Abstract
Background
Female genital mutilation (FGM) is a traditional practice that involves either partial or total removal of female genital organs for non-medical reasons. Research evidence indicates that FGM has no health benefits, whereas the list of its detrimental impacts may be extensive. As a result of international efforts to put an end to the practice, the prevalence of FGM has decreased in many countries. Nevertheless, millions of girls and women remain affected.
Aim
To review evidence on the FGM-related health consequences and evaluate the effectiveness of anti-FGM awareness-raising interventions.
Methods
A critical narrative literature review approach is implemented to evaluate the outcomes of female circumcision, as well as the contexts and effects of interventions described in six empirical studies.
Findings
The review results demonstrated that FGM is associated with such adverse long-term health problems as urinary tract infections, sexual dysfunction, obstetric complications, and depression. The analysis of interventions revealed that multifaceted, community-based education and communication programs can lead to changes in attitudes to FGM and, thus, they can be regarded as promising preventative tools.
Conclusion
The findings indicate that to facilitate FGM prevention progress, interventions should be designed to fit specific community interests and needs. Future policy and research should focus on the realization of contextualized FGM prevention campaigns and the improvement of the healthcare system’s response to the needs of FGM victims.
Introduction
FGM, also known as female circumcision, puts at risk the health and welfare of millions of girls and women across the world. Over the years, global efforts to prevent FGM have significantly intensified, and the prevalence of this health condition has decreased in many countries (Kandala et al. 2018). Nevertheless, considering that millions of individuals continue to be affected (Kandala et al. 2018), there is a need to develop and implement effective and efficient strategies that would put the practice of FGM to an end. Thus, the purpose of this paper is to examine the health consequences of FGM and evaluate interventions that are currently used to prevent the practice and respond to the needs of its victims.
The study is divided into four major sections: Background, Methodology, Critical Appraisal, and Discussion. The first one contains a brief overview of the main definitions of the selected problem, statistical data on the prevalence of female circumcision in different regions, existing international policies and prevention strategies, risk and preventative factors, and most common FGM interventions. The Methodology section covers the issues related to the design of the present study, the search strategy used to locate core sources for the literature review, data analysis tools, and ethical considerations.
The Critical Appraisal provides an overview of the selected empirical studies following the Critical Appraisal Skills Programme (CASP) framework and includes information on their aims, methods, major findings, and implications. Lastly, the Discussion section analyses the findings of the literature review in greater depth and compares them to evidence from other credible sources to outline recommendations for future policy and research of FGM interventions.
Background
Definitions
FGM is a procedure that involves the partial or total removal of the external part of female genital organs for non-medical reasons. The World Health Organisation (WHO 2018) distinguishes four different types of FGM, varying in terms of their intensity and severity. Type 1, clitoridectomy, is the removal of the clitoris; type 2, excision, – the removal of the clitoris and labia minora; type 3, infibulation, – the narrowing of the vaginal opening by making a covering seal through the reposition and cutting of the labia minora (WHO 2018).
Lastly, type 4 refers to such minor yet harmful procedures as piercing, incising, and others (WHO 2018). Different types of FMG are usually carried out on girls throughout infancy, childhood, and adolescence, whereas adult women are exposed to FMG rarer. For this reason, the procedure is often performed on an individual without her consent.
FGM is often performed by people who have no medical background. As stated by Odukogbe et al. (2017), older women often play roles of the so-called circumcisers or cutters and they work either at the house of girls and women or in specialized circumcision centers. Some communities allocate this job to males and, in particular, barbers because they have the skills needed to work with cutting tools (Odukogbe et al. 2017). It is worth noticing that the procedure is frequently performed by insufficiently sterilized and non-professional instruments, such as kitchen knives, sharpened rocks, and so forth (Odukogbe et al. 2017). This factor puts the health of girls and women at greater risk.
Incidence and Prevalence
As Kandala et al. (2018) state, over 200 million women and girls have undergone this procedure worldwide. Its use is most widespread in some regions of Africa and the Middle East but not limited to them. Kandala et al. (2018) note that FMG is also practiced in many Asian countries (including Malaysia, Thailand, and India) and extends to Europe, as well as North and South America, primarily due to immigration.
For example, among immigrant women living in Portugal, there may be more than 6,500 individuals, age 15 and older, as well as 1,830 girls under the age of 15, who had FGM in 2016 (Odukogbe et al. 2017). Overall, approximately 69% of female immigrants from Somali, and 32% of Kurdish immigrants living in developed countries have been circumcised (Odukogbe et al. 2017). Considering that FGM affects even the western countries where it is outlawed, it may be regarded as a problem of the global scope.
In general, statistical data demonstrate a downward trend in the incidence of FMG in many African and Middle Eastern countries. Koski and Heymann (2017) claim that the smallest number of women (5%) undergo FMG in Niger, Tanzania, Togo, Benin, and Uganda, while the practice continues to be universally applied in Guinea, Mali, and Egypt with over 90% of affected females, age 15-49.
When it comes to FGM among children, the prevalence dropped from 71% in 1995 to 8% in 2018 in East Africa, from 57% in 1990 to 14% in 2015 in North Africa, and from 73% in 1996 to 25% in 2017 in West Africa (Kandala et al. 2018). The decline in the international prevalence and incidence of FMG is a positive trend, but it is still a pervasive problem for a large proportion of women.
