women. Our study also draws attention to the complications that may extend to the postpartum period. This work contributes to shaping a reference framework for future research and clinical guidelines.

Painful gynecologic and obstetric complications of female genital mutilation/cutting: A systematic review and meta-analysis

BACKGROUND

The health complications experienced by women having undergone female genital mutilation/cutting (FGM/C) are a source of growing concern to healthcare workers globally as forced displacement and migration from countries with high rates of this practice increases. In this systematic review and meta-analysis, we investigate the association between FGM/C and painful gynecologic and obstetric complications in women affected by the practice.

METHODS AND FINDINGS

We performed a comprehensive literature search from inception to December 19, 2019 of Ovid MEDLINE, Ovid EMBASE, The Cochrane Library (Wiley), and POPLINE (prior to its retirement) for studies mentioning FGM/C. Two reviewers independently screened studies reporting prevalences of painful gynecologic and obstetric sequelae resulting from FGM/C. Random effects models were used to estimate pooled odds ratios (ORs) for outcomes obtained from cross-sectional, cohort, and case-control designs. Subgroup analysis was performed to assess and control for effect differences introduced by study design. Validated appraisal tools were utilized to assess quality and risk of bias. Our study was registered with PROSPERO. Two reviewers independently screened 6,666 abstracts. Of 559 full-text studies assessed for eligibility, 116 met eligibility criteria, which included studies describing the incidence or prevalence of painful sequelae associated with FGM/C. Pooled analyses after adjustment for study design found that FGM/C was associated with dyspareunia (6,283 FGM/C and 3,382 non-FGM/C participants; pooled OR: 2.47; 95% confidence interval [CI]: 1.45-4.21; I2: 79%; p-value < 0.01), perineal tears (4,898 FGM/C and 4,229 non-FGM/C participants; pooled OR: 2.63; 95% CI: 1.35-5.11; I2: 67%; p-value = 0.01), dysuria (3,686 FGM/C and 3,482 non-FGM/C participants; pooled OR: 1.43; 95% CI: 1.17-1.75; I2: 0%; p-value = 0.01), episiotomy (29,341 FGM/C and 39,260 non-FGM/C participants; pooled OR: 1.89; 95% CI: 1.26-2.82; I2: 96%; p-value < 0.01), and prolonged labor (7,516 FGM/C and 8,060 non-FGM/C participants; pooled OR: 2.04; 95% CI: 1.27-3.28; I2: 90%; p-value < 0.01). There was insufficient evidence to conclude that there was an association between FGM/C and dysmenorrhea (7,349 FGM/C and 4,411 non-FGM/C participants; pooled OR: 1.66; 95% CI: 0.97-2.84; I2: 86%; p-value = 0.06), urinary tract infection (4,493 FGM/C and 3,776 non-FGM/C participants; pooled OR: 2.11; 95% CI: 0.80-5.54; I2: 90%; p-value = 0.10), instrumental delivery (5,176 FGM/C and 31,923 non-FGM/C participants; pooled OR: 1.18; 95% CI: 0.78-1.79; I2: 63%; p-value = 0.40), or cesarean delivery (34,693 FGM/C and 46,013 non-FGM/C participants; pooled OR: 1.51; 95% CI: 0.99-2.30; I2: 96%; p-value = 0.05). Studies generally met quality assurance criteria. Limitations of this study include the largely suboptimal quality of studies.

CONCLUSIONS

In this study, we observed that specific painful outcomes are significantly more common in participants with FGM/C. Women who underwent FGM/C were around twice as likely as non-FGM/C women to experience dyspareunia, perineal tears, prolonged labor, and episiotomy. These data indicate that providers must familiarize themselves with the unique health consequences of FGM/C, including accurate diagnosis, pain management, and obstetric planning.

REVIEW PROTOCOL REGISTRATION

The review protocol registration in PROSPERO is CRD42018115848.

