Crossing borders: Discussing the evidence relating to the mental health needs of women exposed to female genital mutilation

Crossing borders: Discussing the evidence relating to the mental health needs of women exposed to female genital mutilation
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  Feature Article Crossing borders: Discussing the evidence relatingto the mental health needs of women exposed tofemale genital mutilation Peggy Mulongo, 1 Sue McAndrew 2  and Caroline Hollins Martin 2 1  NESTAC Charity, Manchester and  2 School of Nursing, Midwifery and Social Work, University of Salford,Salford, UK   ABSTRACT:  The terms ‘Female Circumcision’ (FC), ‘FG Cutting’ (FGC) and ‘FG Mutilation’(FGM) refer to procedures involving the partial or total removal of the external female genitalia for  non-medical reasons. In practicing countries, FGC/FC is more widely used, as it is believed to be inoffensive, providing more impartial ways of discussing the practice. Positive beliefs about FC/FGC include virginity, marriage prospects, family reputation, or passage to adulthood. Regardless of  terminology, the practice exists in at least 28 African counties, and a few Asian and Middle Easterncountries. In Western society, FGM is considered a breach of human rights, being outlawed in a number of countries. With immigration trends, FGC is now prominent in Western society among practicing communities. While the past decade has seen an increase in studies and recommendations for health-care support related to the physical health consequences of FGM, little is known about the psychological impact and its management. For many girls and women, FGC is a traumatic practice, transforming it to FGM and affecting their mental health. This discussion paper focuses on evidencerelating to the mental health consequences of FGM, therapeutic interventions, and the mental health nurse’s role in addressing the needs of this group of women. KEY WORDS:  female genital mutilation, intervention, mental health, nursing, psychologicalconsequence. INTRODUCTION Global estimates suggest that 100–140 million girls and women have undergone female circumcision (FC) withmore than three million girls being at risk of the practiceeach year on the African continent alone (PopulationReference Bureau 2010; World Health Organization2008). FGM is practiced in at least 28 countries inAfrica, and a few others in Asia (e.g. Indonesia) and theMiddle East (e.g. Kurdistan, Yemen). However, to date,data have only been systematically collected from 27developing countries (Population Reference Bureau2010). While it could be suggested that FGM is mainly a sub-Saharan problem, migration trends have playeda major role in transferring cultural and traditionalbeliefs attached to the practice to the Western world(Johnsdotter 2004; Mathews 2011). The social conventionof those srcinating from practicing countries is said to bestrongly rooted, and relocating to Western countries doesnot simply change the perceptions of migrants. Rather,FGM has become a reality in Europe, Northern America,and Australia (Denison  et al . 2009; Johnsdotter 2004; Correspondence: Peggy Mulongo, NESTAC Charity, 237 Newstead,Rochdale, Lancashire OL12 6RQ UK. Email: Peggy Mulongo, MSc DipHE RMN.Sue McAndrew, PhD MSc BSc (Hons) CPN Cert RMN.Caroline Hollins Martin, PhD MPhil BSc PGCE RMT ADM RGNRM MBPsS. Accepted December 2013. bs_bs_banner International Journal of Mental Health Nursing  (2014)  23 , 296–305 doi: 10.1111/inm.12060© 2014 The Authors. International Journal of Mental Health Nursing published by Wiley Publishing Asia Pty Ltd on behalf of Australian College of Mental Health Nurses Inc.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, whichpermits use and distribution in any medium, provided the srcinal work is properly cited, the use is non-commercial and nomodifications or adaptations are made.  Mathews 2011). In England and Wales, it is estimatedthat there are almost 66 000 women who have undergoneFGM, and 21 000 females under the age of eight will beat risk of FGM (Dorkenoo  et al . 2007). With migrationtrends to the UK from sub-Saharan Africa, where FGMprevalence is high (often exceeding 95% in some areas),it is suggested that instances of FGM are significantly higher now in the UK than the estimates above, which were based on the 2001 census (Population ReferenceBureau 2010).During the past decade, there has been an increase inthe number of studies focusing on the health conse-quences of FGM, with many denouncing the practice(Berg  et al . 2010; Dorkenoo  et al . 