WOMENS’ EXPERIENCES OF LIVING
WITH GENITAL MUTILATION
A literature review
KVINNORS UPPLEVELSER AV ATT LEVA
MED KÖNSSTYMPNING
En litteraturöversikt
Nursing program 180 University credits Degree project, 15 University credits Date of submission: June 4th, 2020 Course: K53
ABSTRACT Background
Female genital mutilation refers to procedures where the external female genitalia are either partially or entirely removed. It is estimated that on a global scale more than 200 million girls and women alive today have undergone some form of genital mutilation. It is a present issue and a violation against women’s rights causing severe health consequences, both physical as well as psychological. There is a lack of knowledge and understanding among nurses regarding the issue. Nurses may encounter these women in any medical setting hence increased awareness regarding the consequences is essential.
Aim
The aim was to describe the experiences of women who have undergone female genital mutilation.
Method
The chosen design for the degree project was a literature review which is used in
presenting an overview of current research within a specific topic and can easily be applied to clinical work. Data was collected using the bibliographic databases PubMed, CINAHL and PsychInfo from which 15 scientific articles were analyzed and compiled.
Result
The result showed that women consequently experienced suffering in various ways due to female genital mutilation. The procedure was described as a traumatic experience causing psychological issues. Pain was experienced either in connection to the circumcision procedure or as a result of it. Other commonly presented issues were consequences related to sexual health. These consequences included, but were not limited to, pain, lack of sexual desire and pleasure. Women seeking health care in western countries expressed mostly negative experiences due to how they were approached by health care providers, making them feel abnormal and embarrassed for example.
Conclusion
Women suffer in different forms due to female genital mutilation and are treated with a lack of respect and understanding by health care providers. Increased knowledge and awareness is needed in order for women to be treated in a person-centered way.
SAMMANFATTNING Bakgrund
Kvinnlig könsstympning innebär procedurer där det yttre kvinnliga könsorganet helt eller delvis avlägsnas och det beräknas att fler än 200 miljoner flickor och kvinnor runt om i världen har utsatts för könsstympning. Det är ett aktuellt problem då det är en kränkning av kvinnors rättigheter och orsakar allvarliga fysiska och psykiska hälsokonsekvenser.
Eftersom sjuksköterskor kan möta dessa kvinnor i många olika sammanhang behövs en ökad kunskap och förståelse kring konsekvenserna.
Syfte
Syftet var att beskriva upplevelser hos kvinnor som är könsstympade.
Metod
Litteraturöversikt valdes som design för arbetet vilket ger en överskådlig blick kring nuvarande forskning inom ett specifikt ämne och som enkelt kan tillämpas på kliniskt arbete. Resultatet sammanställdes av 15 vetenskapliga artiklar som hämtades från databaserna PubMed, CINAHL och PsychInfo.
Resultat
Resultatet visade att kvinnlig könsstympning orsakar olika former av lidande. Proceduren beskrevs som en traumatisk upplevelse som resulterade i psykisk ohälsa. Smärta var en vanlig förekommande komplikation som antingen uppstod under själva proceduren eller som en långvarig konsekvens. Ett annat vanligt förekommande problem var sexuell ohälsa som uttrycktes genom exempelvis smärta, nedsatt sexlust och njutning. Kvinnor som sökte sjukvård i västerländska länder beskrev främst negativa upplevelser i hur de blev bemötta av sjukvårdspersonal, vilket orsakade att kvinnorna kände sig generade och onormala.
Slutsats
Lidande i olika former är vanligt förekommande hos kvinnor som genomgått
könsstympning. Dessa kvinnor blir ofta bemötta på ett respektlöst sätt av sjukvårdpersonal. Ökad kunskap och förståelse för deras situation krävs för att sjukvårdspersonalen ska kunna bemöta dessa kvinnor på ett personcentrerat sätt.
TABLE OF CONTENT
INTRODUCTION ... 1
BACKGROUND ... 1
Female genital mutilation ... 1
Health consequences ... 4
Universal declaration of human rights ... 4
Legislation ... 5
Nursing care ... 5
Theoretical starting point - suffering ... 6
Problem area ... 7 AIM ... 7 METHOD ... 8 Design ... 8 Sample selection ... 8 Data collection ... 9 Quality review ... 10 Data analysis... 10 Ethical considerations... 10 RESULT ... 11
The circumcision procedure ... 12
Womens’ daily lives ... 12
Women’s sexual health ... 14
Encounters with health care ... 15
DISCUSSION... 16 Result discussion ... 16 Method discussion ... 18 Conclusion ... 20 REFERENCES ... 23 APPENDIX I-III
INTRODUCTION
Female genital mutilation refers to a ritual that, having its roots in old traditions, has been practiced for thousands of years in many cultures and is a major indicator of gender inequality. It is a violation against women’s rights that causes severe health consequences and suffering (Williams-Breault, 2018). The procedures are performed for non-medical purposes without any known health benefits (United Nations International Children's Emergency Fund [UNICEF], 2013).
This degree project was written as a literature review gathering information on women’s experiences of genital mutilation. The reason being that nurses have limited knowledge on what female genital mutilation is and its effect on women’s health (González-Timoneda, Ruiz Ros, González-Timoneda & Cano Sánchez, 2018). A nurse’s ability to approach these vulnerable women in a person-centered way is flawed and extremely under effective. The authors first came into contact with this subject when studying Global Health. It was not an easy area to research given the shocking information found on what these women experience. This created an interest in improving the health situation for these women. In this degree project, the term “woman” is used to all females regardless of age. A female is characterized as having two X chromosomes, a vagina, a uterus and ovaries
(Dictionary.com, 2020).
BACKGROUND
Female genital mutilation
Female genital mutilation [FGM], also known as ‘female genital cutting‘ or ‘female circumcision’ refers to procedures where the external female genitalia are intentionally removed either partially or entirely. The term ‘female genital mutilation’ was adopted in year 1990 to change the previous term ‘female circumcision’ as it gave the wrong
impression that female circumcision could be comparable to male circumcision (UNICEF, 2013).
Female genitalia
The external female genitalia consist of the labia majora, labia minora, clitoris and glands; these organs make up an area called the vulva. The vulva is responsible for enabling sperm to enter the body, providing sexual pleasure as well as protecting the internal genital organs from infection. The labia majora, which translates to “large lips”, are made up of fatty tissue that encase and protect the other genital organs. They contain glands that produce secretion needed for lubrication. The labia minora, which translates to “small lips”, are situated inside the labia majora and enclose the vaginal opening and the urethra. The urethra is situated in front of and above the vaginal opening. The labia minora are filled with blood vessels which expand during sexual activity causing swelling, making them sensitive to stimuli. The clitoris is a small bulge situated at the top and in between the labia minora. It is very susceptible to sexual stimuli and can become erect, resulting in an orgasm. The opening to the vagina is used for sexual intercourse, for childbirth as well as a way for menstrual blood to leave the body (Knudtson & McLaughlin, 2019).
Definition of female genital mutilation
World Health Organization [WHO] (2020) classifies FGM into 4 main categories.