International Policy and Strategies Aimed to Counteract FGM
An extensive body of research evidence makes it clear that FMG does not have any health benefits, whereas the list of its detrimental effects is very long. The potential immediate health problems due to the procedure may include infection, hemorrhage, urinary problems, severe pain, shock, and death (WHO 2018; Koski & Heymann 2017). Among the long-term complications, there are sexual dysfunctions, menstrual problems, increased risk of childbirth complications, and various psychological conditions, including depression and anxiety (WHO 2018). For this reason, FGM is regarded internationally as a form of discrimination against women and a violation of human rights for health and physical integrity (Khosla et al. 2017).
Moreover, as the policy statement by the World Confederation for Physical Therapy (2017) suggests, not only does it infringe the UN Convention on the Rights of the Child but also conflicts with the core healthcare principle of nonmaleficence. Thus, it is valid to say that medical practitioners who carry out FGM, being aware of the serious health consequences it induces, violate fundamental principles of professional and ethical conduct.
A plethora of international health organizations, including WHO, United Nations International Children’s Emergency (UNICEF), United Nations Population Fund (UNFPA), and many others, strongly oppose the performance of FGM in all forms. These three organizations were the major actors in the efforts to eliminate the harmful practice of genital cutting worldwide and work, both jointly and independently, to reduce the exposure of women and children to FGM-related risks. Since 1997, they have encouraged research of negative health effects of the procedure, actively engaged in the development of public awareness about the problem, and advocated for policy change at the international, national, and sub-national levels (WHO 2018).
The UNFPA-UNICEF Joint Programme can be regarded as the main international strategy aimed at the elimination of FGM. It is based on the human rights approach and collaboration with social and national agents, especially in the countries where FGM was and remains a traditional practice (UNFPA & UNICEF 2014). As a result of this program, as well as advocacy efforts undertaken by many other international activists and stakeholders, some African and Middle Eastern states passed and amended the laws criminalizing FGM (for example, Sudan and Uganda) and increased the national spending for combating the problem of genital cutting among women (UNFPA & UNICEF 2016). Nevertheless, many communities continue to practice FGM and show no or limited willingness to abandon it.
Risk and Preventative Factors
The factors contributing to the practice of FGM are mainly social-cultural. In many African and Middle Eastern states, the procedure considered a social standard closely linked to a broader social norm of allocating gender roles and behaviors. As stated by WHO (2018), it is considered an essential part of bringing up a girl and is meant to prepare her for adulthood and marriage. Many cultures where FGM is widespread see it as a way to ensure premarital virginity and marital fidelity (WHO 2018).
Moreover, although holy scriptures do not prescribe the practice, some people tend to connect FGM to religion as the removal of body parts that are believed to be unclean and associated with immoral behaviors emphasizes such qualities as modesty and feminine beauty (WHO 2018). It means that being raised in a culture that regards genital cutting as a long-term tradition, a person is automatically at risk of undergoing the procedure and experiencing a wide range of unfavorable health consequences as a result of a need to conform with the social and cultural behavioral demands.
It is also valid to say that in the social-cultural environments encouraging FGM, people pay less attention to or are poorly informed about the potentially detrimental effect of the practice. As the results of the study by Mohammed, Seedhom, and Mahfouz (2018) reveal, 37.1% of women living in a rural area in Egypt had poor knowledge of how badly the practice affects girls’ health and overall well-being. For this reason, better access to health-related information may be considered a significant preventative factor to the problem. Besides, laws and policies banning FGM play an essential role in the prevention of the potential negative health consequences of the practice considering that many people would want to avoid being convicted and imprisoned after performing the procedure.
Nevertheless, in the same study by Mohammed, Seedhom, and Mahfouz (2018), a significant percentage of women showed the willingness to practice FGM even knowing about its unfavorable impacts on health (57.9%) and its illegal status (55%). These findings indicate a pivotal role of cultural values in defining one’s health-related behaviors. Thus, to prevent genital cutting among women, it is necessary to develop policies and educational programs that would be culturally sensitive and would address stakeholders’ prior knowledge, experiences, and psychological states.
Interventions
Two primary themes in interventions aimed at the prevention of FGM can be distinguished: awareness-raising and empowerment of professionals. The former type can take place at any level, starting from policymaking to individual cases. Awareness-raising implies informing stakeholders and especially the members of the population at risk about the effects of FGM to reduce their willingness to recommend this procedure to their daughters or undergo it voluntarily (Smith & Stein 2017).
At the national level, the realization of such an intervention would frequently involve the use of traditional media, including television and radio, which allow reaching the general public effectively (Baillot et al. 2018). At the community level, it may take the form of educational programs arranged and implemented by non-governmental bodies and public institutions like hospitals and schools. At the individual level, it is performed by healthcare and social work practitioners who educate women at risk about FGM impacts on health during personal and group conversations.
The second type of intervention â empowerment of professionals â implies a training of healthcare providers, educators, and social workers about FGM and connecting them to the families and communities affected by or at risk of FGM (Baillot et al. 2018). Noteworthily, particular attention is now paid to informing healthcare practitioners about the health needs of patients living with FGM and the improvement of their abilities to render high-quality care and counseling to those women.
