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.
There are many publications that address issues for psychological practitioners to consider in working with BME clients. The focus of this subsection is specific to the FGM context. Service providers who work with women and families affected by FGM have a duty to familiarise themselves with the issues further. This however is easier said than done. FGM has not been part of the teaching and training curriculum for many health and social care professions. The National Clinical Group has been formed precisely to try and improve this situation. Fortunately, peer-reviewed publications and books on the subject have become more available in the UK. Although more work is needed, these publications are beginning to address some of the information gaps. These are included in the preliminary reading list at the end of the section.

Mental health problems

In a rare controlled comparison, two researchers have recently demonstrated the possibility of post-traumatic stress disorder (so called PTSD) symptoms and FGM. The study compared 23 Senegalese women who had undergone FGM with 24 Senegalese women who had not undergone FGM along dimensions of traumatic stress symptoms and other mental health problems. The two groups were comparable on age and socio-demographic variables and, importantly, experiences of non-FGM traumatic events. The key findings are summarised in the table below. This study provides clear evidence for the association between FGM and mental health problems in general and traumatic symptoms in particular.

Whilst traumatic events do not always lead to PTSD symptoms, symptoms are more likely to develop following events that involve threat of death or serious injury to the person or another person, with the sufferer’s response being marked by intense fear, helplessness or horror. They are also more likely to develop where the traumatic experience gives rise to stigma, shame, guilt or self-hate (e.g. rape). Some of the most common psychological symptoms associated with trauma are: anxiety, hyper arousal, hyper vigilance, nightmares, flashbacks, insomnia, and problems with memory and concentration. These problems often co-occur with depression as well as physical symptoms including headaches, gastrointestinal complaints, aches and pains.

Our clinical experience concurs with a report based on interviews carried out by a clinical psychologist with 55 women in the UK who had undergone FGM (Source: Lockhat, 2004). Thus far it would seem that adverse mental health effects are associated with the following factors:

• Severe forms of FGM.
• Immediate post-FGM complications.
• Chronic health problems and/or loss of fertility secondary to FGM.
• Non-consensual circumcision in adolescence or adulthood.
• FGM as punishment.

By contrast, some of the ‘mitigating’ factors include:

• Post-FGM affirmation and social support.
• Absence of complications short and long term.

In case of problems of traumatic stress, the current evidence suggests that generic counselling is not effective (NICE, 2005). Where symptoms persist, it is important to seek help from specialist practitioners. In terms of symptom amelioration, the discipline of the practitioner (e.g. psychologist or psychiatrist) is less important than having had specialist training and experience in PTSD management.

Women may experience few traumatic symptoms but report other difficulties such as problems of anxiety or low mood. Chronic illness is associated with reduced psychological well being and overall quality of life, and some women may suffer chronic health problems (e.g. chronic pain) left behind by FGM. A number of psychological therapies have been shown to be effective in reducing distress and disabilities associated with chronic ill health and these have the potential to benefit women and girls whose health has been adversely affected by FGM.

Sexuality problems

Some forms of FGM can lead to coital difficulties. Whilst surgical reversal can improve the situation, some women or couples do not wish to undergo reversal and sometimes difficulties are not effectively ameliorated by reversal. For example, as a result of previous experiences of pain during sexual activities, a woman may develop an anxiety response to sexual intercourse or sexual activities in general. Anxiety can hinder arousal mechanisms resulting in vaginal dryness, muscular spasm and painful intercourse despite an absence of anatomical problems. Education, counselling and support can be helpful in these situations.

In addition, incision to any part of the genitalia could potentially compromise sensitivity. Damage to the clitoris in particular is associated with difficulties in reaching orgasm. These problems could lead to a reduction or an absence of sensual pleasure for the woman.

Our clinical observations and a number of small studies available suggest that FGM can lead to the following problems:

• Painful intercourse.
• Difficulties in reaching orgasm.
• Absence of or reduction in sexual desire.

These problems could in turn influence relationships (e.g. relationship satisfaction, emotional closeness) and perhaps fertility.

The psychological issues for younger women who have undergone FGM and are living in Westernised societies may be especially complex. These women (and their partners) are subjected to different discourses of sexuality, discourses that centralise erotic pleasure and frame orgasm as the end point of sex for women and men. Some women may struggle with what are deemed irretrievable losses. Some may experience their circumcised genitals, now deemed ‘different’, as shaming. In these circumstances, it is hardly surprising that the women report very little sexual desire, if not sexual aversion. Feelings of aversion may extend beyond sex to physical closeness or even intimate relationships in general. In other situations, a woman may feel inferior to other women or less entitled to positive relationships, so that she may engage in an unsatisfactory or even damaging relationship which could further diminish her self esteem.

