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.
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.
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.
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.