At the policy level, various organizations, including UNICEF and WHO, create practice guidelines and educational tools for practitioners to fill in the gaps in their knowledge of this health condition (WHO 2018). However, this type of intervention is closely interrelated with the first one with the primary difference that it emphasizes the role of individual professionals in the prevention of FMG. It implies that they can engage in information sharing and advocacy at multiple levels, primarily focusing on work with communities and families.
Health Promotion Theory
The Health Belief Model (HBM) is closely related to the discussed preventative interventions for FGM. It focuses on individuals’ health beliefs and values that drive their health-related behaviors and choices. The key HBM concepts include perceived susceptibility to an adverse health condition, perceived severity (belief of consequence), perceived benefits of performing an action or avoiding it, cues to action (existence of environmental factors that prompt certain behaviors), and self-efficacy (belief in the ability to attain positive outcomes) (Rural Health Information Hub n.d.).
It is valid to say that the discussed awareness-raising interventions target and consider all these concepts. For instance, the provision of information regarding the detrimental effect of FGM increases perceived severity, whereas advocacy for the development of laws against the practice is a favorable factor for making individuals refuse to perform female circumcision. At the same time, the ultimate goal of these interventions is to create an environment that would be free of any threats to women’s health and in which women with FGM would become more confident in their ability to receive high-quality care and manage their condition better.
Methodology
Literature Review
The major research method utilized in the present research project is a narrative literature review. It can be defined as a critical and objective evaluation of up-to-date evidence of the topic of interest. The major purposes of the literature review are to contribute to the development of theories, identify links and relational patterns among different variables and trends detected in academic and professional sources, as well as gaps and inconsistencies in the available information (Charles Sturt University 2019). Along with the HBM theoretical framework, this method will provide a reference point for the interpretation and conceptualization of existing research evidence on the effects of FGM.
Search Strategy
The PICO framework was used when designing a search strategy for the literature review. PICO stands for Population, Intervention, Comparison, and Outcome. Considering this, the main search keywords included women with FGM (P), education and communication interventions (I), and health consequences (O). Besides, since the present study aims to evaluate the effects of female circumcision, the health outcomes in the target population will be compared to the outcomes in non-FGM women (C). Two separate initial search phrases were used: “health consequences of female genital mutilation” and “female genital circumcision and education intervention” The selected keywords allowed locating the eligible articles and, therefore, no alternative words were required.
The search strategy diagram for outlining the process of findings necessary articles by using the second phrase: âfemale genital circumcision and education interventionâ is provided in Appendix 2. During the identification limiters for publication date, full-text, and peer-reviewed articles were implemented. The expanders in one of the databases were as follows: âapply related words,â âalso search within the full text of the articles,â and âapply equivalent subjects.â
However, the Boolean operators (OR, AND, NOT) were not used but, to improve the search outcomes and reduce time, it could be appropriate to apply them as well. These operators serve to connect the selected words and expand or narrow down the search. Noteworthily, they may be utilized to connect not only keywords but also other types of relevant information, including publication year, author names, and article titles.
Therefore, the utilization of Boolean operators is especially beneficial when focusing on the search or looking for a specific study. However, many databases have search limiters/filters (for instance, year, type of source, and others), as well as expanders/truncation. In general, they have the same purpose of narrowing and expanding the search like the Boolean operators. Either of them largely facilitates the process by helping to see either more or less search items.
EBSCO and PubMed databases were chosen for the search because they contain a large number of full-text, high-quality, peer-reviewed articles that can be accessed freely. Thus, convenience and quality were two of the primary criteria for the selection of the databases. A detailed list of inclusion and exclusion criteria for selecting core articles is given in Appendix 1. In brief, studies published during the period between 2006 and 2019, focused on the comparison of health outcomes in FGM and non-FGM populations, and the evaluation of education intervention effects was considered eligible. At the same time, secondary studies and literature reviews, as well as studies published before 2006, were excluded.
Overall, considering that the scope of the present paper is relatively broad and it aims to explore different aspects of FGM prevention and response, the implemented search strategy was appropriate and successful. Nevertheless, more databases could be searched to find additional sources and expand the variety of articles to choose from.
CASP Tools
The CASP tables used in the present study are meant to evaluate the scientific rigor of core articles. They include several questions aimed to summarise research methods implemented by the authors, major research objectives, findings, and implications. Overall, these tables help to systematize information and largely facilitate the identification of similarities and differences in the ideas described in the sources. Moreover, they assist in measuring the validity, reliability, and generalisability of studies.
Reliability is a degree to which research results are consistent when repeatedly tested (Al-Jundi & Sakka 2017). It is identified through critical appraisal of data collection and analysis tools and methods. Generalisability is an extent to which findings can be applied to wider population groups (Al-Jundi & Sakka 2017). To examine this quality, the analysis of sampling methods is particularly important.
Lastly, internal validity is a degree to which analysis tools measure what they are intended to measure (Al-Jundi & Sakka 2017). It is identified by evaluating the soundness and accuracy of chosen test measures. The analysis of these three research features is an essential part of the critical appraisal process.
