Skip to main content
×
×
Home

Mental health problems associated with female genital mutilation

  • Jeroen Knipscheer (a1), Erick Vloeberghs (a2), Anke van der Kwaak (a3) and Maria van den Muijsenbergh (a2) (a4)
Abstract
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.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Mental health problems associated with female genital mutilation
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Mental health problems associated with female genital mutilation
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Mental health problems associated with female genital mutilation
      Available formats
      ×
Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Jeroen W. Knipscheer (j.w.knipscheer@uu.nl)
Footnotes
Hide All

Declaration of interest

None.

Footnotes
References
Hide All
1 World Health Organization. Female Genital Mutilation: Integrating the Prevention and the Management of the Health Complications into the Curricula of Nursing and Midwifery. A Student's Manual. WHO, 2001: pp. 25–7.
2 World Health Organization Media Centre. Female genital mutilation, fact sheet no. 241. WHO, 2012 (updated 2014) (http://www.who.int/mediacentre/factsheets/fs241/en/index.html).
3 van der Kwaak, A, Bartels, E, de Vries, F, Meuwese, S. Strategieën ter voorkoming van besnijdenis bij meisjes: Inventarisatie en aanbevelingen [Strategies preventing female circumcision: inventarisation and recommendations]. VrijeUniversiteit, VU Medisch Centrum, 2003.
4 Behrendt, A, Moritz, S. Posttraumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry 2005; 162: 1000–2.
5 Gruenbaum, E. Socio-cultural dynamics of female genital cuttings: research findings, gaps and directions. Cult Health Sex 2005; 7: 429–41.
6 Obermeyer, CM. The consequences of female circumcision for health and sexuality: an update on the evidence. Cult Health Sex 2005; 7: 443–61.
7 Utz-Billing, I, Kentenich, H. Female genital mutilation: an injury, physical and mental harm. J Psychosom Obstet Gynaecol 2008; 29: 225–9.
8 Whitehorn, J, Ayonrinde, O, Maingay, S. Female genital mutilation: cultural and psychological implications. Sex Marital Ther 2002; 17: 161–70.
9 Yount, KM, Balk, DL. A demographic paradox: causes and consequences of female genital cutting in Northeastern Africa. Adv Gend Res 2004; 8: 199249.
10 Johansen, REB. Pain as a counterpoint to culture. Analysis of pain associated with infibulation among Somali immigrants in Norway. Med Anthropol Q 2002; 16: 312–40.
11 Johnsdotter, S. Somali women in Western exile: reassessing female circumcision in the light of Islamic teachings. J Muslim Min Aff 2003; 23: 361–73.
12 Lockhat, H. Female Genital Mutilation: Treating the Tears. Middlesex University Press, 2004.
13 Menage, J. Post-traumatic stress disorders after genital medical procedures. In Male and Female Circumcision. Medical, Legal and Ethical Considerations in Pediatric Practice (eds Denniston, G, Mansfield Hodges, F, Fayre Milos, M): 215–9. Kluwer Academic Publishers, 1998.
14 Dekkers, W, Hoffer, C, Wils, JP. Besnijdenis, lichamelijke integriteit en multiculturalisme. Eenempirischeennormatief-ethischestudie [Circumcision, physical integrity and multiculturalism. An empirical and normative ethical study]. Damon, 2006.
15 Chalmers, B, Omer Hash, K. 432 Somali women's birth experiences in Canada after earlier female genital mutilation. Birth 2000; 27: 227–34.
16 Denholm, N. Psychological and social consequences. In Female Genital Mutilation in New Zealand: Understanding and Responding: pp. 6972. Refugee Health Education Programme, 2004.
17 Vloeberghs, E, van der Kwaak, A, Knipscheer, JW, van den Muijsenbergh, M. Coping and chronic psychosocial consequences of female genital mutilation in the Netherlands. Ethnicity Health 2012; 17: 677–95.
18 de Jong, JTVM, van Ommeren, M. Toward a culture-informed epidemiology: combining qualitative and quantitative research in transcultural contexts. Transcult Psychiatry 2002; 39: 422–33.
19 World Health Organization. Eliminating Female Genital Mutilation: An Interagency Statement. WHO, 2008.
20 Mollica, RF, Caspin-Yavin, Y, Bollini, P, Truong, T, Tor, S, Lavelle, J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992; 180: 110–5.
21 Mollica, RF, Wyshak, G, de Marnette, T, Tu, B, Yang, T, Khuon, F, et al. Hopkins Symptom Checklist (HSCL-25): manual for Cambodian, Laotian and Vietnamese versions. Torture 1996; 6: 3542.
22 Hansson, L, Nettelbladt, R, Borgquist, L, Nordström, G. Screening for psychiatric illness in primary care. Soc Psychiatry Psychiatr Epidemiol 1994; 29: 83–7.
23 Kleijn, WC, Hovens, JE, Rodenburg, JJ. Posttraumatic stress symptoms in refugees: assessments with the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 in different languages. Psychol Rep 2001; 88: 527–32.
24 Smith Fawzi, MC, Pham, T, Lin, L, Nguyen, TV, Murphy, E, Mollica, R. The validity of posttraumatic stress disorder among Vietnamese refugees. J Trauma Stress 1997; 10: 101–8.
25 Tinghog, P, Carstensen, J. Cross-cultural equivalence of HSCL-25 and WHO (ten) Wellbeing Index: findings from a population-based survey of immigrants and non-immigrants in Sweden. Community Ment Health J 2010; 46: 6576.
26 Carver, CS, Scheier, MF, Weintraub, JK. Assessing coping strategies: a theoretically base approach. J Pers Soc Psychol 1989; 57: 267–83.
27 Mooren, TTM, Knipscheer, JW, Kamperman, AN, Kleber, RJ, Komproe, IH. The Lowlands Acculturation Scale: validity of an adaptation measure among migrants in the Netherlands. In The Impact of War: Studies on the Psychological Consequences of War and Migration (ed. Mooren, TTM): 4468. Eburon, 2001.
28 Andro, A, Cambois, E, Lesclingand, M. Long-term consequences of female genital mutilation in a European context: self-perceived health of FGM women compared to non-FGM women. Soc Sci Med 2014; 106: 177–84.
29 Asmundson, G, Coons, M, Taylor, S, Katz, J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Can J Psychiatry 2002; 47: 930–7.
30 Foa, EB, Rothbaum, BO. Treating the Trauma Of Rape: Cognitive–Behavioral Therapy for PTSD. Guilford Press, 1998.
31 Summerfield, D. Asylum-seekers, refuges and mental health services in the UK. Psychiatrist 2001; 25: 161–3.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Bulletin
  • ISSN: 2056-4694
  • EISSN: 2056-4708
  • URL: /core/journals/bjpsych-bulletin
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Mental health problems associated with female genital mutilation