Understanding the Experiences and Needs of Migrant Women Affected by Female Genital Mutilation Using Maternity Services in Australia

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for non-therapeutic reasons. Changing patterns of migration in Australia and other high-income countries has meant that maternity care providers and health systems are caring for more pregnant women affected by this practice. The aim of the study was to identify strategies to inform culturally safe and quality woman-centred maternity care for women affected by FGM who have migrated to Australia. An Appreciative Inquiry approach was used to engage women with FGM. We conducted 23 semi-structured interviews and three focus group discussions. There were four themes identified: (1) appreciating the best in their experiences; (2) achieving their dreams; (3) planning together; and (4) acting, modifying, improving and sustaining. Women could articulate their health and cultural needs, but they were not engaged in all aspects of their maternity care or considered active partners. Partnering and involving women in the design and delivery of their maternity care would improve quality care. A conceptual model, underpinned by women’s cultural values and physical, emotional needs, is presented as a framework to guide maternity services.

Polyvictimization and mental health consequences of female genital mutilation/circumcision (FGM/C) among Somali refugees in Kenya

Female genital mutilation or circumcision (FGM/C) is a perilous social and cultural practice that affects the physical, mental, and psychological health of affected women. It is widespread around the world, affecting 200 million women and girls. This study aimed to explore the relation of FGM/C to mental and physical conditions in Somali refugees displaced in a low-resource setting, applying the concept of poly-victimization to reveal multifaceted trauma sequelae. Data for this cross-sectional study with 143 female Somali youth living in Eastleigh, Kenya were collected between April and May in 2013. FGM/C was strongly associated with negative physical and mental health outcomes, including post-traumatic stress disorder and depressive, anxiety, and somatic symptoms. Logistic regression analysis revealed that separation from a parent and poly-victimization experiences were significantly associated with FGM/C experience. The results also showed that FGM/C and other traumas did not occur singly but were indicative of cumulative adversities, especially for women who were socially vulnerable and marginalized. The results of this study highlight the practice of FGM/C in the context of other adverse living conditions of refugees and the importance of attending to other co-occurring risk factors that prevail with FGM/C practice in the ecological system of refugee forced migration.

Female genital mutilation in the UK: considerations for best nursing practice

Female genital mutilation (FGM) is any process that injures or removes part or all of the external female genital organs for non-medical reasons. FGM is a growing public health concern in the UK because of an increase in migration from countries where it is widely practised. Education on FGM for nurses is key to supporting women who have undergone the practice, as well as safeguarding girls and women who are at risk. Nurses must understand the history and culture of FGM as well as the long-term health complications to be able to support affected women both professionally and sensitively.

"It's not perfect but it's mine": Genital self-image among women living in Italy

The purpose of this article is to describe Italian women's attitudes toward their genitals, and the intersection of genital self-image (GSI) and reproductive and sexual health behaviors. Individual interviews were conducted with 46 reproductive-aged women. All interviews were transcribed verbatim with observer comments to identify emerging data patterns. Researchers completed coding between and within interviews for a constant comparative approach to data analysis to identify emergent themes. Participants expressed embarrassment discussing genitals and equated this with societal taboos; however, friends provided one opportunity to speak more openly. Odor discussions and hygiene practices were frequently occurring themes, especially during menstruation. GSI limited some daily activities and sexual experiences due to feelings of self-consciousness. Concerns stemmed from limited knowledge about how women's genitals should look, smell, and feel. In contrast, some women detailed positive GSI in terms of autonomy and self-care. Results illustrate practical recommendations for healthcare providers to address women's genital concerns and improve women's GSI and overall reproductive and sexual health experiences.

The experience of NHS care for women living with female genital mutilation

This qualitative study aims to explore and analyse the experiences of women living with female genital mutilation (FGM) who have sought help from healthcare providers within the NHS. Nine women aged 20-46 years were recruited from support organisations in the north-west of England and interviewed about their experiences of NHS care and if any screening had taken place in relation to the consequences of living with FGM. The interviews were undertaken in English, audiotaped, transcribed and analysed using a framework analysis method. Eight of the women had given birth and the main contact with the NHS had been with midwifery, gynaecology and paediatric services. Three key themes emerged from the qualitative data: involvement with healthcare professionals; silent suffering; and compassionate communication. Findings highlight the importance of sensitive and culturally competent communication nurses require to support women and refer them to appropriate services.

Using electronic maternity records to estimate female genital mutilation in Lothian from 2010 to 2013

Background

Female genital mutilation (FGM) is most commonly encountered in Africa and the Middle East, with migration from FGM-practicing countries meaning it is increasingly seen in Europe. Addressing FGM requires accurate information on who is affected but ascertainment is notoriously difficult. This study estimated FGM prevalence in women presenting for maternity care in the Lothian region of Scotland and compared this with that expected by extrapolation of survey data from women's country of birth.