The CASP framework also helps to compare different study designs associated with a distinct quality of evidence. For instance, randomized controlled trials (RCTs) are regarded as the gold standard in research because they involve the comparison of interventions and control treatments and provide new evidence on side effects, efficacy, and safety (Movsisyan et al. 2018). Random allocation of study participants in intervention and control groups minimize selection bias, whereas double-blinding reduces interpretation bias.
The main weakness of this design methodology is that the experimental conditions in RCTs usually differ considerably from real-life situations. Nevertheless, they still often provide stronger evidence than observational research designs, such as cohort and cross-sectional studies associated with a lower level of rigor. In cohort studies, two groups of a population (exposed and unexposed to a certain factor) are evaluated for an extended period and frequently allow measuring multiple outcomes for a single exposure. However, they are usually more prone to confounding bias compared to RCTs.
Cross-sectional studies imply the collection of data in a single point of time and, thus, allow describing certain characteristics of the population and phenomena, as well as the prevalence of factors. However, they are incapable of measuring the incidence and prone to multiple biases. Moreover, in such studies, it may be difficult to establish causal associations and interpret them.
Research Ethics
The selected studies were conducted following ethical principles and standards. The responsibilities of medical researchers include the protection of life, dignity, integrity, and confidentiality of human subjects (Masic, Hodzic & Mulic 2014). It means that research cannot be conducted when risks to participants’ well-being considerably outweigh the potential benefits of study outcomes. It is valid to say that such unethical actions of researchers as disclosure of sensitive information and investigation of subjects without their consent not only harms participants but is also detrimental to the overall image of scientific research and is in conflict with its mission.
As a result, the findings of unethical research may be perceived as less valuable. Additionally, when researchers violate publication ethics (for instance, when their studies lack transparency, when other authors are plagiarised and not acknowledged, and when data is fabricated), the trustworthiness of findings significantly decreases (Masic, Hodzic & Mulic 2014). Thus, to attain credible results during the secondary research, it is essential to make sure that all of the sources included in the literature review conform to ethical principles.
Critical Appraisal
Education Interventions
An RCT by Babalola et al. (2006) had an objective to describe a multimedia communication program, Ndukaku, aimed to raise the awareness of FGM effects and encourage community members to end the practice. The study evaluated the impacts of the program on individuals’ knowledge, behaviors, and perceptions. Data was gathered by using cross-sectional surveys in July/August 2003 (baseline) and September 2004 (follow-up) in the Nigerian Enugu State (intervention sample) and Ebonyi State (control sample).
Babalola et al. (2006) randomly selected 100 households in which eligible men and women (aged 18-59) were invited to participate. The intervention group consisted of 484 respondents during the baseline survey and 454 â during the follow-up survey, while the comparison group included 473 and 517 individuals respectively. 35-48% of participants were males, 67-79% were employed, 28-39% had a secondary education level, or higher. 66-84% of female respondents in all samples had undergone FGM.
Babalola et al. (2006) analyzed data in terms of the following ideational predictors: belief in the benefits of FGM, personal approval of the practice, perceived ability to resist external pressures to perform FGM, and perceived community willingness to abandon FGM. Additionally, the researchers measured participants’ intentions to not perform FGM on their daughters. Post-intervention results as per the mentioned ideational predictors showed significant improvement in Enugu, whereas the situation remained the same or worsened in Ebonyi.
Babalola et al. (2006) noted that the use of the logistic regression model that involved the ideational predictors had higher predictive power than a model with socio-demographic variables alone, and this may be regarded as the strength of the study. The researchers also stated that such communication programs as Ndukaku can foster changes on the policy level by increasing the number of anti-FGM advocates and encouraging the adoption of new laws against the practice.
The aim of another study conducted by Graamans et al. (2019) was to evaluate the effectiveness of the Alternative Rites of Passage (ARP) program implemented by Amref Health Africa with a purpose to end FGM in Kenya. The ARP is an alternative to standard educational interventions that are sometimes associated with cultural clashes and negative perceptions by community members. The ARP encourages to substitute of FGM with other harmless practices that would also symbolize a girl’s transition to womanhood. Graamans et al. (2019) had objectives to identify major barriers to this anti-FGM intervention and propose some ways to cope with those barriers efficiently. They implemented an observational, qualitative research design (phenomenology), focusing on the subjective experiences of major stakeholders involved in the intervention.
The researchers carried out 94 in-depth interviews with the members of the Maasai and Samburu communities in 2016, and the data collection process lasted for one month. The participants were recruited by using the maximum variation sampling and, thus, were highly diverse in terms of demographic characteristics. The final sample included both male and female children, adults, and elderly that played different roles in the community, as well as representatives of the local organizations, activists, foreign diplomats, journalists, and other stakeholders. Moreover, Graamans et al. (2019) gathered Amref Health Africa records of data about the organization’s efforts to abolish FGM. All the collected information was consequently analyzed through a discourse-analytic approach and a cultural psychological approach.
Graamans et al. (2019) identified five reasons for non-adherence to anti-FGM interventions: perceived risk of exclusion, perceived culture clash, lack of program contextualization and consideration of individual community interests, lack of credibility, and stereotyping of people who practice FGM. The value of these findings is in their applicability to the design of more balanced and effective strategies. They prompt the involvement of more community insiders, the creation of education curricula emphasizing the matters of Maasai culture, and so forth. The weakness of the study is the lack of quantifiable data to support the researchers’ major arguments.
The aim of the study by Galukande et al. (2015) was to evaluate the effectiveness of an education campaign targeted at the eradication of FGM in a rural, Tanzanian community. The objectives were to assess the level of knowledge about FGM-related risks among participants, their attitudes to the practice before and after the intervention, as well as the overall prevalence of FGM in the community.
It was a mixed-method, observation study: the cross-sectional survey was utilized to obtain quantitative data (the attainment of benchmark indicators) and interviews were conducted to evaluate the contextual situation. An 18-month intervention commenced in 2013 in Arusha, Tanzania, and included such activities as community dialogue sessions, sharing of information regarding FGM-related health risks with local leaders and circumcision practitioners, youth training, and so forth.
The sample comprised 675 households, which were randomly approached by 14 enumerators in 26 different sub-villages. In those households, 1139 individuals (675 females and 464 males) were selected by using the Kish grid technique. The mean age of female participants was 34 and of male participants â 43; only 51% of women and 55% of men involved in the study finished primary school, while others had no education. Additionally, Galukande et al. (2015) conducted interviews with key informants (a health worker, a community leader, a project coordinator, and others), as well as children in local schools. The data were collected before and after the implementation of the intervention.
It was revealed that the education campaign helped to improve the level of knowledge about FGM risks among the participants and resulted in a considerable shift in community members’ attitudes towards the practice.
Nevertheless, it is not clear whether substantial changes in individual behaviors and FGM prevalence were attained. Noteworthily, there was no control group and, thus, the effects of the intervention could be overestimated, which is the major weakness of the study. Moreover, some respondent bias could take place due to language barriers and social-psychological factors. Galukande et al. (2015) concluded the discussion by emphasizing the need to engage community leaders in the interventions and improving the competence of educators delivering them.
A longitudinal before-after study by Asekun-Olarinmoye and Amusan (2008) was dedicated to the topic of FGM education as well. It aimed to identify factors supporting the practice of FGM and the most common types of FGM in a Nigerian Shao community, and evaluate the impacts of an educational intervention on the members of that community. The study comprised three stages: pre-intervention, intervention, and post-intervention (after 12 weeks).
During the first and the last stage, data were collected through structured interviews and questionnaires aimed to capture participants’ attitudes to FGM and future intentions to practice it. During the intervention stage, the study population was exposed to educational sessions on FGM and its health effects for 10 days. Health talks covered such topics as female anatomy, practice-related complications, and the role of health beliefs. Additionally, in-depth interviews were carried out with two traditional circumcisors found in the community to clarify their perception of FGM and details about their profession.
The optimal sample size was calculated by using the Leslie Fishersâ formula and respondents were then randomly selected from 40 ancestral compounds located in the Shao community. The majority of participants were females; the mean age of respondents was 30-39 during pre-intervention and 20-29 years in the post-intervention sample. 71-72% of participants had formal education and a vast majority (63-67%) were Christians.
The findings revealed an 88% prevalence of FGM in the Shao community and a larger number of respondents who had their daughters circumcised had no formal education. Younger and more educated individuals tended to disapprove of FGM, whereas males were found to support the practice more. However, after the intervention, the percentage of male and female respondents disapproving of FGM increased from 35.2% to 71.3% and from 49% to 69.1% respectively. Asekun-Olarinmoye and Amusan (2008) identified such study limitations as responder-bias and the lack of a control sample yet stated that research results can be used when designing FGM education programs for the analyzed community and recommended to focus on the role of males in fostering the desired change.
Analysis of FGM-Related Health Effects
The main aim of a cross-sectional study by Andro, Cambois, and Lesclingand (2014) was to identify adverse physical and psychological effects of FGM by comparing the health indicators of women who underwent the procedure (n = 678) with those who did not (n = 1706). The research took place in multiple regions of France, and participants were recruited in mother-and-child health centers and hospital departments rendering gynecological care and family planning services.
Data collection lasted for two years (2007-2009), and the researchers used medical records, personal interviews, and a survey designed to investigate links between FGM and different aspects of health. The interviews were conducted without knowing if a participant had FGM or not to ensure equal treatment of both cases and controls. The FGM status was reported in the survey, and FGM and non-FGM populations were grouped consequently based on the self-reported data and back-matched.
A significant number of cases and controls were immigrants (n = 1944) and under 30 years old (n = 1263). 816 women were single, 1393 were married, and 175 â divorced or widowed; 203 women had no education, while the majority attained either secondary or tertiary education levels.
Andro, Cambois, and Lesclingand (2014) identified that FGM is associated with poor self-perceived health, gynecological and urinary infections, sexual dysfunction, pain, psychological and sleep disorders. However, the researchers failed to establish clear links between the severity of symptoms and different types of FGM, stating that further research of this problem is required. A notable limitation of the study is the likelihood of respondent bias. Moreover, the sample may be non-representative of the target population. However, the case-control design increases the reliability of study results that emphasize the need to develop alternative strategies for providing care to women with FGM.
Another study devoted to the investigation of the same issue was conducted by Pastor-Bravo, Almansa-MartĂnez, and JimĂ©nez-Ruiz (2018) with a purpose to evaluate the health consequences of FGM and the effectiveness of healthcare services received by 14 patients with this condition during pregnancy, childbirth, and postpartum. The researchers implemented a qualitative methodology with a phenomenological approach to analyze the subjective experiences of respondents.
The main data collection tools were open-ended personal interviews, socio-demographic questionnaires, and life histories focused on the question: “How has female genital mutilation affected your life and health” (Pastor-Bravo, Almansa-MartĂnez & JimĂ©nez-Ruiz 2018, p. 121). The total sample (n =14) comprised women between 23 to 41 years of age, with FGM types 1 and 2, who migrated from Senegal, Nigeria, and Gambia and lived in Murcia, Spain, at the moment of study. Three participants were approached in the local African associations, while the rest of the respondents were selected through snowball sampling.
Pastor-Bravo, Almansa-MartĂnez, and JimĂ©nez-Ruiz (2018) identified a plethora of complications due to FGM, including recurrent urinary infections, pain, depression, sexual health issues, a greater need for cesarean deliveries, and other problems. Overall, the respondents were satisfied with the healthcare services they received during pregnancy in Spain. Nevertheless, care providers failed to educate these women on FGM-related matters and general health, which may indicate the lack of professionals’ awareness of the condition and transcultural communication skills.
The findings of the study can be used to enhance healthcare for women with FGM. Nevertheless, its main limitations are the subjective nature of data and the use of interpretative analysis associated with respondent and researcher bias. Moreover, the sample size was small and limited to three African nationalities. Therefore, the findings may do not apply to other population groups.
Discussion and Recommendations
The major themes that emerged from the critical appraisal of the six core articles are the detrimental effects of FGM on women’s health and their implications for care providers’ practice, educational interventions, and change in attitudes to FGM, as well as factors defining the effectiveness of FGM education, awareness-raising, and culturally-sensitive community-based campaigns. These themes are key to the understanding of what constitutes the basis of effective FGM interventions aimed at both the prevention of and the response to the problem. The findings of the reviewed articles will be synthesized in this section of the dissertation and their significance to policymakers and future research projects will be discussed in detail as well.
FGM-related Health Consequences and Need for the Healthcare System Response
The studies by Pastor-Bravo, Almansa-MartĂnez, and JimĂ©nez-Ruiz (2018) and Andro, Cambois, and Lesclingand (2014) revealed that women with FGM experience a plethora of diverse health complications that can be either physical or psychological. When speaking of long-term adverse consequences, the researchers identified urinary tract infections, sexual dysfunction, childbirth complications, and depression as the most common.
These observations are consistent with the findings obtained in other studies. For example, in their cross-sectional study of sexual function in 107 Sudanese women who underwent circumcision, Rouzi et al. (2017) showed that 92.5% of participants had low scores in such domains as arousal, satisfaction, and orgasm, and also reported pain during intercourse. Moreover, Rouzi et al. (2017) demonstrated that the severity of FGM is positively correlated with the intensity of symptoms.
Additionally, in a prospective cohort study focused on the investigation of birth outcomes in Ethiopian women with FGM, Gebremicheal et al. (2018) revealed that circumcised females are at increased risk of such birth complications as obstructed labor, perineal tear, and postpartum blood loss. Similarly to Pastor-Bravo, Almansa-MartĂnez, and JimĂ©nez-Ruiz (2018), Gebremicheal et al. (2018) indicated that women with FGM more frequently require a cesarean section than non-FGM women. Moreover, the researchers also indicated that more extensive types of FGM are associated with greater obstetric risks.
When it comes to psychological effects of FGM, they were studied in the research conducted in the Netherlands by Knipscheer et al. (2015) who revealed that Somali women whose memories about the circumcision process were vivid tended to show more severe symptoms of post-traumatic stress disorder and depression, and frequently used negative coping mechanisms, such as substance misuse.
Nevertheless, Knipscheer et al. (2015) also noted that while a significant portion of the study participants had some mental health problems, they did not meet the psychopathology criteria. To a large extent, it can be explained by the fact that a lot of women of Somali origin, including immigrants living in Europe, regard FGM as a norm and, thus, cope with traumatic experiences linked to the procedure relatively well.
Though findings on psychological effects of FGM, including pain, are subjective and can be associated with respondent bias, they nevertheless have multiple implications for future policy and research along with the results of circumcised women’s objective health assessment. First of all, Pastor-Bravo, Almansa-MartĂnez, and JimĂ©nez-Ruiz (2018) and Andro, Cambois, and Lesclingand (2014) stated that there must be an alternative approach to the health of women living with FGM, considering the discomfort they may experience in their daily lives due to their health condition, as well as the overall extended list of health risks to which they are exposed.
Thus, healthcare practitioners should be trained to address the needs of the target population effectively. Noteworthily, it is particularly important to provide education for medical professionals working in the countries where FGM is outlawed and was never embedded in culture since, without the experience of dealing with FGM patients, those practitioners may fail to acknowledge all their special needs and render appropriate care.
Such organizations as the WHO publish guidelines for the management of health complications from FGM and encourage health practitioners to enhance their knowledge of the issue. According to Elliott et al. (2016), even brief training for healthcare practitioners on the matters of female circumcision can significantly increase their awareness of the experiences linked to FGM and the problems that women who had been cut can face. As a result of such short education, professionals may become able to respond to patients’ needs more efficiently.
Nevertheless, FGM training for medical specialists is still not widespread in many European and other countries of migration, including the United States and Australia, as they lack FGM coordination and monitoring systems and do not have funding allocated specifically to this problem (Johansen et al. 2018). Thus, it is valid to presume that to accelerate the development and implementation of policies focused on the management of FGM-related health effects and improve the response of healthcare systems in different regions, it is pivotal to conduct more research on the effectiveness of education programs for medical practitioners and impacts of professional training on the quality of services for the target population.
Additionally, to devise efficient care systems for patients with FGM, Knipscheer et al. (2015) indicate a need to examine the contextual factors that affect the decisions of circumcised women to utilize services. It is suggested that both prevention and clinical efforts must take into account individuals’ unique health-related behaviors and also consider that many women with FGM may be hesitant to seek help, especially the psychological one (Knipscheer et al. 2015). Moreover, rigorous research on various adverse health consequences of FGM should continue in the future as well because the findings can be used to inform the design of training and education programs for medical specialists, communities, and individual patients.
Educational Interventions and Change in Attitudes to FGM
The reviewed core studies by Babalola et al. (2006), Galukande et al. (2015), and Asekun-Olarinmoye and Amusan (2008), which were dedicated to the evaluation of education interventions, revealed that the sharing of information about women’s health helps to improve individuals’ awareness of adverse FGM impacts and to shift their attitudes to the practice from approval to disapproval.
However, even though many participants in the appraised studies reported that their motivation to abandon the practice increased the researchers were not able to capture if the changes in attitudes translated into behavioral changes and whether interventions could indeed reduce the FGM prevalence due to methodological limitations.
There is a probability that the findings presented in the selected articles were prone to the bias inherent with self-reporting data collection tools and the positive effects of interventions were overstated. For instance, Galukande et al. (2015) noted that the self-reported rate of FGM was 69.2% in their study, while the results of obstetric examinations showed a 96% rate.
In the systematic review of six RCTs conducted in different African countries, the Norwegian Knowledge Centre for the Health Services (NKCHS 2009) also noted that the number of controlled before-and-after studies dedicated to the problem was scarce in the available literature pool, and the methodological quality of many research publications that they located was weak. The NKCHS (2009) concluded that education interventions targeted at female students had led to small changes in their knowledge and attitudes to FGM, while multifaceted education interventions aimed at community empowerment could lead to more positive results.
The latter observation is consistent with evidence regarding the moderate and significant positive effects of educational interventions on community members’ attitudes to FGM provided by Galukande et al. (2015), Babalola et al. (2006), and others. However, the NKCHS (2009) raised doubts about the trustworthiness and validity of findings included in their systematic review, which means that more rigorous research on the effectiveness of FGM education should be done.
Feldman-Jacobs and Ryniak (2006) and WHO (2018) also suggest that well-designed education interventions can help to raise awareness of FGM and result in some attitudinal shifts. Nevertheless, they state that education alone is usually not enough to attain substantial changes since FGM is a complex problem that involves multiple factors of a different character. Feldman-Jacobs and Ryniak (2006) state that behavioral change programs not only must convey the right messages but also include skill-building elements. Therefore, strategies aimed to end FGM should be comprehensive and appropriately contextualized.
Factors of Intervention Effectiveness
The evidence from the core articles prompts some ideas about factors that define individuals’ positive or negative perceptions of FGM and ensure better effectiveness of educational interventions. The works by Asekun-Olarinmoye and Amusan (2008) and Graamans et al. (2019) were especially informative in this regard. Evidence from the former study suggests that educational status and age are positively correlated with one’s attitude to FGM.
he findings of a study by Van Rossem, Meekers, and Gage (2016), who analyzed married women’s attitudes to circumcision based on data derived from the Egypt Demographic and Health Survey throughout the period between 1995 and 2014, support the assumption that poorly educated individuals tend to support FGM more, whereas those with the highest level of education resist the practice most. At the same time, their study does not provide evidence for the links between younger age and negative attitudes to FGM.
Van Rossem, Meekers, and Gage (2016) state that general increases in the opposition to female circumcision over the years in Egypt were not due to younger cohorts but rather imply that a greater number of people from diverse demographic and social backgrounds began to regard female circumcision as an adverse practice.
A study of young women’s attitudes to circumcision carried out by Dalal et al. (2018) based on data from the Demographic and Health Surveys of seven African countries adds to the understanding of factors determining one’s perceptions of FGM. Dalal et al. (2018) revealed that there is a significant variance in the percentage of teenage girls supporting the practice of FGM in Mali (72%), Egypt (58%), Guinea (63%), Sierra Leone (52%), Kenya (16%), Niger (3%), and Senegal (23%). They also revealed that in five of the analyzed counties, low social-economic status, and Muslim religious background predict one’s support of female circumcision.
It is also worth noticing that the level of education was not associated with individuals’ attitudes to FGM in some of the states (Dalal et al. 2018). Overall, the controversies regarding the links between FGM perceptions and social, cultural, and demographic factors identified in the literature make it clear that there cannot be a single, universal solution to the problem of female circumcision and signify that interventions should necessarily take into account the features of the target population and the overall context in which people live.