Partners may also experience conflict. For example, some male partners of women who have undergone FGM have expressed their sadness, having come to view the woman’s inorgasmia as a sign of their own lack of sexual potency. Some male partners have also expressed feelings of guilt for experiencing sexual desire towards the woman, knowing that it is not reciprocated by her. In other situations, women presenting sexual difficulties may be devalued in relationships.

Some individuals have opportunities to discuss their difficulties with confidantes within their network of friends and family. Other women (with or without partners) may consult trusted helpers within their own community. Some may prefer to talk to a health professional in mainstream services. Where possible, all of these options should be explored with the individual.

Family conflict

FGM could lead to relationship difficulties within the (extended) family. The procedure is performed primarily on young girls. Small-scale studies with women in the UK suggest that some girls are prepared and agree to the procedure whilst others are taken, typically but not necessarily, to their parents’ country of origin to have the procedure with minimal preparation. They may be told before or after that the procedure was to be a secret, that they and/or their parents would ‘get into trouble’ if the secret were out. Girls who are negatively affected by the experience may exhibit psychological or behavioural difficulties, but these may not be understood at school or within the family. Where FGM has been identified, child protection considerations are of course paramount. However, these situations should also be viewed as opportunities to assist girls and families through education and counselling.

Our experiences suggest that whilst many girls appear to be well adjusted, where opportunities for self expression arose, many teenagers have expressed their outrage at what had happened to them. Regret and blaming may result in relationship discord, for example when an adolescent girl or young woman blames her elders for her loss of bodily integrity. In some households, mothers and daughters may not be on speaking terms. In others, relationships are preserved by avoidance of the topic or by emotional distancing. A girl or young woman who is unable to discuss her problems with friends or family, whether it is due to shame, blame or some other reasons, is at risk of becoming socially isolated and psychologically vulnerable.

Many psychological practitioners are skilled in working with families to develop their optimal solutions. However, psychological help seeking may be a strange concept to some individuals who may prefer to seek advice from within their own community. It is sometimes more appropriate to assist communities who can provide continuing support for their members. In other times, working directly with individuals is more appropriate, though some may need encouragement from within their community to take up offers from mainstream services. Collaboration and partnership between services and communities are crucial in FGM care and prevention.

Clinical considerations

The choice of seeing a female practitioner is crucial. Appropriate reference to the genital cutting should be agreed early on. Suffice it to say that not all affected individuals regard their genital cutting as ‘FGM’. It is important to ask clients what words or terms they would prefer. For some, references to ‘the circumcision’ or ‘the cut’ may be more appropriate. Service providers should, as far as possible, share the vocabularies of those they assist.

When consulting to more than one person, it is important to bear in mind that diverse ideas about FGM may exist and these differences could profoundly influence relationships and alliances. The therapist may invite a range of (sometimes apparently contradictory) ideas about FGM without judgement. Where information is offered on FGM, e.g. pertaining to health or fertility consequences, it should be done with sensitive consideration of the possible impact on the individual and her relationships with those connected to her.

Because psychological therapy is peculiar to Westernised societies, BME clients may especially appreciate clear explanations about roles, remit, duties and obligations. An initial exploration about clients’ relationships to help would seldom go amiss, for example, what is the clients’ understanding as to why she has been referred, what may be some of the meanings for her. Indeed an important task throughout the consultation process is to clarify meanings.

A range of therapeutic modalities may be adapted to assist women, girls and families affected by or at risk of FGM. However, practitioners trained in systemic psychotherapy and trans-cultural therapy may be particularly skilled in building mutual knowledge and understanding with clients. Whatever the theoretical orientation, a deep self awareness on the part of the therapist of his/her own attitudes and beliefs relating to FGM is pivotal.

Work with asylum seekers can have its own challenges. Asylum seeking is itself an extremely arduous process socially and psychologically, even if the individual is in optimal health. Experiences are often marred by disenfranchisement, lack of predictability and controllability and, more often than not, material hardship. In these circumstances the effectiveness of psychological interventions for mental health difficulties can be vastly compromised. In some instances, engagement with structured therapy programmes may not be possible, and emotional containment through community support may be more relevant for a time.


Individuals with minor problems are unlikely to be referred to mental health practitioners, so practitioners who find themselves consulting to people affected by FGM are more likely to witness extreme suffering. These experiences could lead to feelings of abhorrence towards FGM. The enormity of some situations could leave the helper feeling helpless, whilst attempts to find support amongst colleagues may be greeted with blank expression, because few practitioners are aware of care issues relating to FGM. Practitioners who are committed to FGM care and prevention could be at risk of professional isolation, rendering their work unsustainable.