Methods

Electronic clinical records were linked to birth registration data to estimate FGM in the obstetric patients in Lothian from 2010 to 2013.

Results

Among all, 107 women affected by FGM were detected, at a rate of 2.8/1000 pregnancies. Of 487 women from UNICEF-recognized FGM-practicing countries who accessed care, 87 (18%) had documented evidence of FGM (three quarters of whom came from Nigeria, Sudan or The Gambia). The prevalence was 54% of the level expected from the extrapolation method. Country of birth had a sensitivity of 81% for FGM.

Conclusion

Women from FGM-practicing countries commonly access maternity care in Lothian. This confirms the need for ongoing training and investment in identifying and managing FGM. Matching electronic clinical records with birth registration data was a useful methodology in estimating the level of FGM in the maternity population. In a European country like Scotland with modest migrant numbers, asking country of birth during pregnancy and making sensitive enquiries could detect 81% of women with FGM. Extrapolation from maternal country of birth surveys grossly overestimates the true prevalence.

Maternity care experiences and health needs of migrant women from female genital mutilation-practicing countries in high-income contexts: A systematic review and meta-synthesis

BACKGROUND

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM.

METHODS

We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers.

RESULTS

Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care.

CONCLUSIONS

The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented.

Delivery and its complications among women of Somali, Kurdish, and Russian origin, and women in the general population in Finland

INTRODUCTION

Limited information is available on delivery and its complications among migrant women in Finland. We compared mode of delivery, delivery complications, and use of pain medication during delivery between migrant women of Somali, Kurdish, and Russian origin and women in the general population in Finland.

METHODS

The women were of Russian (n = 318), Somali (n = 583), and Kurdish (n = 373) origin and 243 women from the general population (reference group) who had given birth in Finland between 2004 and 2014. The data were obtained from the National Medical Birth Register and the Hospital Discharge Register. The most recent birth of each woman was included in the analyses. The main statistical methods were logistic regression analyses adjusting for age, parity, body mass index, gestational age, and smoking during pregnancy.

RESULTS

Vaginal delivery was the most common mode of delivery among all study groups (79%-89%). The prevalence of any delivery complications varied between 15% and 19% among all study groups. When adjusted for confounders, Russian women had lower odds (OR 0.49; CI 0.29-0.82) of having a cesarean delivery, whereas Somali and Kurdish women did not differ from the reference group. Somali women had an increased risk of any delivery complications (OR 1.62; CI 1.03-2.55) compared with the reference group. No differences were observed in the use of pain medication between the groups.

CONCLUSION

Delivery complications were more common among migrant Somali women than among women in the general Finnish population. Somali women represent a high-risk group calling for special attention and care.

Theorising women's health and health inequalities: shaping processes of the 'gender-biology nexus'

Since the theoretical frameworks and conceptual tools we employ shape research outcomes by guiding research pathways, it is important that we subject them to ongoing critical reflection. A thoroughgoing analysis of the global production of women's health inequality calls for a comprehensive theorization of how social relations of gender and the biological body mutually interact in local contexts in a nexus with women's health. However, to date, the predominant concern of research has been to identify the biological effects of social relations of gender on the body, to the relative neglect of the co-constitutive role that these biological changes themselves may play in ongoing cycles of gendered health oppressions. Drawing on feminist and gender theoretical approaches, and with the health of women and girls as our focus, we seek to extend our understanding of this recursive process by discussing what we call the 'shaping processes' of the 'gender-biology nexus' which call attention to not only the 'gender-shaping of biology' but also the 'biologic-shaping of gender'. We consider female genital mutilation/cutting as an illustration of this process and conclude by proposing that a framework which attends to both the 'gender-shaping of biology' and the 'biologic-shaping of gender' as interweaving processes provides a fruitful approach to theorising the wider health inequalities experienced by women and girls.

The lived experience of female genital cutting (FGC) in Somali-Canadian women's daily lives

Many of the Somali women who have immigrated to other countries, including Canada, have experienced Female Genital Circumcision/ Mutilation/ Cutting (FGC). While there is literature on the medical aspects of FGC, we were interested in understanding the daily life experiences and bodily sensations of Somali-Canadian women in the context of FGC. Fourteen women living in the Greater Toronto Area were interviewed. Interview data were analyzed using a phenomenological approach. We found that the memory of the ceremonial cutting was vivid but was frequently described with acceptance and resignation–as something that just is; that was normal given the particular context, familial and cultural, and their young age. Most of the women recounted experiencing pain and discomfort throughout their adult lives but were intent on not noticing or giving the pain any power; they considered themselves healthy. The following themes emerged from our interviews: Every Body Had It: Discussing FGC, I’m Normal Aren’t I?, and Feeling in My Body–all themes that work at normalizing their bodies in a society that they know views them as different. They dealt with both pain and pleasure in the context of their busy lives suggesting resilience in spite of the day-to-day difficulties of daily life.

Living with mutilation: A qualitative study on the consequences of female genital mutilation in women's health and the healthcare system in Spain

INTRODUCTION

Female genital mutilation is a health and human rights issue which extends to western countries. It is estimated that there are some seventeen thousand women and girls living in Spain who have either been mutilated or are at risk of being so. Healthcare professionals face the challenge of providing adequate care in response to this emerging problem.

AIM

To discover the repercussions of female genital mutilation on the health of sub-Saharan women residing in Spain, as well as the healthcare received.

METHODS

A life-history qualitative research design was utilized. The study population included 14 genitally mutilated women residing in the Region of Murcia who had given birth in Spain and been attended to by the national public healthcare system.

RESULTS

Women suffer physical, psychological, obstetric and sexual health issues as a result of female genital mutilation and despite having a favourable perception of the healthcare received during the pregnancy and the delivery, the provision of health education, detection and treatment of female genital mutilation by healthcare professionals was seen to be lacking.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Healthcare policy must address insufficiencies in delivering adequate care to immigrant women who have been the victim of female genital mutilation by implementing the necessary resources and training for professionals to effectively meet the specific healthcare needs of this population and prevent this cruel practice from being perpetuated.

Challenges in providing quality care for women with female genital cutting in Sweden - A literature review

Due to migration, health care needs in relation to female genital cutting (FGC) are increasingly emerging in European health care contexts, with Sweden being no exception. Recent estimates suggest that up to 38 000 girls and women with some form of FGC are living in Sweden, the majority from Somalia. Despite receiving high numbers of immigrants from FGC practising countries, health care services in many European countries seem largely unprepared in caring for circumcised patients. This literature review aims to identify challenges involved in providing quality care for circumcised women in Sweden. Two themes were identified; lacking technical skills and communication problems and ethnocentric attitudes. Lacking technical skills involved midwives and gynaecologists feeling insecure in how to technically deal with infibulated women during childbirth, something that often resulted in ad hoc solutions and improvisation. They related this insecurity to a lack of theoretical and practical training of FGC related health problems. In communication problems and ethnocentric attitudes both health care professionals and circumcised women reported facing difficulties in communicating about FGC, largely due to language barriers and perceived sensitivity of the issue. In conclusion, skills among health care professionals in Sweden caring for circumcised patients could be strengthened. This should be taken into consideration when planning midwifery and gynaecology curricula, and in providing in-service training for health care professionals likely to meet circumcised women in their practice.

Clitoral reconstruction: Understanding changing gendered health care needs in a globalized Europe

The migratory flows of recent decades that have exercised Europe as a socio-political and economic entity have produced extensive responses and interventions from European gender scholars. One relatively recent phenomenon in this context is the question of reparative surgical interventions, specifically clitoral reconstruction, in cases where women who have migrated to Europe have experienced female genital cutting. Clitoral reconstruction, which this article begins to explore, is recent in part because the related surgery was only established in the 1990s and is to date only practised in a few European countries, and in part because the research with women who ask for and have undergone such surgery has also only recently begun. This article is therefore an initial attempt to map some of the related terrain and to suggest further work that needs to be done in this increasingly important area.

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.