  • Jeroen Knipscheer (a1), Erick Vloeberghs (a2), Anke van der Kwaak (a3) and Maria van den Muijsenbergh (a2) (a4)
Submit a response

eLetters

Female Genital Mutilation and Mental Health: How Can Research Help the Victims?

Mustafa Alachkar, Specialist registrar in psychiatry and psychotherapy, Manchester Mental Health and Social Care NHS Trust
01 March 2016

In their paper on mental health problems associated with female genital mutilation (FGM) Knipscheer et al concluded that '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' [1].

I welcome the authors’ brave contribution to this crucial but under-researched topic, and appreciate their attempt at exploring the relationship between FGM and psychopathology in circumcised migrant women. However, despite their genuine acknowledgement of the limitations of their findings, it is my opinion that their paper suffers from various shortcomings which I will try to address here.

The study uses a valid definition of FGM based on a World Health Organisation document, and considers the practice a violation of human rights. However, the authors approach the issue with an assumption that FGM is a traumatic event that is likely to lead to symptoms of Post Traumatic Stress Disorder (PTSD) in victims. This assumption is evident throughout the article, especially through their use of the Harvard Trauma Questionnaire in which the item on the list of traumatic events that corresponds most closely to FGM would be 'Sexually abused or raped i.e., forced sexual activity'[2]. In my view this assumption is based on a Western view of what constitutes a traumatic event and does not take into consideration that such practice, however abhorrent it may seem, could be accepted as normal practice by its own ‘victims’ and might not be perceived by them as traumatic or as an assault.