In the UK, all licensed providers of psychological therapy are obliged to receive regular supervision. Supervision is an important context in which to reflect on thoughts and feelings about FGM and how to work effectively and compassionately whilst preserving the client’s dignity. It is also an important context in which to receive support to sustain effort.
The not inconsiderable constraints placed on academic research could mean that many questions about the psychological effects of FGM may remain unanswered for some time, although development of services and prevention strategies should not be predicated on proof of psychological harm.

A range of methods

Even partial attempts at providing answers to some of the questions would require researchers to consider the use of a wide range of methods. Controlled comparisons such as the study cited above are helpful and possible in the UK, within communities where FGM is not universally practised (hence allowing for FGM and non-FGM comparisons to be made). Greater use should also be made of qualitative methods. Qualitative research has developed from different epistemological traditions. The validity of qualitative research is generally not founded on representativeness and replicability. However, it has its own rigour. Furthermore, qualitative methods may be more adept at addressing some questions about FGM. For example, a few years ago, in their FGM study involving 24 Bedouin women in Israel, the researchers made use of both standard questionnaires and qualitative interviews. Responses to the questionnaires from women who had experienced circumcision were characterised by legitimization and cognitive rationalization about FGM. In the semi-structured interviews, however, the same women reported traumatization and emotional difficulties and offered accounts that were suggestive of subsequent difficulties in mother-daughter relationships and diminished abilities to form trusting relationships (Source: al-Krenawi & Wiesel-Lev, 1999). Some of the observations could not have easily surfaced in questionnaires offering pre-conceived response categories.

The effectiveness of professional services, including educational efforts, could be significantly enhanced by improvement in knowledge about psychological aspects of FGM via research. In turn, practice experience could contribute to the formulation of research questions and hypotheses. With that in mind, a few themes for future work are tentatively suggested.

Knowledge and beliefs about FGM

A recent study of beliefs about FGM involving a large number of male and female university students in Khartum represents an interesting example about the type of research that may be feasible in the UK, with findings of the kind that could be of interest to education programmes and may influence parental decisions about circumcision for their daughters. Results were based on a high response rate of 82.8% and the key findings are summarised in the table below:

The small percentage of students who relate FGM practices to religion suggests that the message may to some extent have successfully filtered through to the educationally privileged sectors of the populations. At the same time, it is alarming that close to one in five men continue to believe in the myth! What is significant is that close to half of the students were not aware of the fact that FGM was illegal. Again, men appear to be less well informed than women. What is also significant is that the majority of these women no longer subscribe to the belief that FGM would increase marriage prospects and the majority of men did not prefer circumcised women, at least on paper.

In collaboration with target communities, more attempts could be made to assess knowledge and beliefs about FGM in the UK. Such work could lead to interesting observations and help services target their educational effort. A range of methods might be developed to explore variations in beliefs and practices within a given community, their perceptions of professionals and their interventions, their preferences for informal and formal help, and so on. Likewise, assessment of health and social care professionals’ knowledge and skills could make training effort more appropriate and effective.
There remain considerable difficulties in investigating the relationships between FGM practices and experiences and subsequent psychological well being. Despite that, small studies, qualitative analyses, personal accounts and clinical observations suggest that first of all, FGM under a number of circumstances could have enduring traumatic effects and/or lead to sexual difficulties, which could reverberate on relationships and overall quality of life. Furthermore, a number of studies have demonstrated that with sensitivity and awareness, collaborative psychosocial studies with individuals, communities and health professionals are possible. This work has the potential to further our understanding about FGM issues in the UK context, thereby enhancing the quality of community and statutory services.

Content of this section represents an integration of Lih-Mei Liao’s clinical experience at the African Women’s Clinic at University College London Hospitals and her discussion papers:

● Liao LM. ‘Female Genital Mutilation: Psychological Implications’. Papers presented at Development Support
Agency Regional Conferences on Female Genital Mutilation & Mental Health, County Hall, London,
21 November 2005, and St James’ Hospital, Leeds, 10 February 2006.

● Liao LM. ‘Health Psychology’. In: N Patel, L Bennett, M Dennis, N Dosanjh, A Mahtani, A Miller & Z Nadishaw
(Eds.) Clinical Psychology, ‘Race’ and Culture: A Training Manual. Leicester: British Psychological Society Books
(2000), pp160-167.