2007; PopulationReference Bureau 2010; Yoder & Kahn 2008). Whilemany of the studies are contextualized within a histo-rical perspective, policy development, and/or proceduraldescriptions, there is very little documentation on theemotional repercussions of FGM. The World HealthOrganization (2008) referred to the emotional traumasrelating to FGM, stating that the possible shame orcomplications are not addressed or treated by healthand social care professionals. Although the psychologicalimpact attached to the practice of FGM is describedin some studies (Behrendt & Moritz 2005; Dare  et al .2004; World Health Organization 2006), evidence is very limited on its treatment and management. ORIGINS OF FGM FGM is primarily associated with Africa; however,the World Health Organization (1996) suggest that ithas existed in all countries at one time or another. Forexample, there were several reported cases in the UKand the USA during the early 20th century, where FGM was performed by physicians to ‘treat hysteria, lesbianism,masturbation and other so called female deviancies’(Toubia 1994, p. 225). There are a number of sociocul-tural factors that impact on the practice of FGM, particu-lar beliefs, behavioural norms, customs, rituals, and socialhierarchies inherent in religious, political, and economicsystems (Momoh 2005). For example, in Somalia, thereis a strong belief that FGM is a religious requirement(Keizer 2003; Nienhuis  et al . 2008), although there is nodescription of the practice in the Quran or the Bible,although it was in existence prior to Christianity and Islam(World Health Organization 1996; 2006). In some prac-ticing countries, uncircumcised girls and women are not welcome in their society. The Masai of Tanzania refuse tocall a woman ‘mother’ if she has children and has not beencircumcised (Boyle 2002, p. 36). A more common reasonfor FGM, particularly for those communities living in Western society, is that of preserving a girl’s or woman’s virginity (Berggren  et al . 2006; Gruenbaum 2001; Talle2007). For women and girls brought up in Westernsociety, who are possibly still at risk of FGM, the effects of acculturation might impact further on their mental well-being (Whitehorn  et al . 2002).These experiences might be even more traumatic ongirls who share Western cultural norms and on whomFGM is inflicted. For some practicing communities,FGM is a way of ensuring marital fidelity and preventingsexual behaviour that is considered deviant and immoral(Abusharaf 2001; Ahmadu 2000; Gruenbaum 2001;Hernlund 2003).The stigma inherent is likely to further compromise women’s mental well-being, particularly for those who areopposed to FGM, yet resides in communities where it ispart of the cultural practice. FGM AND HUMAN RIGHTS According to the World Health Organization (2008),FGM of any type is a harmful practice and a violation of the human rights of girls and women. Across the world,the migrant population is strongly represented by vulner-able groups of refugee and asylum seeker families, wheregirls and women experience various forms of genderoppression (Burnett & Peel 2001; Correa-Velez  et al .2005). In considering FGM as being a serious breach of human rights, the United Nations (UN) High Commis-sioner for Refugees and other agencies of the UN havestated that refugee and asylum status should be grantedto women and girls fleeing their country to escape thepractice; a statement reiterated by the British MedicalAssociation (2008). However, globally, there are very few records of girls and women granted refugee status on theground of FGM. In 1998, one case of successful asylumapplication was registered in Canada, another one in theUSA, and two in Sweden (Amnesty International 1998).In 1999, one further application was registered in theUSA (Amnesty International 2000). In the UK, thereare no statistics available reporting successful asylumapplications on the basis of FGM, while Article 3 of theEuropean Convention on Human Rights (1984) defendsthe right to be free from torture and inhumane or degrad-ing treatment (Home Office Immigration and Nationality Directorate, pers. comm., 2001). The Female GenitalMutilation Act (2003) ( it an offence for UK national or permanentresidents to carry out FGM, or to aid, abet, counsel,or procure the carrying out of FGM abroad, even in MENTAL HEALTH AND FEMALE GENITAL MUTILATION 297© 2014 The Authors. International Journal of Mental Health Nursing published by Wiley Publishing Asia Pty Ltd on behalf of Australian College of Mental Health Nurses Inc.  countries where the practice might be legal (Gordon2005). More recently, the UN General Assembly’sHuman Rights Committee 2012 (http://www.amnesty .org) placed FGM in a human rights framework, high-lighting the need for a holistic approach that includesrecognizing the importance of empowering women, thepromotion and protection of sexual and reproductivehealth, and breaking the cycle of discrimination and vio-lence (Díaz 2012). PSYCHOLOGICAL IMPACT OF FGM  While the physical health consequences of FGM are welldocumented (Behrendt & Moritz 2005; Dare  et al . 2004;Royal College of Obstetricians and Gynaecologists 2009; World Health Organization 2006), the emotional affectsremain limited. The World Health Organization (2000)found that only 15% of studies focusing on the healtheffects of FGM considered mental health, and most of these were case reports, highlighting an important gap inthe literature. Where studies on psychological conse-quences of FGM have been undertaken, factors, such assevere forms of FGM, immediate post-FGM complica-tions, chronic health problems and/or loss of fertility secondary to FGM, non-consensual circumcision in ado-lescence or adulthood, and FGM as punishment, have allbeen identified as causes of distress (Lockhat 2004). Like- wise, depression, post-traumatic stress (PTS), and symp-toms of impaired cognition comprising of sleeplessness,recurring nightmares, loss of appetite, weight loss orexcessive weight gain, panic attacks, and low self-esteemhave been attributed to FGM (Behrendt & Moritz 2005;Elnashar & Abdelhady 2007; Kizilhan 2011; Osinowo &Taiwo 2003; Vloeberghs  et al . 2011).For many girls and women, undergoing FGM is atraumatic experience that has been found to have lastingpsychological consequences (World Health Organization2011). Undertaking a systematic review of the litera-ture pertaining to psychological problems resulting fromFGM, Berg  et al ., (2010) indicated that there is a highprobability that women who have been subjected to FGMsuffer emotional disorders, such as anxiety, somatization,and low self-esteem, and are at greater risk of a mentalillness. These findings were reiterated by Chibber  et al .(2011). A controlled study undertaken by Behrendt andMoritz (2005) in Senegal compared the mental status of 23 circumcised and 24 uncircumcised females, and foundthat almost 80% of circumcised females met the criteriafor mental illness, with 90% of circumcised womendescribing severe pain and feelings of intense fear, help-lessness, and horror at the time of the trauma. More than80% continued to have flashbacks, a common phenom-enon of PTS (Behrendt & Moritz 2005). The presentstudy reiterates previous findings. Lockhat (1999) con-ducted a study in Manchester, UK, of Somali and Suda-nese women, of which 75% of participants recognizedthat they suffered recurrent, intrusive memories and lossof impulse control. More recently, Zayed and Ali, (2012), who conducted a prevalence study of female circumcisionin Egypt, after a change in the law banning the procedure,found that 63.9% of the sample had experienced circum-cision, of which 94.9% had emotional trauma. In theUK, young women receiving psychological counsellingfor FGM report feelings of betrayal by parents, incom-pleteness, regret, and anger (World Health Organization2000). In addition, a pilot project undertaken in the UKby an African organization providing psychosocial therapy to women who have experience of FGM described theoverwhelming trauma, the long-lasting emotional damageit causes, and the difficulty of suffering in silence reportedby the women (New Step for African Community, 2012). While FGM is condemned in Western society, thepsychosocial implications of not undergoing FGM couldadversely impact on females living in practicing commu-nities. Not undergoing the practice could lead to a loss of cultural identity or anomie, resulting in mental distress,manifesting as anxiety due to fear of becoming socially excluded from their community. A number of studiesreport that women who have been subjected to FGMhave minimal psychological morbidity, often feelingproud and believing that they are a better person(Chalmers & Hashi 2000; Mwangi-Powell 1999). In astudy of 432 Somali women living in Canada, the partici-pants reported memories of FGM, including intense fear,severe pain, and being seriously ill at the time of mutila-tion, but also having a sense of pride, happiness, andenhanced purity and beauty (Chalmers & Hashi 2000).The strong belief that a woman needs to be circumcisedto be seen as good is often inherent within the culture andpassed from one generation to another (Nienhuis  et al .2008), presenting a challenge for those in Westernsociety, whose concern is that of mental well-being.The complexity of FGM in the cultural context is dem-onstrated in a pre- and post-intervention study of 100 women undertaken by Ekwueme  et al . (2010). Knowl-edge, attitudes, and behaviours pre- and post-FGM wereexplored. The women were recruited by systematicsampling from the General Outpatient Department atthe University of Nigeria Teaching Hospital (Enugu,Nigeria). The results showed that prior to undergoingFGM, the knowledge of the respondents on the truemeaning of the practice was 54%, with 70% believing that P. MULONGO  ET AL .298© 2014 The Authors. International Journal of Mental Health Nursing published by Wiley Publishing Asia Pty Ltd on behalf of Australian College of Mental Health Nurses Inc.  FGM was good, and based on culture and tradition, thepractice should be continued. Respondents displayed ahighly-negative and stigmatizing attitude toward women who had not been circumcised; 74% said they are promis-cuous, 49% said they are shameful, 14% said they arecursed/outcast, and 66% would not recommend them formarriage. After the women had been circumcised, theresults showed that 85% of the respondents had a betterunderstanding of the meaning of FGM, 71.3% knew the complications, 11% supported FGM, but 83% wereagainst the practice. The stigmatizing attitudes heldagainst women who had not been circumcised decreasedsignificantly post-intervention; beliefs of women beingpromiscuous fell from 74% to 22%, being shameful fellfrom 49% to 12%, being outcast/cursed fell from 14% to2%, and not being suitable for marriage fell from 66% to19% (Ekwueme  et al . 