Type I: Clitoridectomy – a procedure where the clitoris is partially or totally removed, or in
rare cases only the prepuce is removed. The prepuce is the skin surrounding the clitoris.
Type II: Excision – a procedure where both the clitoris and the labia minora are removed
with or without cutting the labia majora. Type III: Infibulation – a procedure where the vaginal opening is narrowed by first cutting the labia minora or majora and then
repositioning them to form a seal to cover the vaginal opening, leaving only a small hole for urine and menstrual blood to pass. In doing so the skin will almost completely cover the urethra and the vaginal opening and it sometimes also includes a clitoridectomy.
Type IV: Other harmful non-medical procedures include for example piercing, pricking,
scraping, incising and cauterizing the genital area. Pricking is in some communities used as a symbolic circumcision and involves cutting to draw blood without causing permanent alteration or removal of external genitalia (WHO, 2020).
Defibulation is a procedure that reverses infibulation by cutting open the sealed vaginal opening. This is often carried out to allow intercourse, to facilitate childbirth or as a health improvement (WHO, 2020).
Prevalence
It is estimated that on a global scale more than 200 million women alive today have undergone some form of FGM. The procedures are prevalent in about 30 countries mainly situated in Africa, Middle East as well as parts of Asia. It can also be found in Europe, Australia and North America due to immigration (UNICEF, 2019).
The highest prevalence of FGM is found in Somalia, Guinea and Djibouti where over 90 percent of women between the ages of 15 and 49 have been reported to have undergone the procedure. The practice is most often carried out on girls between the ages of 0 to 15 (UNFPA, 2019).
Social and cultural determinants
FGM is viewed as a tradition and a rite of passage in many cultures, thus creating a pressure to conform. The pressure stems not only from negative beliefs of being excluded by family or society but also from personal moral norms. Women who have undergone FGM are portrayed as clean, smooth and pure while uncut women are labelled as smelly and scorned (Shell-Duncan, Moreau, Wander & Smith, 2018).
The main argument for female genital mutilation is that it proves a woman’s readiness for adulthood and marriage, thereby confirming her social acceptance in the community (Boyden, 2012). Although social acceptance is most often the primary reason for the continuation of the practice many factors are integrated with both social as well as cultural aspects. These include gender and ethnic identity, family honor, female “purity” and femininity as well as cleanliness and health (Williams-Breault, 2018). Many women believe FGM is hygienic for the vagina while others are unsure (Mohammed, Seedhom & Mahfouz, 2018). Moreover, the practice is also considered to prevent rape, reduce a woman’s libido to prevent promiscuous behavior before marriage and to ensure fidelity after marriage, enhancing aesthetic appeal as well as ensuring a source of income for circumcisers. In addition, certain cultures believe that the clitoris is considered a dangerous
organ full of poison that will cause a man to fall ill or even die if it comes in contact with the male genitalia. Other perceptions include believing that the cause of male impotency and babies dying upon delivery are due to women having an uncut clitoris (Williams-Breault, 2018). A majority of women also believe FGM will protect virginity, indicating that the overall knowledge regarding FGM is inadequate (Mohammed et al., 2018). The practice has, compared to 30 years ago, slowly been decreasing over time and an adolescent girl today would be about a third less likely to undergo the procedure (Khosla, Banerjee, Chou, Say & Fried, 2017). The decrease of FGM is dependent on social status factors such as education and literacy level. A small percentage of women without formal education favored the discontinuation of FGM while the majority of women with higher education wanted it to be discontinued. Another contributing factor to the attitudes was geographic. The opposition towards FGM was low in rural areas especially among women within agriculture while it increased in urban areas where the occupation level was higher (Van Rossem, Meekers & Gage, 2015). Furthermore, a comparison between younger and older mothers indicated that the latter are more inclined to have their daughters undergo FGM. This being due to their more positive attitudes regarding the practice as well as a general belief that they are more in control over their behavior than younger mothers (Pashaei, Ponnet, Moeeni, Khazaee-pool & Majlessi, 2016).
A change in attitude is also seen among women who have emigrated from countries where FGM is common and culturally acceptable to western countries. After having been well integrated into society for decades, their attitudes shifted into referring to FGM as
something brutal that should not be practiced. Many of these women now believe that they can still be considered religious and morally decent people in spite not undergoing these painful procedures (Johnsdotter, 2019). Hassanen, Woldu & Mkuu (2019) concur that immigrating to a western country makes some women question values, existing ideas and norms and that it positively influences their perception of the practice. Many women stated that because of their shift in attitude, they will not be subjecting their daughters to the tradition.
Religion
It is believed by many that FGM stems from a specific religious background (Mohammed et al., 2018). However, the practice is carried out among both Jews, Catholics, Protestants, Muslims and animists and is not mentioned in any major religious texts such as the Bible or the Quran (Williams-Breault, 2018). The practice is commonly considered to be a religious requirement (Koski & Heymann, 2019). Many women however, do not consider FGM to be a mandatory religious practice. With each of the various religions there are both endorsers as well as opposers of the practice (Mohammed et al., 2018).
Tradition
The tradition is most often upheld by mothers and grandmothers since they are the biggest contributors to its propagation, mainly to ensure marriageability (Jiménez Ruiz, Almansa Martinez & Alcón Belchi, 2017). However, men play an equally important role either by passively approving the tradition by refusing to marry an uncut woman or by actively initiating the practice. In fact, in some countries it is reported that fathers, grandfathers and male community leaders have been prone to instigate the process (Varol, Fraser, Ng, Jaldesa & Hall, 2014).
The practice
The procedure is often performed by traditional circumcisers that play a vital role in the community, or by the health care professionals as it is a common misbelief that the procedure would be safer if performed by them. In reality, when performing these procedures in a medicalized way, the operation often results in too much skin being removed due to better lighting, having more time as well as the patient being under anesthesia (WHO, 2020). In Egypt, which has the highest rate of medicalized FGM procedures in the world, mothers choose to have their daughters cut by health care
providers to minimize health risks and because care providers have better knowledge and training regarding FGM than traditional birth attendants (El-Gibaly, Aziz & Abou Hussein, 2019).
Health consequences
Female genital mutilation is a practice that is often carried out using unsterile instruments such as knives, razor blades, scissors or sharp pieces of glass (Momoh et al., 2016). The procedure can cause both physical and psychological effects which can present as
immediate as well as long-term for exposed women. Immediate health consequences can include hemorrhage, infection, shock, bleeding, open sores, severe pain including urinary pain, sepsis, increased risk of sexually transmitted infectious and even death. Long-term health consequences can consist of severe pain, infection, fibrosis, keloids, primary infertility, urinary tract problems, menstruation pain, pregnancy related issues as well as severe suffering. Psychological symptoms include post-traumatic stress disorder and depression. FGM can severely impact a woman’s romantic and sexual relationships (Williams-Breault, 2018; Hassanen, Woldu & Mkuu, 2019). Commonly experienced sexual dysfunctions include anorgasmia, dyspareunia, arousal disorder and frigidity (Komboigo et al., 2019). Clitoridectomy not only creates sexual disability but also a reproductive disability. Stimuli to the clitoris creates different changes in the female body which are factors of major importance in the success of reproduction (Levin, 2019). Furthermore, the severity of the procedure directly correlates to an increased risk in complications during childbirth. These complications include, but are not limited to, newborn deaths, caesarean section and post-partum haemorrhage (Williams-Breault, 2018).
Universal declaration of human rights
In 1948 The United Nations established a document called The Universal Declaration of Human Rights. It consists of 30 articles that each define a human right and states that every human is born with all 30 rights (United Nations, n.d.a). The articles include things such as the right to life and freedom, a life free from torture and inhuman or degrading treatment, the choice to enter into marriage by own free will as well as the choice to end a marriage, the right to education as well as freedom of opinion. These rights apply to all regardless of gender, race, religion, ethnicity, social status or any other status (United Nations, n.d.b). When a girl is physically held down in order to undergo any type of FGM or when their legs are tied together for days or even weeks after infibulation, it is a violation against her
rights. It is an act of inhuman and degrading nature. Furthermore, even if a girl gives consent to undergo FGM, the decision is based on social pressure and expectations from the community and thereby can not be seen as a decision made freely or free from
coercion. Subjecting one’s daughter to FGM is sometimes done in belief that the benefits outweigh the risks. However, this does not make it a justifiable attitude make when supporting a practice that is life-changing and permanent. It infringes on every woman’s fundamental human rights in many different ways; the right to freedom from torture and inhuman punishment, the right to life (when the outcome of a procedure results in death), the right to a life free from discrimination based on gender, among others. FGM is also a violation against the right to the highest accessible standard of health. This is due to the alteration of healthy genital tissue without medical necessity resulting in serious physical and psychological consequences to women's health (Williams-Breault, 2018).
While FGM is acknowledged among many governments worldwide as a violation to the human rights of women and as an act of violence, the challenge lies in approving and enforcing legislation. This challenge stems from the practice being so deeply rooted in tradition and culture (Williams-Breault, 2018).
Legislation
In Africa, where approximately 92 million women over the age of 10 have undergone FGM, Burkina Faso is identified as one of the few countries with effective and
systematically enforced legislation. A strong political will and the law being translated into local languages were key factors in making their opposition against FGM successful. Even though many other African countries have enforced legislations against FGM it does not automatically guarantee the protection of women. When a system lacks effective ways to report, refer and protect victims at risk the offenders rarely see consequences and thus have no reason to fear persecution. Other contributing factors for the continuation of the
practice, despite criminalization, include religious and traditional leaders exerting more influence and power than the government, a lack of respect for the laws prohibiting the practice, weak human rights establishments with inadequate financial, technical and human support as well as the practice being deeply rooted in tradition (Nabaneh & Muula, 2019).
Nursing care
A nurse’s main responsibility is nursing care which is based on a humanistic perspective where the main focus lies on the patients’ and their needs. Nursing care means possessing both practical and theoretical knowledge about the human being, what health is as well as what care entails in order to assess a patient based on individual needs and prerequisites. Thereafter adequate measures can be taken to provide individualized and quality care (Svensk sjuksköterskeförening, 2018). Patient safety is an important element in providing quality care. It requires nurses to be adequately trained using safe clinical practices in a safe environment. Nurses have a responsibility to promote patient safety and to inform patients and family members regarding health risks as well as promote to reduce said risks (International Council of Nurses, n.d.).
Person-centered care
Person-centered care is one of many pillars in nursing care and requires a person-centered approach where a holistic perspective is used to recognize the person as a whole, taking into account both the physical, psychological, social, existential and spiritual needs. A person is seen as more than a diagnosis or illness and rather as an equal and worthy partner who is able to make decisions based on free will, values and resources (Svensk
sjuksköterskeförening, Svenska läkaresällskapet & Dietisternas riksförbund, 2019). Three important key concepts in person-centered care are: ‘partnership’, ‘patient narrative’ and ‘documentation’. Nurses need to create an atmosphere of trust and respect which allows for a partnership. In this partnership the patient and the nurse are considered equals, each providing their own expertise: the patient being an expert regarding her life and current situation while the nurse is an expert in nursing care. It is essential for the nurse to listen to the patient’s narrative in order to understand her specific needs. A thorough documentation of the patient narrative and a health plan is needed for nurses to provide a cohesive care (Gothenburg University Centre for Person-centered Care [GPCC], 2017). A person-centered approach is necessary in order to mitigate suffering (Svensk
sjuksköterskeförening et al.,2019).
Theoretical starting point - suffering
Suffering is defined as a psychological or physical pain that a person experiences (Cambridge dictionary, 2020). Suffering is a subjective experience of each person’s existence, well-being, sickness, as well as the care they receive (Wiklund Gustin, 2014).
According to Katie Eriksson, suffering is divided into three main categories: suffering related to disease, suffering related to life and suffering related to care. All types of suffering are seen as unique and subjective as it is a natural phenomenon in life and is consequently part of one’s health. It is in itself something evil that has no meaning but depending on how it is perceived, it can create meaning. Suffering is believed to be a result of a threat to one’s dignity. Dignity can be something absolute or relative. An absolute dignity is seen as something one possesses simply by being human, creating an
inviolability whereas a relative dignity correlates to exterior attributes and can thus be taken away (Eriksson, 2015).
Suffering related to care occurs when there is a gap between the patient’s needs and the knowledge and attitudes presented by the nurse. How the environment is being presented and interpreted can either create a feeling of security or a feeling of hostility. A negative attitude can contribute to a feeling of uncertainty and a violation to one’s dignity. A positive attitude, contrarily, can create a welcoming atmosphere and encourage a conversation (Eriksson, 2015).
Nursing and suffering
Suffering related to care is a process that can be divided into three parts and the nurse plays a crucial part in this process. The first part being acknowledgement which requires the nurse to be present in the moment and for both parties to acknowledge the suffering. It is not until the suffering has been expressed and acknowledged that the possibilities to deal with it arise. If the acknowledgement does not occur, it can lead to withdrawal; meaning the person might give up instead of fighting the issue causing the suffering. The second
part requires to be one with the suffering, to have the strength and courage to be engaged in the process and to let the suffering take place. It is only then the third part of reconciliation becomes graspable. To reconcile is to accept the situation for what it is rather than running away from it and the nurse has an important role in helping with the reconciliation
(Eriksson, 2015).
Studies show of an immense lack of understanding and knowledge among nurses regarding FGM and the reasons behind the procedures. Many were unaware of the definition or how to differentiate the types of FGM, where it geographically occurs as well as a lack of knowledge or use of protocols; in the occurrences where protocols were implemented. Little or no training regarding the subject had been offered to increase awareness
(González-Timoneda et al., 2018). While most knew in some form what FGM entailed, a small percentage of healthcare providers were unaware that the procedures even existed (Ashimi, Aliyu, Shittu & Amole, 2014). Knowledge regarding what suffering is and how it affects health is crucial information a nurse needs to acquire since alleviating suffering is the fundamental cornerstone for all basis of care in accordance with Eriksson (2015). Nurses may encounter women exposed to FGM in any medical setting and it is therefore important that they are able to recognize these women. Hence, it is vital knowing the consequences the procedures cause as well as knowing which countries the procedures are prevalent in (Momoh et al., 2016). Nurses need to have knowledge of and recognize common complications related to FGM, such as for instance genital pain or genital tissue swelling, haemorrhage or haemorrhagic shock, infections and septicaemia, urinary tract infections/retention or pain, menstrual problems as well as psychological distress in order to provide proper care for women who have undergone FGM (WHO, 2018).
Moreover, it is critical to approach these women without judgement and with sensitivity and respect to their customs and values. When seeing their genitalia, nurses need to behave in a compassionate way and avoid showing any potential signs of horror, shock or
revulsion (Momoh et al., 2016).
Problem area
Female genital mutilation is a human rights issue affecting millions of women worldwide causing severe health consequences, both physical as well as psychological. Still many nurses have limited knowledge regarding what the procedures involve and what they result in. Studies show that nurses also have insufficient understanding concerning the practice, resulting in a challenge of knowing how to meet the needs of these women. This
consequently can lead to a lack of adequate care. With increased knowledge regarding how these women view their situation and experience living with genital mutilation, nurses as well as other healthcare providers can identify and treat these women using a person-centered approach. This knowledge will hopefully help to improve health care that can alleviate the suffering these women experience.
AIM
The aim was to describe the experiences of women who have undergone female genital mutilation.
METHOD Design
This degree project was conducted as a literature review. A literature review is a summary of current evidence answering a specific research question on a topic of interest and can be carried out using either a systematic or non-systematic approach (Polit & Beck, 2017). A systematic review has a high scientific value since it compiles all current research within the topic and follows specific steps. A non-systematic review does not need to meet the same requirements as a systematic review but can nonetheless attain a high-quality
standard (Kristensson, 2014). In this literature review a non-systematic approach was used, however following a systematic structure that was carefully documented.
Sample selection
Three databases were identified as useful in searching for relevant articles. According to Polit & Beck (2017) Public Medline [PubMed] is by far the vastest of databases for scientific articles within the field of medicine covering about 5,600 nursing and health journals in approximately 70 countries. The second biggest database, Cumulative Index to Nursing and Allied Health Literature [CINAHL], is an important database in nursing science, covering references to all English language articles in nursing and health. The third chosen database was American Psychological Association PsycINFO [PsycINFO], which is the largest database for peer-reviewed articles in behavioral science and mental health (EBSCO, 2020). Searches were limited to articles within a publication date of January 1st, 2010 – April 17th, 2020 using an English language. The term “women” was not used as a search limitation. Therefore, newer articles which had not yet been appointed a “subject heading” index could be found. According to Polit & Beck (2017) the articles also need to be peer-reviewed, meaning that the articles are reviewed by other researchers and thereafter published in a scientific journal. Moreover, the research area needs explicit inclusion- and exclusion criteria to enable the evidence finding to be reproduced. Inclusion criteria:
Inclusion criteria are used as a way to identify a population. In a scientific context, a population is a group of people who will be examined for the purpose of the study (Kristensson, 2014). Inclusions consisted of women from all parts of the world who had undergone FGM regardless of type, nationality, marital status, age, country of origin or country of residence. Women who sought health care, pregnant women as well as mothers of girls who had faced circumcision were also included. Only original articles which were peer-reviewed with a publication date within 10 years were included. Only non-controlled studies (P) and qualitative studies (Q) were incorporated.
Exclusion criteria:
Exclusions are specific characteristics that a population does not have (Polit & Beck, 2017). Exclusions were male experiences of female genital mutilation, experiences from health care providers and uncut women as well as experiences of deinfibulation. Other exclusions were articles which were not peer-reviewed or original, written before 2010 as well as articles of low quality.
Data collection
The data collection was conducted using the steps in Polit & Beck’s (2017) data collection process for literature reviews. The data collection process was initiated by selecting a topic of interest and identifying a research issue which resulted in a research question. The purpose of the research process was to provide an answer to the selected question. The next step was to gather information relevant to the chosen question by implementing a good search strategy which began by finding the right keywords and bibliographic databases. The search words used in the search were ‘female genital mutilation’, ‘female genital cutting’, ‘FGM’, ‘FGC’, ‘FGM/C’ and ‘experiences’. An experience is per definition “an event or occurrence that leaves an impression on someone” (Lexico, 2020).
The initial search for articles was done with a librarian in the chosen databases and with the chosen search words. The librarian suggested to use subject headings in the databases. Subject headings include code words allowing relevant articles to be found without using the exact search word for each article (Kristensson, 2017). In CINAHL and PsycINFO the subject headings consisted of ‘circumcision, female’and ‘psychosocial factors’. In PubMed the subject headings were called ‘MeSH’ (Medical Subject Heading) and the terms used were ‘circumcision, female’ and ‘psychology’.
The initial search was followed by a more specific search where limiters were used in order to narrow the search to more relevant articles. Articles were limited to the English language and publication date of January 1st, 2010 – April 17th, 2020 thus generating current research only. Articles were limited to peer-reviewed articles which have a high scientific value as they are critically examined by reviewers and published in a scientific journal (Polit & Beck, 2017). In addition, so-called Boolean operators such as ‘AND’ and ‘OR’ were used. The operator ‘AND’ includes both search words delimiting the search to be more specific, while the operator ‘OR’ expands the search to each search word allowing more articles to be identified. The third Boolean operator ‘NOT’ was not used since it would have limited the findings to exclude important search words (Forsberg &
Wengström, 2016). Two search blocks were needed in order to combine the search words using the Boolean operators. The search blocks in PubMed consisted of ‘circumcision, female’, ‘female genital mutilation’, ‘female genital circumcision’, ‘FGM’, ‘FGC’, ‘FGM/C’ AND ‘psychology’, experiences. In CINAHL and PsychINFO the blocks consisted of ‘circumcision, female’, ‘female genital mutilation’, ‘female genital
circumcision’, ‘FGM’, ‘FGC’, ‘FGM/C’ AND ‘psychosocial factors’ and ‘experiences’ (see appendix I).
The data collection process was concluded by selecting articles that were to be included in the literature review (Polit & Beck, 2017). This step began by reading all abstracts to find articles which answered the literature review’s aim. 67 articles were of interest and after duplicates were excluded, 46 articles remained. A total of 34 articles were read in full text of which 15 articles were included in the literature review to gather enough material for a proper analysis to be done (see appendix III).
Quality review
A quality review is necessary to perform in order to verify that the articles used in the literature review are up to standard and of a scientific nature. An assessment template is needed for a systematical examination and evaluation of the included articles. The purpose of critically evaluating each article is to ensure the results have strong credibility by
filtering out all articles that are of low quality (Kristensson, 2014).
The Sophiahemmet University assessment template was used to verify said article’s scientific value. Articles were assessed using different categories: I = high quality, II = average quality and III = low quality (see appendix II). High quality articles were well executed with enough participants, had a well-defined purpose and sample selection, a calculated method and data collection process as well as a strong and clear result and discussion. If these criteria were partly met the articles were then of average quality while articles that did not meet any of the criteria were considered to be of low quality (Berg, Dencker & Skärsäter, 1999; Willman, Stoltz & Bahtsevani, 2011).
Data analysis
The data was organized and analyzed using inspiration from Kristensson’s (2014) integrated analysis. This analysis method helped present the results in a comprehensible way. Firstly, when the data collection was complete two copies of each article were printed and given a number. The authors carefully evaluated and examined each article separately which, according to Polit and Beck (2017), allow for an objective perspective. Interesting findings were highlighted, and all articles were then reviewed together to compare
similarities and differences in women’s experiences. Secondly, findings were written into various documents using ‘Microsoft Word version 16.36’ and then categorized according to how the articles related to one another. In order to remember from which article
information was retrieved, findings were marked with the number correlating to the correct article. Once this process was finished all documents were printed in order to secure a hard copy of all findings. The reason being that information might be lost when moved from one document to another online. Thirdly, the result was compiled and during this process, new categories were found, and subcategories were created. The final categories consisted of: ‘The circumcision procedure’, ‘Womens’ daily lives’, ‘Womens’ sexual experiences’ and ‘Encounters with health care’.
Ethical considerations
Ethical considerations need to be taken into account when performing any type of medical research; qualitative and quantitative studies as well as literature reviews since the latter requires other researcher’s work to be critically examined (Kristensson, 2014).
According to Vetenskapsrådet and World Medical Association [WMA] ethical
considerations date back to a time after World War II, when people were subjected to cruel and gruesome experiments without their consent. As a result, different ethical codes were formed to regulate and set a standard for good research in order to protect the participants’ lives, well-being, dignity, privacy and autonomy. The Declaration of Helsinki is the most important of these codes. It was adopted in year 1964 by the WMA and emphasizes that in
all research the health and well-being as well as integrity of the participants must be protected. To accomplish this all research must be executed with informed consent and participants be informed of their right to, at any stage, withdraw their participation. Medical research must put the participant above all else, in spite of the possibility of this causing the trial or study to fail (Vetenskapsrådet, 2019; WMA, 2018).
To protect the integrity of participants in research, the Swedish Government issued a law regarding the protection of personal data (SFS 1998:204) as well as a law concerning the ethical review of research involving humans (SFS 2003:460). The latter states that research requires approval by ethical review boards. Research is only approved when human rights and human dignity are protected and when the necessity and value of the research is considered to be greater than the risks for the participants health, security and integrity. During the data collection, ethical considerations were critically evaluated in each article such as the setting in which interviews were conducted. The settings were adapted to the womens’ preferences. While some women wished to be interviewed at home others preferred a neutral environment. Due to the topic’s sensitivity researchers purposefully chose not to use the word mutilation since it was often considered offensive. Other women found the word circumcision to be offensive and wording was therefore chosen based on what the women preferred. Women who wished were interviewed by a female researcher or research assistant. In qualitative articles women’s anonymity was safeguarded by changing names on the narratives.
In accordance with good research practice (Helgesson, 2015),no texts have been fabricated, distorted nor plagiarized in this review, why all articles and texts have been accounted for and are referred to in the reference list.
RESULT
When categorizing and analyzing the findings four major categories emerged along with subcategories as presented below.
Major categories Subcategories
The circumcision procedure
Womens’ daily lives
The day of circumcision
Emotions relating to the procedure Physical complications in daily life Living with psychological issues
Women’s sexual health First sexual encounter Sexual intercourse
Encounters with health care Negative experiences Positive experiences
The circumcision procedure
The day of circumcision
The circumcision procedure was described as painful and traumatizing (Adinew & Mekete, 2017; Isman, Ekéus & Berggren, 2013; Mbanya, Terragni, Gele, Diaz & Kumar, 2020; Moxey & Jones, 2016; Omigbodun et al., 2020; Pastor-Bravo, Almansa-Martínez & Jiménez-Ruiz, 2018). For some it was a devastating experience although they did not remember much of it due to a young age or that it did not affect their lives after the
procedure (Ahmed, Shabu & Shabila, 2019; Moxey & Jones, 2016; Ormrod, 2019). Others said they would never forget the day they were circumcised (Ahmed et al., 2019; Ormrod, 2019; Vloeberghs, van der Kwaak, Knipscheer & van den Muijsenbergh, 2012).
Pain was a common experience during the procedure (Adinew & Mekete, 2017; Ahmed et al., 2019; Battle et al., 2016; Isman et al., 2013; Jacobson et al., 2018; Ogunsiji, Wilkes & Chok, 2018; Omigbodun et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). The intensity of pain however, increased with the severity of the procedure. Women who had undergone excision experienced extreme pain while infibulated women described severe and prolonged pain (Battle et al., 2016). A dissenting view was expressed by
women who felt very little or no pain during the procedure (Battle et al., 2016; Jacobson et al., 2018).
Emotions relating to the procedure
Ambivalent feelings were represented by women who despite the negative effects of the procedure also recognized and acknowledged the positive cultural values. After the
procedure women experienced regret, they felt betrayed and grieved over not being able to undo the cutting (Isman et al., 2013; Omigbodun et al., 2020). Yet being cut gave a sense of belonging to the culture and country of origin and being circumcised was considered normal and beautiful (Isman et al., 2013).
Even though many negative memories arouse from the circumcision procedure, positive experiences were also accounted for (Battle et al., 2016; Jacobson et al., 2018; Omigbodun et al., 2020; Vloeberghs et al., 2012). Women who had undergone a clitoridectomy recalled feeling more feminine as well as feeling narrower and tighter, making sitting down more comfortable (Battle et al., 2016). Circumcision instilled a sense of fulfillment, improved self-esteem and created harmony in marital relationships (Omigbodun et al., 2020) as well as making women feel ‘whole’ and good in their bodies (Jacobson et al., 2018). Further, being circumcised created a feeling of honor along with the hope of getting married (Omigbodun et al., 2020). Happiness over the procedure was mentioned more frequently among women with a clitoridectomy or excision than women who had undergone infibulation (Battle et al., 2016). Women recalled feeling happy and relieved due to not having to be ashamed, embarrassed and humiliated (Battle et al., 2016; Omigbodun et al., 2020).
Womens’ daily lives
Physical complications in daily life
Women who reported long-lasting pain recalled having pain on a daily basis (Adinew & Mekete, 2017; Jacobson et al., 2018; Mbanya et al., 2020; Omigbodun et al., 2020;
Pastor-Bravo et al., 2018). Dysuria was another frequently mentioned problem causing long-lasting pain (Jacobson et al., 2018; Omigbodun et al., 2020; Ormrod, 2019; Pastor-Bravo et al., 2018). Pain was also associated with a difficult menstruation, this was seen among the majority of women who had undergone infibulation (Isman et al., 2013; Jacobson et al., 2018; Moxey & Jones, 2016; Vloeberghs et al., 2012). A common problem was recurring urinary tract infections which caused immense suffering (Mbanya et al., 2020; Omigbodun et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012) as well as other urinary issues (Mbanya et al., 2020; Vloeberghs et al., 2012). Bleeding was mentioned as a long-lasting consequence of being circumcised (Mbanya et al., 2020; Omigbodun et al., 2020). A dissenting experience was presented by several women who reported having no
problems with the circumcision (Ahmed et al., 2019; Battle et al., 2016; Isman et al., 2013; Omigbodun et al., 2020).
Living with psychological issues
Women described suffering from fear that affected their daily lives (Ahmed et al., 2019; Battle et al., 2016; Isman et al., 2013; Mbanya et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Some women specifically mentioned being afraid or worried not finding husbands or husbands divorcing them due to their circumcision (Ahmed et al., 2017; Mbanya et al., 2020; Ogunsiji et al., 2018). Women who had not circumcised their daughters experienced a social pressure from family or the community to perform the procedure (Adinew & Mekete, 2017; Ahmed et al., 2019; Battle et al., 2016; Isman et al., 2013; Ormrod, 2019) Immigration to western countries caused women to fear that their daughters would be forced to undergo FGM during family visits to home countries (Isman et al., 2013).
Depression was a common experience regardless of type of circumcision (Ahmed et al., 2017; Mbanya et al., 2020; Ormrod, 2019; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Anxiety was also mentioned (Ahmed et al., 2017; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012) and was together with depression more common among women who had undergone excision (Vloeberghs et al., 2012). Anger was expressed toward the mindset in different cultures to perform the procedure, despite its harmfulness (Adinew & Mekete, 2017; Esho et al., 2017; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Similar views were found among other women who were frustrated and angry toward the community, elders or men in general for not stopping the procedure (Adinew & Mekete, 2017; Jacobson et al., 2018; Omigbodun et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Suffering was mentioned in various contexts affecting the everyday life of women (Adinew & Mekete, 2017; Battle et al., 2016; Turkmani, Homer & Dawson, 2020; Vloeberghs et al., 2012). Women expressed suffering in silence due to not talking about the complications and painful memories (Isman et al., 2013; Jacobson et al., 2018; Ormrod, 2019).
A frequently mentioned emotion was an ongoing sadness (Adinew & Mekete, 2017; Ogunsiji et al., 2018; Omigbodun et al., 2020; Ormrod, 2019; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Women expressed hurt feelings and an ongoing emotional pain or painful memories (Isman et al., 2013; Ogunsiji et al., 2018; Omigbodun et al., 2020). Regardless of type of circumcision, sleeping disorders and nightmares were often reported (Omigbodun et al., 2020; Ormrod, 2019; Pastor-Bravo et al., 2018; Vloeberghs et al.,
2012). Eating disorders (Ormrod, 2019) and psychological recalls were also expressed by a few (Mbanya et al., 2020; Ormrod, 2019; Vloeberghs et al., 2012).
Shame was described in various ways having diverse meaning for different women (Adinew & Mekete, 2017; Vloeberghs et al., 2012). For exampel shame over letting one’s child undergo circumcision due to social pressure (Adinew & Mekete, 2017). Women who immigrated to western countries felt shame or embarrassment of being genitally different when examined by care providers (Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Other women felt embarrassed bringing up the subject about their private parts (Moxey & Jones, 2016; Pastor-Bravo et al., 2018) or talk about FGM in communities (Jacobson et al., 2018).
Furthermore, other negative experiences were described. These include hostility (Ahmed et al., 2017), apathy, guilt, a feeling of exclusion (Vloeberghs et al., 2012), social withdrawal and a sickly life (Omigbodun et al., 2020). Loss of identity as a woman, hopelessness (Pastor-Bravo et al., 2018) the feeling of being different, isolation, loneliness (Vloeberghs et al., 2012) and being unhappy were also mentioned as negative experiences (Omigbodun et al., 2020).
Women’s sexual health
First sexual encounter
A correlation was seen between fear and losing one’s virginity (Battle et al., 2016; Pastor-Bravo et al., 2018) and pain was also associated with virginity loss (Adinew & Mekete, 2017; Battle et al., 2016; Pastor-Bravo et al., 2018). The intensity of pain however, varied depending on the type of circumcision. Women with a clitoridectomy described a painful but not traumatic experience (Battle et al., 2016; Pastor-Bravo et al., 2018) while excision was correlated to mild or tolerable pain or extreme agony. Most women who had undergone infibulation had traumatic experiences and described virginity loss as a death sentence (Adinew & Mekete, 2017; Battle et al., 2016). Contrarily, some women described feeling no pain during their first sexual encounter (Battle et al., 2016; Pastor-Bravo et al., 2018). Sexual intercourse
Pain was commonly described during intercourse even after virginity loss regardless of type of circumcision. (Isman et al., 2013; Jacobson et al., 2018; Mbanya et al., 2020; Omigbodun et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). In contrast, a small percentage of women expressed feeling no pain (Omigbodun et al., 2020). Bleeding was mentioned frequently among infibulated women as a commonly recurring problem during sexual intercourse (Mbanya et al., 2020). Another frequently mentioned issue was a lack of sexual desire (Ahmed et al., 2019; Battle et al., 2016; Esho et al., 2017; Jacobson et al., 2018; Omigbodun et al., 2020; Pastor-Bravo et al., 2018). On the contrary, some women did experience sexual desire (Esho et al., 2017). A decrease or lack of pleasure from sexual stimuli was a common experience (Ahmed et al., 2019; Battle et al., 2016; Isman et al., 2013; Jacobson et al., 2018; Mbanya et al., 2020; Ormrod, 2019; Pastor-Bravo et al., 2018). However, pleasure was sometimes obtained through prolonged sexual
stimulation (Pastor-Bravo et al., 2018). A small percentage of women described a loss of feeling during intercourse (Jacobson et al., 2018; Omigbodun et al., 2020) and other, not
specified, sexual difficulties were also experienced (Esho et al., 2017; Isman et al., 2013; Moxey & Jones, 2016; Omigbodun et al., 2020; Ormrod, 2019).
Encounters with health care
Negative experiences
Many women expressed negative experiences when in contact with health care. These feelings correlated to emigration from a country where FGM was acceptable to a western country. Feelings of embarrassment and abnormality were often described (Jacobson et al., 2018; Mbanya et al., 2020; Moxey & Jones, 2016; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Care provider’s body language during intimate examinations caused women to feel uncomfortable. They experienced shame and lost confidence in care provider’s ability to deliver good care due to the look of shock and surprise on the care providers’ faces (Mbanya et al., 2020; Turkmani et al., 2020; Vloeberghs et al., 2012). Intimate
examinations where care providers would see and/or touch the womens’ genitals were described as scary situations (Mbanya et al., 2020; Moxey & Jones, 2016; Ormrod, 2019; Vloeberghs et al., 2012) and in some cases the examinations caused flashbacks to the moment of circumcision (Mbanya et al., 2020; Vloeberghs et al., 2012).