Migrating with Special Needs? Projections of Flows of Migrant Women with Female Genital Mutilation/Cutting Toward Europe 2016-2030

Female genital mutilation/cutting (FGM/C) is a rising issue in western societies as a consequence of international migration. Our paper presents demography-driven projections of female flows with FGM/C from each practicing country to each EU28 member state for the 3 sub-periods 2016-2020, 2021-2025, and 2026-2030, with the aim of supporting resource planning and policy making. According to our projections, the EU28 countries will receive a flow of around 400,000 female migrants between 2016 and 2020, and around 1.3 million female migrants between 2016 and 2030 from FGM/C practicing countries. About one-third of them, corresponding to an estimated 127,000 between 2016 and 2020, and more than 400,000 between 2016 and 2030 will have undergone FGM/C before migration. Among these female flows, slightly more than 20% is expected to be made up of girls aged 0-14. According to the expected age at arrival, 20% of these girls are expected to have already undergone FGM/C, while slightly less than 10% are to be considered potentially at risk of undergoing FGM/C after migration. As the number of women with FGM/C in Europe is expected to rise at quite a fast rate, it is important to act timely by designing targeted interventions and policies at the national and at the European level to assist cut women and protect children. Such measures are particularly compelling in France, Italy, Spain, UK, and Sweden that are expected to be the most affected countries by migration from FGM/C practicing countries.

The mothering experience of women with FGM/C raising 'uncut' daughters, in Ivory Coast and in Canada

Background

While Female Genital Cutting (FGM/C) is a deeply entrenched cultural practice, there is now mounting evidence for a gradual decline in prevalence in a number of geographical areas in Africa and following migration to non-practicing countries. Consequently, there is now a growing number of women with FGM/C who are raising ‘uncut’ daughters. This study used a qualitative methodology to investigate the experience of women with FGM/C raising daughters who have not been subjected to the ritual. The aim of this study was to shed light on mothers’ perception of the meaning and cultural significance of the practice and to gain insight into their mothering experience of ‘uncut’ girls.

Methods

To this end, in-depth interviews were conducted with fifteen mothers living in Abidjan, Ivory Coast and in Montreal, Canada (8 and 7, respectively).

Results

Thirteen mothers intrinsically refused to perpetuate FGM/C onto their daughters and two diasporic mothers were in favour of FGM/C but forewent the practice for fear of legal repercussions. Whether the eschewing of FGM/C was deliberate or legally imposed, raising ‘uncut’ daughters had significant consequences in terms of women’s mothering experiences. Mothers faced specific challenges pertaining to community and family pressure to have daughters undergo FGM/C, and expressed concerns regarding their daughters’ sexuality. Conversely, women’s narratives were also infused with pride and hope for their daughters, and revealed an accrued dialogue between the mother-daughter dyad about cultural norms and sexuality. Interestingly, women’s mothering experience was also bolstered by the existence of informal networks of support between mothers with FGM/C whose daughters were ‘uncut’. These communities of mothers engaged in open dialogue about the consequences of FGM/C and offered reciprocal solidarity and support in their decision to forego FGM/C for their children.

Conclusion

Women with FGM/C who are raising ‘uncut’ daughters in their homeland and in their country of immigration vastly report a positive experience. However, they also face specific challenges related to immigration, psychosocial, and psychosexual considerations, which must be tackled from a multidisciplinary perspective.

Female sexual dysfunction in female genital mutilation

Female genital mutilation (FGM), otherwise known as female genital cutting (FGC), is currently very topical and has become a significant global political issue. The impact of FGM on the lives of women and girls is enormous, as it often affects both their psychology and physical being. Among the complications that are often under-reported and not always acknowledged is female sexual dysfunction (FSD). FSD presents with a complex of symptoms including lack of libido, arousability and orgasm. This often occurs in tandem with chronic urogenital pain and anatomical disruption due to perineal scarring.To treat FSD in FGM each woman needs specifically directed holistic care, geared to her individual case. This may include psychological support, physiotherapy and, on occasion, reconstructive surgery. In many cases the situation is complicated by symptoms of chronic pelvic pain, which can make treatment increasingly difficult as this issue needs a defined multidisciplinary approach for its effective management in its own right. The problems suffered by women with FGM are wholly preventable, as the practice need not happen. The current global momentum to address the social, cultural, economic and medical issues of FGM is being supported by communities, governments, non-governmental agencies (NGOs) and healthcare providers. It is only by working together that the practice can be abolished and women and girls may be free from this practice and its associated consequences.

Female Genital Mutilation/Cutting among Women of Somali and Kurdish Origin in Finland

BACKGROUND

The tradition of female genital mutilation/cutting (FGM/C) has spread in Europe as a result of immigration. Although it is known to have negative health impacts, the exact prevalence of FGM/C and its health effects in Finland are unknown. This study explores the prevalence of FGM/C, the sociodemographic characteristics associated with it, and its health effects among women of Somali and Kurdish origin in Finland.