PTSD has been seen by many researchers as a Western construct originating from the context of war and ‘shell shock’ [3], and it might therefore not have strong validity in individual trauma caused by personal assault. The cross-cultural validity of PTSD has therefore been questioned [4]. However, even if we accept that PTSD is a valid construct in this population and that FGM is a traumatic event likely to give rise to PTSD, it is unsurprising that they found PTSD symptoms given that they actively looked for them. Nonetheless, and despite the small sample of 66 women, they causally link their findings to the experience of FGM. Casting further doubt on this link is that the women sampled might have been through various types of traumatic experiences, including domestic violence and sexual abuse (which are highly associated with FGM) [5], political and other types of persecution, as well as traumatisation or re-traumatisation during their journey into the Netherlands and their battle to obtain asylum. All these experiences could have contributed to the levels of PTSD symptoms observed in the study, and singling out FGM as the main traumatic event is therefore unjustified and unscientific.

The researchers used screening tools to assess the levels of psychological disturbance in their subjects. However, it is well known that screening tools, however validated and culturally adapted, are not diagnostic. Structured clinical interviews remain the gold standard to establish a diagnosis. Despite that, the authors discuss the occurrence of depression, anxiety and PTSD in the study participants as though they were established diagnoses. Moreover, more than half (57%) of the subjects interviewed were ‘alone’, i.e. single, widowed or divorced. This is likely to have contributed to the high levels of anxiety and depression observed in the study. It is also worth noting that 34% of the subjects had no income which begs the question of whether reporting bias and subjective exaggeration of the psychopathology scores, for reasons such as financial gain, might have affected the results. Finally in this context, political motivation and activism might have also been a source of bias, especially in view of snowball sampling being the recruitment method for the study.

This brings us to the major flaw of the study, which is the lack of a control group. This is unjustified in view of the research question posed here and, in my view, renders the findings of the study rather difficult to interpret. Certainly it is difficult to arrive at any meaningful conclusions. let alone establish a causal link, from the data presented. A case-control study design is the gold standard to address this kind of research question [6], and a control group of immigrant women from the same countries as the study group, but without the experience of FGM, could have easily been recruited. Another control group could have been women who were subject to FGM but continue to reside in their country of origin (i.e. non-immigrants). A causal link between FGM and psychopathology still cannot be inferred, even using a case-control study.

Female genital mutilation is an appalling practice that needs the collaboration of individuals, governments and non-governmental organisations in order to eradicate. Mental health professionals are expected to take the lead in this fight by providing research evidence that is objective and reliable. This is best achieved, in my view, by using research studies based on a robust methodologies that take into account the cultural context of individuals affected by this practice, and that do not force Western concepts and patronising preconceptions on FGM victims.

Finally, a qualitative research study that lends a voice to the victims of FGM and gives them a chance to tell their story about their true lived experiences might be far more validating of the victims’ experiences, and more informative from a research viewpoint, than applying screening tools and carrying out regression analyses.

References

1. Knipscheer J, Vloeberghs E, van der Kwaak A, van den Muijsenbergh M. Mental health problems associated with female genital mutilation. BJPsych Bull 2015; 39:273–277.

2. Mollica R, Capsi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire: Validating a Cross-Cultural Instrument for Measuring Torture, Trauma, and Posttraumatic Stress Disorder in Indochinese Refugees. J Nerv Ment Dis 1992; 180:111–116.

3. Crocq MA, Crocq L. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. Dialogues Clin Neurosci 2000; 2:47–55.

4. Hinton DE, Lewis-Fernández R. The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5. Depress Anxiety. 2011; 28:783–801.

5. Peltzer K, Pengpid S. Female genital mutilation and intimate partner violence in the Ivory Coast. BMC Women's Health 2014; 14:13.

6. Lewallen S, Courtright, P. Case-Control studies. Comm Eye Health 1998; 11:57–58.

... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *