It is generally assumed that FGM is psychologically harmful to girls and women; many publications make references to adverse psychological effects. FGM can be an extreme and devastating experience for some recipients, so that psychologists are, not unreasonably, expected to answer questions about the psychological impact without hesitation. But an absolute answer to these questions would compromise not just the evidence base but more importantly, the diversity, complexity and multiplicity in the realities of women and girls who have undergone FGM. Psychologists could perhaps more usefully deploy their skills in helping to ‘unpack’ the questions and provide tentative answers (or hypotheses) based on available literatures. This would allow the question to be re-framed in ways that make it more answerable through research and practice in future, taking into account the many constraints placed on providing definitive answers. This is the overall aim of the section. Suffice it to say, however, that FGM is illegal in the UK and interventions to prevent it should not be predicated on proof of negative psychological consequences.

The three broad objectives of this section are addressed in a number of subsections. The first objective is to outline what I believe are some of the key challenges that FGM poses for British psychologists. The second is to hypothesise some of the likely consequences of FGM with which psychological practitioners might provide assistance. In the final part, I offer tentative suggestions as to how psychologists might begin to improve knowledge and skills in relation to care and prevention through research and practice. A list of useful contacts is offered at the end of the section, as are suggestions for further reading.
Psychology has a potential to contribute to care and prevention relating to FGM. But, perhaps in common with other health professionals, psychological practitioners and researchers in the UK are relatively uninformed about FGM. Important gains have been made within Psychology and related disciplines in recent years in terms of clinical interventions, theoretical developments and research methodology, some of which may be usefully exploited for the UK FGM context. However, there are also challenges to consider and overcome, not least from within Psychology.

The academic discipline of Psychology as we know it in Britain has developed within European culture and tradition, so that its interests and methods may not always capture the realities of people who are not of white British ancestry. The cultural appropriateness of psychological methods in research and practice has long been a subject of debate. For example, constructs that many healthcare psychologists take almost entirely for granted, such as ‘depression’ or ‘self esteem’ may not have their exact equivalence in many societies, nor do they adequately describe the people’s experiences or characteristics. Measurement of psychological attributes in people from Black and minority ethnic (so called BME) populations is likewise fraught with difficulties, because the attributes (e.g. ‘body image’) being measured may not be universal, so that even when language barriers are overcome, direct comparisons between groups could yield distorted results.

Forms of FGM have been practised in Britain, for example removal of the clitoris was a treatment for insanity in Victorian times. In our contemporary world, however, FGM affects mainly African women, girls and families. British-trained psychologists would need to be aware of the limitations of their models when applied to problems presented by BME clients, including those affected by FGM. In particular, psychologists should be sensitive to the following observations about their own discipline:

● There have been relatively few opportunities for BME groups including communities of African origins to
define research frameworks and questions in health-care psychology in Britain; rates of uptake in mainstream
research and clinical services are generally lower for BME than other groups and the reasons are not
well understood.

● For these and other reasons, there has been relatively little published research that examines the health-
related psychological outcomes in BME groups. This is also true for health-related attitudes and beliefs,
although there is rather more information on the distribution of health-related behaviours
(e.g. smoking prevalence).

● As a result, there are fewer reliable psychological norms to allow for meaningful comparisons within BME
populations or to define ‘clinical’ levels or levels that indicate a potential need for professional assistance.

● There have been relatively few psychological interventions targeting the health issues of BME communities;

● In theorising about differential clinical outcomes, psychologists have a general tendency to emphasise
individual factors (e.g. the relationship between emotional states and behaviour), sometimes at the expense
of institutional factors (e.g. limited occupational choice, reduced access to health services). The emphasis on
personal agency in terms of health outcome may lead psychologists and other health professionals to neglect
the role of socio-economic disadvantages in impaired health and well being in BME populations.

Against this backdrop, specific problems exist in gathering information about psychological aspects of FGM. Considerable difficulties exist in recruiting participants due to the sensitive nature of the topic and to language and cultural barriers. Some psychologists may also have concerns about holding strong views of unfamiliar cultural practices or providing interventions in unfamiliar cultural contexts. These and other reasons have made psychological workers relatively silent on the subject of FGM. Ironically, one of the most common questions related to FGM is about its psychological impact.
Whilst it is reasonable to hypothesise that FGM may have adverse psychological consequences, the evidence base at present does not allow us to make a categorical statement. This is not to say that serious consequences do not exist, rather, that major constraints including those outlined below have meant that authoritative studies have not been (and may never be) feasible. Personal testimonies and case studies of course offer important and valuable insight. However they are generally not considered sufficient evidence because we do not know how representative they are of larger populations of girls and women.

Reliability, validity and parsimony

● Findings in FGM research in the UK may be biased towards individuals who are not committed to FGM, not
least because:

• FGM is illegal in the UK; those found involved in its practice could face a fine or prison sentence or
both. It is unlikely that individuals who have engaged in illegal practices would come forward to
participate in research;

• Researchers who are informed about the illegal practice of FGM by research participants are obliged
to report this to the authorities who may initiate child protection work where appropriate. All this
must be made clear to research participants before they give consent to participation;

• There may be situations whereby an individual wishes to but is disallowed to participate.

● Recruitment may be hampered further by contact difficulties, e.g. the lack of a stable address for potential
participants who are seeking asylum.

● The time lag between FGM (typically in childhood) and the manifestation of psychological or mental
health problems in adolescence or adulthood means that women are less likely to link any current difficulties
to FGM. It has been said that “Most of the consequences [of FGM] become evident only several years after
the operation; as a result the connection between cause and effects is not made by all of the women.”
(Source: Gallo, 1985)

● It could be claimed that other sources of adversity, such as difficulties relating to cultural transition, poverty,
social exclusion and other socio-economic factors, provide more salient explanations for mental health
difficulties than FGM per se. Indeed for some women, major struggles in the here and now may render
unimportant a childhood event that is only vaguely remembered.

● In studies where women do recall negative FGM experiences in childhood and offer an estimate of the
impact, these accounts are by definition retrospective and may not be reliable. Furthermore, the increased
public exposure of negative aspects of FGM, or a perception that the study is ‘looking for’ negative
psychological effects, could influence participants’ responses (so called demand characteristics).

Ethical concerns

● Language barriers may necessitate the engagement of interpreters, who may belong to the same
community. This raises ethical issues for confidentiality. Recruitment of English-speaking participants on the
other hand may yield findings that are less generalisable.

● Any effort to encourage participation, which may involve disclosure about third parties, could run into ethical
problems, especially for individuals who are socially vulnerable.

Given these and also resource considerations, the paucity of psychological research in FGM in the UK (and worldwide) is not surprising. Epidemiological studies demonstrating a strong and specific link between impaired mental health and FGM are currently absent. The relative unavailability of psychological reports makes it difficult to comment with confidence on the interaction patterns between mental health and age of FGM, type of FGM, physical consequences of FGM, family support, socio-economic status, and so on.

Nevertheless, the fact that many community workers and groups have been assisting women, girls and families affected by FGM suggests that assistance is needed in some instances. Psychologists have a duty to explore whether they can make a useful contribution to clients and colleagues. On the basis of the experience of the National Clinical Group and the evidence available, the most likely sets of psychological consequences for which psychologists may offer effective assistance include the following, which may inter-relate for some individuals:

• Traumatic stress.
• Sexual difficulties.
• Relationship discord within couples or families.