METHODS

Data were obtained from the Migrant Health and Well Being Study carried out in 2010-2012. This study uses data from interviews with Somali (N = 165) and Kurdish origin (N = 224) women. The participation rate was 37 percent for Somali and 54 percent for Kurdish origin women.

RESULTS

The prevalence of FGM/C was 69 percent among those of Somali origin and 32 percent among those of Kurdish origin. Having no education and older age were significantly associated with FGM/C, as was marriage amongst women of Somali origin, and the practice of Islam among women of Kurdish origin. Reporting good self-perceived health was more common among women without FGM/C. Outpatient visits to medical doctors were less common among women of Somali origin with FGM/C, compared with women without FGM/C. About 26 percent of Somali origin and 39 percent of Kurdish origin women with FGM/C reported reproductive or other health problems because of FGM/C.

DISCUSSION

FGM/C is more common in Finland than previously assumed, particularly among women of Kurdish origin. Women with FGM/C need improved access to culturally competent health services to address the health impacts of FGM/C. Education and outreach to immigrant communities to prevent future FGM/C are also urgently needed.

Daughters at Risk of Female Genital Mutilation: Examining the Determinants of Mothers' Intentions to Allow Their Daughters to Undergo Female Genital Mutilation

Female genital mutilation (FGM) is still a common practice in many countries in Africa and the Middle East. Understanding the determinants of FGM can lead to more active interventions to prevent this harmful practice. The goal of this study is to explore factors associated with FGM behavior among Iranian mothers and their daughters. Based on Ajzen's theory of planned behavior, we examined the predictive value of attitudes, subjective norms, perceived behavioral control and several socio-demographic variables in relation to mothers' intentions to mutilate their daughters. A paper-and-pencil survey was conducted among 300 mothers (mean age = 33.20, SD = 9.09) who had at least one daughter and who lived in Ravansar, a county in Kermanshah Province in Iran. Structural equation modeling was used to investigate the relationships among the study variables. Our results indicate that attitude is the strongest predictor of mothers' intentions to allow their daughters to undergo FGM, followed by subjective norms. Compared to younger mothers, older mothers have more positive attitudes toward FGM, perceive themselves as having more control over their behavior and demonstrate a greater intention to allow their daughter to undergo FGM. Furthermore, we found that less educated mothers and mothers living in rural areas had more positive attitudes toward FGM and feel more social pressure to allow FGM. The model accounts for 93 percent of the variance in the mothers' intentions to allow their daughters to undergo FGM. Intervention programs that want to decrease FGM might focus primarily on converting mothers' neutral or positive feelings toward FGM into negative attitudes and on alleviating the perceived social pressure to mutilate one's daughter. Based on our findings, we provide recommendations about how to curtail mothers' intentions to allow their daughters to undergo FGM.

Geographic Variation and Factors Associated with Female Genital Mutilation among Reproductive Age Women in Ethiopia: A National Population Based Survey

Background

Female genital mutilation (FGM) is a common traditional practice in developing nations including Ethiopia. It poses complex and serious long-term health risks for women and girls and can lead to death. In Ethiopia, the geographic distribution and factors associated with FGM practices are poorly understood. Therefore, we assessed the spatial distribution and factors associated with FGM among reproductive age women in the country.

Method

We used population based national representative surveys. Data from two (2000 and 2005) Ethiopian demographic and health surveys (EDHS) were used in this analysis. Briefly, EDHS used a stratified, two-stage cluster sampling design. A total of 15,367 (from EDHS 2000) and 14,070 (from EDHS 2005) women of reproductive age (15–49 years) were included in the analysis. Three outcome variables were used (prevalence of FGM among women, prevalence of FGM among daughters and support for the continuation of FGM). The data were weighted and descriptive statistics (percentage change), bivariate and multivariable logistic regression analyses were carried out. Multicollinearity of variables was assessed using variance inflation factors (VIF) with a reference value of 10 before interpreting the final output. The geographic variation and clustering of weighted FGM prevalence were analyzed and visualized on maps using ArcGIS. Z-scores were used to assess the statistical difference of geographic clustering of FGM prevalence spots.