2010). PSYCHOSOCIAL INTERVENTIONS TO ADDRESS THE EMOTIONALCONSEQUENCES OF FGM Although there are now extensive studies in the clinicalfield of psychosocial interventions for mental illnessesexperienced by the black and minority ethnic (BME)population, including groups of refugees and asylumseekers (Department of Health 2005; Kieft  et al . 2008;MIND organization 2009), there is still a lot that needs tobe done to provide specific emotional support for womenexposed to FGM. A number of studies (Behrendt &Moritz 2005; Elnashar & Abdelhady 2007; Kizilhan 2011;Osinowo & Taiwo 2003) have made recommendationsfor current psychological interventions to be adapted asa way of providing culturally-sensitive therapy. However,studies reporting on the implementation and evaluationof psychological interventions, specifically addressing theneeds of women who have experienced or who are at riskof FGM, are limited.The limited research relating to the psychological con-sequences of FGM, coupled with the nuanced context of tradition and cultural beliefs, will impact on the way in which mental health services might provide support for women exposed to the practice. When developing thera-peutic interventions for women exposed to FGM, deep-rootedbeliefsinthepracticeofFGMneedtobetakenintoaccount,aswellastheculturalandsocialpressureswomenfrom practicing communities are likely to experience.A successful therapeutic relationship is fundamentalto good mental health care (Cleary 2003; Warne &McAndrew 2005). To promote healing, cognisance needsto be taken of both the physical consequences of FGMand the cultural issues surrounding it in order to providesensitive care (Daley 2004). A number of countries,such as the UK, Germany, Belgium, and Sweden, haveestablished guidelines on FGM for medical providers(Nour 2004; British Medical Association 2011); however,little attention has been paid to effective interventionsaddressing psychological needs (MIND organization2009). Only one study, which was carried out in theNetherlands (Vloeberghs  et al . 2011), looked at parti-cipants’ experiences of mental health provision. Theresults of that study indicated both positive and negativeexperiences. Positive experiences indicated that theirinteractions with mental health services were positive,as practitioners were better informed about circumcisionand were aware of its existence in the Netherlands.Participants also reported positive interaction withdoctors and nurses when in the reception centre (forasylum seekers and refugees), with mental health profes-sionals showing understanding, providing correct infor-mation, and referring women to appropriate services toaddress specific problems (Vloeberghs  et al . 2011).In the UK, current mental health provision for asylumseekers and refugees includes a limited number of spe-cialist services for asylum seekers located in trusts or runby independent bodies or trauma services, includingsurvivors of torture or violent conflicts in their patientpopulation. These include Freedom from Torture (for-merly the Medical Foundation for the Care of Victims of Torture), interagency partnerships (developed specifi-cally to provide services for this group), and specialistgeneral practices of in-house sessions with community mental health nurses or counsellors (Aspinall & Watters2010). Drawing on an evaluation of the impact of theintroduction of a community psychiatric nurse in a largerefugee camp, Kamau  et al ., (2004) argued that even asmall amount of mental health care can have a dramaticimpact on the mental well-being of refugees. However, Ward and Palmer (2005) found that only five of the 11mental health trusts based in London provide specialistservices that are specifically designed with the needs of refugees and asylum seekers in mind. They also foundthat, with the exception of a small number of primary care trusts, there appears to be a general lack of aware-ness that refugees and asylum seekers are a group thathave distinct needs, which are multiple, complex, andrequire specialist knowledge. In these circumstances, theeffectiveness of psychological interventions for mentalhealth difficulties can be compromised, and especially for those at risk of FGM, whose cultural beliefs are atodds with the legal system of the country they are now residing in. MENTAL HEALTH AND FEMALE GENITAL MUTILATION 299© 2014 The Authors. International Journal of Mental Health Nursing published by Wiley Publishing Asia Pty Ltd on behalf of Australian College of Mental Health Nurses Inc.  MAKING SENSE OF THE EVIDENCE  While there are only a small number of empirical researchstudies on the psychological consequences of FGM, whatis evident is that the mental health of women who haveundergone or who are at risk of FGM will be compro-mised (Behrendt & Moritz 2005; Chibber  et al . 2011;Elnashar & Abdelhady 2007; Kizilhan 2011; Nnodum2002; Osinowo & Taiwo 2003; Vloeberghs  et al . 2011).Common mental illnesses, such as affective disorder,anxiety, and somatization (Behrendt & Moritz 2005;Chibber  et al . 2011; Elnashar & Abdelhady 2007), wereevident for women who have undergone FGM, andhave implications for those mental health professionals working in primary care. In addition, it would appear that women exposed to FGM are more likely to report symp-toms commensurate with PTS, and in particular, recur-rent flashbacks (Behrendt & Moritz 2005; Chibber  et al .2011; Kizilhan 2011), the latter being more commonamong women exposed to more severe forms of FGM(Lockhat 2004).Regardless of the type of FGM and its psychologicalconsequences, Berg  et al . (2010) reiterated the impor-tance of considering the fact that the practice is culturally embedded; this might well form a protective factoragainst the emergence of psychological distress in itsaftermath. Berg  et al . (2010) suggested that futureresearch should take the possible protective element of FGM into account when examining the short- and long-term psychological consequences of the practice. Alterna-tively, it has been suggested that FGM should be viewedas a social convention, and the taboo surrounding thepractice might account for why women do not com-plain about their emotional distress after circumcision(Vloeberghs  et al . 2011). However, Behrendt and Moritz(2005) argued that despite the fact that FGM constitutesa part of their participants’ ethnic background, the resultsof their study implied that cultural embeddedment doesnot protect against the development of PTS and othermental illnesses.Coping strategies are also important to consider whendeveloping services for those exposed to FGM. In theirstudy, Vloeberghs  et al . (2011) explored coping factors,and concluded that both support seeking and avoidance-coping styles appear to be associated with higher levels of anxiety and depression. Vloeberghs  et al . (2011) identifiedfour categories of women: the adaptive woman, thereligious woman, the disempowered woman, and thetraumatized woman, and provided information about women’s ways of coping in terms of whether or not they seek support. Their findings showed that ‘adaptive’ women were able to cope with their problems, which were mainly physical and of a sexual nature. ‘Religious’ women also revealed that they knew how to deal withtheir problems related to FGM and preferred not to talkabout it, considering sexuality as a private matter. Thisgroup reported less fear and depression than non-religious women. The ‘disempowered’ women’s behav-iour was prone to emotional reticence, anger, and defeat.In refusing to talk about their experience of FGM, they developed negative ways of coping, developing problems,such as substance misuse, binge eating, excessive televi-sion watching, and sometimes serious mental illnesses.Hidden tension and a fatalism tendency were character-istics of these women. Finally, ‘traumatised’ women (i.e.mostly women who had been infibulated) appeared to beeither divorced or in a bad relationship, and had a lot of pain and sadness. Within this group, there was a higherincidence of psychological problems, including recurrentmemories, sleep problems, chronic stress, and higherlevels of anxiety and depression. TRANSLATING THE EVIDENCEINTO PRACTICE Holistic approaches taking into account socioculturalfactors (Department of Health 2009; Ward & Palmer2005) could contribute to a better understanding of thepsychological traits of women exposed to FGM, whetherthey remain in practicing countries or have migratedto Western countries, ensuring valuable resources aredirected to those at greatest risk. While it is important for mental health professionals todemonstrate adequate knowledge and awareness of thesrcins, traditions, and psychosocial implications of FGM(Utz-Billing & Kentenich 2008; Whitehorn  et al . 2002),it is equally important to put the acquired knowledgeinto practice through the use of sensitive, therapeuticapproaches that address the needs of women who havebeen circumcised.There appears to be limited research relating topsychological interventions for women who experiencenegative consequences of FGM. To date, talking aboutpsychological interventions for those exposed to FGM islimited to recommendations and guidance on how toprovide adapted, existing emotional support (Applebaum et al . 2008; Behrendt & Moritz 2005; Elnashar &Abdelhady 2007; Kizilhan 2011; Vloeberghs  et al . 2011; Whitehorn  et al . 2002). In her doctoral thesis, Jones(2010) explored the theme of FGM and clinical psychol-ogy in London and the south of England. Jones’s study  was divided into two parts. The first part comprised P. MULONGO  ET AL .300© 2014 The Authors. International Journal of Mental Health Nursing published by Wiley Publishing Asia Pty Ltd on behalf of Australian College of Mental Health Nurses Inc.
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