It was relatively common for women to avoid seeking health care for their problems or discussing sensitive topics with care providers which was mostly due to a feeling of shame (Mbanya et al., 2020; Pastor-Bravo et al., 2018; Vloeberghs et al., 2012). Others avoided seeking help due to fear of rejection, violence and disapproval from their husbands, family or the community (Mbanya et al., 2020; Turkmani et al., 2020). Other reasons for not seeking care was expressed in a difficulty finding information regarding where to go for specific FGM care as well as not knowing how the health care system worked in other countries (Mbanya et al., 2020; Moxey & Jones, 2016).
For some women it was difficult when care providers asked many or intrusive questions regarding circumcision and it was majorly difficult for women who had undergone
infibulation (Mbanya et al., 2020; Vloeberghs et al., 2012). In contrast, several women felt comfortable answering questions and discussing their circumcision with care providers, in particular when the conversation was initiated by the care provider (Moxey & Jones, 2016).
During childbirth a few women felt disempowered and disappointed by maternity care providers. The women felt as though they were not being listened to and that the care providers took control over and dominated the situation. The women also felt pressured to deliver their child in a way that was not their choice (Jacobson et al., 2018; Turkmani et al., 2020). Women who had undergone infibulation recalled a fear of giving birth due to their genital area being closed for many years or due to a worry that midwives did not have enough experience to give the care needed (Isman et al., 2013; Jacobson et al., 2018). Pain during childbirth was only mentioned by women who had undergone infibulation (Adinew & Mekete, 2017; Battle et al., 2016; Isman et al., 2013; Jacobson et al., 2018; Moxey & Jones, 2016) and was in some cases referred to as a death sentence (Adinew & Mekete, 2017; Battle et al., 2016).
Positive experiences
Even though many negative experiences were portrayed regarding health care after immigration to a western country, several women were happy and satisfied with the care they received, describing positive experiences and being well treated (Moxey & Jones, 2016; Ormrod, 2019; Pastor-Bravo et al., 2018; Turkmani et al., 2020). Some of these women mentioned having been treated by knowledgeable and skilled health care providers (Ormrod, 2019; Turkmani et al., 2020).
DISCUSSION Result discussion
The findings show that almost all women who had undergone FGM suffered in various degrees of psychological issues. Even if similarities in womens’ experiences were found when comparing the findings, the suffering was always a subjective experience colored by each woman’s individual perception of well-being and sickness. Interestingly, despite facing many physical complications in daily life, some women defined themselves as feeling whole and feeling good in their bodies. It seems that physical illness and sickness did not automatically result in women considering themselves being ill. This is in
accordance with Eriksson’s view on suffering that in spite of suffering being evil, it can still create a meaning in life (Eriksson, 2015). This is seen in some womens’ accounts of circumcision being a necessary evil in order to gain something good. Even if the procedure was described as an unpleasant experience it gave a sense of belonging to a culture where FGM was believed to make women beautiful and normal.
From an outsider's perspective it is easy to see FGM as being purely evil, causing immense suffering. Without trying to diminish its harmfulness it is important to understand how deeply rooted FGM is in many cultures. For many women FGM had ‘made them normal’ and it was not until immigrating to a western country and coming in contact with health care that these women started to feel abnormal and ashamed of being circumcised. This creates a different type of suffering that is related to care. It occurs when health care providers are unable to meet the needs of patients’ due to lack of knowledge or incorrect attitudes (Eriksson, 2015). According to the findings women found it difficult to seek health care due to care providers’ negative attitudes and presumptions. If care providers were properly educated regarding the subject, women would feel more comfortable in seeking health care. By taking into account each woman’s individual story and previous experiences nurses can adapt their approach to avoid an offensive behavior. Nurses can for example ask the question ‘which word would you prefer me to use when talking about female circumcision?’ thus creating a welcoming atmosphere where women feel safe speaking about their experiences. This facilitates a partnership between the woman and the nurse which is a key factor in person-centered care. According to Kristensson Uggla, a partnership means that information is shared between the nurse and the woman so that she is an equal participant and decision maker in the care she receives. Documentation is an important part in facilitating the partnership (Kristensson Uggla, 2014). By documenting a woman’s narrative the nurse does not need to continuously ask the woman to tell her story every time health care is sought thus avoiding traumatizing recalls.
Health care providers need to tread carefully and see each woman who have undergone FGM as an individual with a background and a history. Only by understanding womens’ previous experiences care providers will succeed in reaching out to these women,
providing ease to their suffering. For this to become a reality, a proactive solution would be for FGM to be incorporated into university curriculums in order for students to familiarize with all aspects of female genital circumcision.
Another topic that emerged in the findings was pain. It was a major complication
experienced by women either in connection to the circumcision procedure or as a result of it. An interesting observation was that pain in relation to first sexual intercourse seemed to differ depending on the severity of FGM with the pain being more intense and the
experience more traumatizing when excision or infibulation had been performed. The finding is in accordance with WHO (2020) who states that the risks followed by FGM generally increase with the severity of the circumcision. However, the findings in Rouzi et al. (2017) contradict this statement by arguing that women with the most severe type of FGM experienced the least pain in sexual intercourse. No explanation was given as to the reason pain was experienced less by infibulated women than women who had undergone a clitoridectomy. It seems no conclusion can be drawn that infibulated women always experience the most severe complications.
An equally important finding was that women with FGM, regardless of type, experienced a loss of sexual desire or lack of sexual pleasure. The finding is consistent with previous research by Rouzi et al. (2017) stating that the level of sexual dysfunction increases with the severity of FGM. Other studies show differences in sexual dysfunction among women with FGM. Andersson, Rymer, Joyce, Momoh and Gayle (2012) showed that women who had undergone FGM experienced a lower sexual quality of life than women who had not undergone FGM. This is in alignment with Abdulcadir et al. (2016) who states that uncut women had higher overall scores relating to sexual quality than cut women. There were however no significant distinctions between the groups in regard to satisfaction, desire or orgasm. Further, cut women reported more dyspareunia than uncut women. On the contrary, Catania et al. (2007) showed in their research that female genital mutilation might in fact not have a negative impact on sexual quality. Women who had been
subjected to FGM scored higher in satisfaction, arousal, desire and orgasm during sexual intercourse than women who had not been subjected to FGM and no noticeable difference was found between the two groups regarding pain during sexual intercourse. Chu and Akinsulure-Smith (2015) on the other hand did not find any noticeable differences between cut and uncut women, except that uncut women experienced a greater sense of arousal during sexual intercourse.
A noteworthy weakness are articles where the reliability of the result is limited by womens’ self-reports of their FGM status, thus inquiring clinical examinations to determine the type of FGM (Rouzi et al., 2017). It is however questionable whether the gain would be worth the potential harm it would cause as it could result in psychological recalls of the traumatic experience. Another factor affecting the reliability is that womens’ self-reports are not always in alignment with WHO’s typology. It is therefore difficult to know if the presented result is accurate when referring to a specific type of circumcision. Also, many articles did not specify the type of FGM when referring to experiences, making it difficult to draw conclusions on what impact the type of FGM had on womens’
experiences. Moreover, the authors could not always determine whether experiences were expressed by uncut or cut women in articles where these two groups were compared. Thus, risking excluding valuable findings.