Result

The trend of FGM weighted prevalence has been decreasing. Being wealthy, Muslim and in higher age categories are associated with increased odds of FGM among women. Similarly, daughters from Muslim women have increased odds of experiencing FGM. Women in the higher age categories have increased odds of having daughters who experience FGM. The odds of FGM among daughters decrease with increased maternal education. Mass media exposure, being wealthy and higher paternal and maternal education are associated with decreased odds of women’s support of FGM continuation. FGM prevalence and geographic clustering showed variation across regions in Ethiopia.

Conclusion

Individual, economic, socio-demographic, religious and cultural factors played major roles in the existing practice and continuation of FGM. The significant geographic clustering of FGM was observed across regions in Ethiopia. Therefore, targeted and integrated interventions involving religious leaders in high FGM prevalence spot clusters and addressing the socio-economic and geographic inequalities are recommended to eliminate FGM.

Mental health problems associated with female genital mutilation

Aims and method To study the mental health status of 66 genitally mutilated immigrant women originating from Africa (i.e. Somalia, Sudan, Eritrea and Sierra Leone). Scores on standardised questionnaires (Harvard Trauma Questionnaire-30, Hopkins Symptom Checklist-25, COPE-Easy, Lowlands Acculturation Scale) and demographic and psychosocial correlates were analysed. Results A third of the respondents reported scores above the cut-off for affective or anxiety disorders; scores indicative for post-traumatic stress disorder were presented by 17.5% of women. Type of circumcision (infibulation), recollection of the event (a vivid memory), coping style (avoidance, in particular substance misuse) and employment status (lack of income) were significantly associated with psychopathology. Clinical implications A considerable minority group, characterised by infibulated women who have a vivid memory of the circumcision and cope with their symptoms in an avoidant way, reports to experience severe consequences of genital circumcision. In terms of public healthcare, interventions should target these groups as a priority.

Female genital cutting: confronting cultural challenges and health complications across the lifespan

Female genital cutting affects over 140 million women worldwide. Prevalent in certain countries of Africa and the Middle East, the practice continues among immigrants to industrialized countries. Female genital cutting is a deeply rooted tradition that confers honor on a woman and her family, yet also a traumatic experience that creates significant dermatological, gynecological, obstetric and infectious disease complications. Little is known about postmenopausal health in cut women. The international community views this practice as a human rights violation. In addition to genital health complications, the medical community must confront an understudied concern of what happens as this population ages. These challenges must be addressed to provide optimal care to women affected by female genital cutting.

Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis

OBJECTIVE

Worldwide, an estimated 125 million girls and women live with female genital mutilation/cutting (FGM/C). We aimed to systematically review the evidence for physical health risks associated with FGM/C.

DESIGN

We searched 15 databases to identify studies (up to January 2012). Selection criteria were empirical studies reporting physical health outcomes from FGM/C, affecting females with any type of FGM/C, irrespective of ethnicity, nationality and age. Two review authors independently screened titles and abstracts, applied eligibility criteria, assessed methodological study quality and extracted full-text data. To derive overall risk estimates, we combined data from included studies using the Mantel-Haenszel method for unadjusted dichotomous data and the generic inverse-variance method for adjusted data. Outcomes that were sufficiently similar across studies and reasonably resistant to biases were aggregated in meta-analyses. We applied the instrument Grading of Recommendations Assessment, Development and Evaluation to assess the extent to which we have confidence in the effect estimates.

RESULTS

Our search returned 5109 results, of which 185 studies (3.17 million women) satisfied the inclusion criteria. The risks of systematic and random errors were variable and we focused on key outcomes from the 57 studies with the best available evidence. The most common immediate complications were excessive bleeding, urine retention and genital tissue swelling. The most valid and statistically significant associations for the physical health sequelae of FGM/C were seen on urinary tract infections (unadjusted RR=3.01), bacterial vaginosis (adjusted OR (AOR)=1.68), dyspareunia (RR=1.53), prolonged labour (AOR=1.49), caesarean section (AOR=1.60), and difficult delivery (AOR=1.88).

CONCLUSIONS

While the precise estimation of the frequency and risk of immediate, gynaecological, sexual and obstetric complications is not possible, the results weigh against the continuation of FGM/C and support the diagnosis and management of girls and women suffering the physical risks of FGM/C.

TRIAL REGISTRATION NUMBER

This study is registered with PROSPERO, number CRD42012003321.