Williams-Breault (2018) states that FGM is a violation to womens’ rights and that even when a woman gives consent it is due to social pressure. Gordon (2018) argues that it is possible to reconcile female genital mutilation with universal human rights by making sure that a properly informed consent is given prior to the procedure and that the only way an informed consent can be justifiable is if it is given no earlier than at the age of 16.
Furthermore, a woman who decides against FGM should be respected by family members and society and not fall victim to social pressure or socio-political disadvantages.
Having previous knowledge regarding the issue of FGM, it was an interesting realization to find that a surprising number of women experienced positive outcomes relating to FGM. The expectation was to only find information casting a negative light on the tradition, however many women had either a positive standpoint or a neutral one. Nonetheless, it was surprising to make this discovery. On one hand, it is good that many women are unaffected by their circumcision. On the other hand, with women being positive about the tradition and with an absence of negative consequences it makes the discontinuation of FGM that much more difficult.
In conclusion, the results of all articles answer this literature review’s aim of how women experience genital mutilation and all articles included women expressing how FGM has affected their lives.
Method discussion
Literature review was chosen as an appropriate design when conducting a degree project as it presents an overview of valuable and useful information from current research within a specific topic that can easily be applied to clinical work (Jakobsson, 2011). A non-systematic approach was chosen as the time frame given did not allow for a non-systematic review to be conducted. A limitation with the chosen approach was that the result was based on 15 articles, hence the trustworthiness was not as reliable as if all available articles on the topic would have been included (Kristensson, 2014). In spite only using a limited number of scientific articles the aim of this literature review was answered since the chosen design allowed for a variety of findings to be compiled.
To increase the trustworthiness of the literature review credibility needs to be taken into account. Credibility refers to how truthful the result is and if interpretations are based on the collected data or preconceptions. To strengthen the credibility both authors analyzed and interpreted the articles’ results together. A varied sample selection and using women with different types of circumcision increased the literature review’s credibility. Another way to increase the literature review’s credibility is by making sure that the included articles’ credibility is high. The duration of interviews in the qualitative articles should therefore be presented to ensure that enough time was given for a proper interview to be conducted. By properly documenting the analysis process and always using references when presenting findings, the literature review’s credibility increased (Kristensson, 2014).
Included articles mentioned almost no loss of participants in their research. It could be argued that this increases the studies trustworthiness since it seems as though all the participants believed in and wanted to participate in the study. On the contrary this raises the question whether participants were informed that they at any time could withdraw their participation or if they were forced to complete the study. Informed consent is according to Helgesson (2015) an important factor in showing respect for the participants integrity and autonomy. This makes participants feel involved in the research which is an important ethical consideration. A few articles did not mention informed consent nor that the participants could withdraw their participation at any time. This may affect the studies credibility. Another question arose whether the researchers have been truthful in their reports regarding how many participants were recruited from the beginning.
The result of this literature review is mainly based on qualitative research apart from two mixed-method studies. According to Kristensson (2014) qualitative research can not generalize the results the way quantitative research can, therefore decreasing the literature review’s transferability. Transferability refers to in what extent the result can be applied in a further context. A factor that enhances the transferability is that the majority of the articles in detailed manner describe the sample selection and the context of the study. In quantitative research the interest lies according to Polit & Beck (2017) in understanding which factors are associated with FGM, rather than describing how women experience genital circumcision. According to Polit & Beck (2017), the purpose of qualitative research is to study experiences, patterns and lifeways as opposed to quantitative research where the interest lies in understanding which factors are associated with FGM. Therefore,
quantitative research does not allow women to express their individual experiences. Because this literature review uses mainly qualitative articles it gives a deeper
understanding of womens’ experiences of living with genital mutilation in spite the result not being transferable.
Searches were limited to three bibliographic databases and it is possible that other databases would have given additional findings and therefore increased the
trustworthiness. The databases were chosen as they were recommended when consulting librarians as well as the examiner. The use of only three databases may have affected the presented result and a more appropriate design would have been to conduct a systematic literature review to cover all current research from all available databases. Due to the interesting nature of this topic and the genuine interest from both authors, it would have been preferable to conduct a qualitative research study with in-depth interviews. Such a study would most likely have given deeper and more specified information regarding different dimensions of the experiences caused by the procedure.
The authors discussed back and forth whether to focus on a specific ethnicity, culture, age group or country as to gain deeper understanding of the FGM experiences of women in specific settings. The authors finally decided not to apply such limitations to see if the experiences of women would differ depending on for example country of origin. The reason being that nurses in their clinical work may encounter women from all parts of the world who have undergone FGM. The desire was therefore to present an overall account of womens’ experiences that would give a deeper understanding of what these women have gone through and how their lives may have been affected. This was seen as a strength because it gave a better picture of how women from different parts of the world have
similar experiences. Further, articles were limited to a publication date of no more than 10 years to increase the literature review’s credibility as well as to present the latest research on the subject. Only peer-reviewed articles were included making the result’s scientific value more trustworthy and credible (Polit & Beck, 2017).
A second topic of discussion when specifying the aim of the study was whether to focus only on experiences in encounters with health care. When exploring the subject, it became evident that there is an immense lack in nurse’s and other health care provider’s knowledge regarding how to provide good quality care for women who have undergone FGM.
Eventually the chosen aim became to portray womens’ overall experiences of FGM. With English not always being women’s native language there is a chance that the accounted experiences have been misinterpreted by the researchers. When examining the articles, the authors noticed that the researchers mentioned either themselves speaking the local language or using a native interpreter, thus eliminating any misunderstandings due to language barriers.
In the data collection process articles of low quality were excluded to avoid questionable or incorrect results. Using Polit & Beck’s (2017) steps for data collection the authors were able to operate in a structured way making documentation and reproducibility easier. All included articles were assessed separately by the authors using Sophiahemmet University assessment template (Berg et al., 1999; Willman et al., 2011). Factors affecting the article’s quality were discussed and resulted in all article meeting the criteria of a high-quality standard.
The data was analyzed using inspiration from Kristensson’s (2014) integrated analysis to provide a good structure while developing and personalizing the analysis process. Since the authors had no previous experience conducting a literature review it is difficult to evaluate whether a different analysis method would have made the review more successful. Lastly, the author’s preunderstanding of the subject can be seen as a limitation, risking bias when compiling the result. Being aware of this the findings were critically examined and discussed to avoid misinterpretations and exclusion of important findings. Experiences of deinfibulation were purposefully excluded due to the procedure being a correction of the anatomical anomalies caused by infibulation.
Conclusion
Female genital mutilation is a complex matter, deeply rooted in social norms and
traditions. It affects women both physically and psychologically, resulting in various forms of suffering. The main overall findings were presented as negative experiences such as pain in relation to the procedure, in daily life as well as in sexual intercourse. Many different psychological aspects such as fear, depression, anxiety, sadness and shame were presented causing long term consequences. Women who in their countries of origin saw themselves as normal experienced various feelings in contact with health care after immigrating to a western country. These experiences differed from a feeling of