The core article by Galukande et al. (2015) touched upon the issue of the educational program’s contextualization. The researchers suggested that interventions limited only to individual capabilities and motivation are less likely to provoke a substantial behavioral change than those that also take into account broader social, cultural, and economic factors. In the same way, the core study by Graamans et al. (2019) included program contextualization and consideration of unique community features and needs in the list of factors contributing to greater intervention effectiveness. These findings are supported by the evidence presented by Waigwa et al. (2018) in a recent systematic review of twelve quantitative and qualitative studies on the effects of health education in FGM-practicing communities.
Waigwa et al. (2018) identified that sociodemographic and socioeconomic factors, as well as overall traditions and beliefs in a community, may affect a person’s attitude to FGM and his or her response to educational messages. Besides, the systematic review made it clear that the approach to education programs, methods of delivery, and the structure of interventions also play a significant role. For instance, Waigwa et al. (2018) noted that if outsider health education facilitators do not approach communities cautiously, their efforts may be rejected. This observation is consistent with the findings of Graamans et al. (2019) as they also claimed that distrust of outsiders is one of the main reasons why intervention programs fail.
Moreover, it is clear from the results of the study by Babalola et al. (2006) that multifaceted interventions that use several communication channels (including dialogues with local leaders, information sharing by male and female community dwellers, various media personalities, and others) increase the accessibility of promotional information to the majority of the target population. In this way, it becomes more feasible to attain positive intervention outcomes.
The reviewed research evidence can be applied when developing policies aimed to raise awareness of the FGM problems and encourage the abolishment of the practice. The need to tailor education messages and information to meet the needs and interests of target communities is the primary implication for future public health policy. Waigwa et al. (2018), Graamans et al. (2019), Galukande et al. (2015), and others state that contextualization of interventions is possible merely when all the characteristics of target populations are taken into account. It means that the inclusion of community members into the planning and realization of programs is essential.
Waigwa et al. (2018) and Galukande et al. (2015) suggest that religious and other key leaders in the target communities should be actively involved in the promotion of FGM education and awareness-raising interventions because they have the needed power and influence to make culturally-relevant decisions. Moreover, Galukande et al. (2015) recommend focussing on the improvement of competence among those who deliver education sessions.
Additionally, communities, where interventions take place, should be provided with resources and knowledge to perform a regular evaluation of their progress in terms of FGM education results (Galukande et al. 2015). These initiatives would help to increase communities’ ownership and control over FGM prevention efforts and consequently lead to more sustainable behavioral shifts.
It is also worth noticing that, when searching sources for the literature review a scarcity of recent, high-quality studies on the impacts of FGM education interventions was identified. Thus, there is a need to continue to investigate various strategic approaches to the prevention of FGM by using rigorous research methodologies and reporting techniques. Since contextualized, community-led, evidence-based, and multifaceted interventions are considered to be the most promising, it is appropriate to focus future research on the development of targeted education and awareness-raising programs that would be tailored to fit communities’ specific characteristics. Moreover, research must aim at the assessment of their effects within an extended period.
To increase the validity of findings, it can also be recommended to compare samples exposed to interventions with non-exposed populations that would share similar sociodemographic, socioeconomic, and other features. In this way, it will be possible to fill the existing gaps in knowledge about educational intervention effects with high-quality empirical evidence.
Conclusion
The findings of the critical literature review make it clear that despite ongoing efforts to end the practice of FGM, it remains a prevalent problem. Negative impacts of the practice on women’s health can be long-term and severe. The most common FGM-related side effects include recurrent urinary and gynecologic infections, sexual dysfunction, childbirth complications, and various adverse psychological conditions.
First of all, it means that healthcare systems across the globe should be able to respond to the special needs of FGM victims. Thus, medical practitioners should be provided with the necessary resources and information to improve the quality of care for circumcised women. Moreover, policies must be developed and enacted to enforce and accelerate professional development in this area.
Secondly, it is valid to state that, like in the case of an irreversible and highly detrimental health condition, the prevention of FGM incidence is the best option. Education interventions turn out to be a promising solution since they can contribute to attitudinal shifts and the development of health literacy. The review findings suggest that an effective intervention always draws on high-quality research evidence to build credibility.
It is multifaceted and involves a plethora of communication channels and stakeholders at once. Moreover, it takes into consideration the diverse characteristics of target populations. The contextualization of interventions seems to be one of the most crucial requirements for its effectiveness because each community has a distinct set of values and beliefs associated with FGM. Therefore, in every region, people will likely react to the same interventions differently.
Lastly, it is appropriate to note that the body of research on preventative interventions to stop FGM is still scarce, whereas previous research findings may lack validity and reliability. More research should be done to stimulate the progress towards the complete abolishment of this detrimental practice. The results of the present analysis suggest that future studies must be dedicated to the evaluation of comprehensive community-based awareness-raising campaigns, as well as educational interventions designed to improve professionals’ knowledge of FGM and related skills.
Reference List
Al-Jundi, A & Sakka, S 2017, âCritical appraisal of clinical researchâ, Journal of Clinical and Diagnostic Research, vol. 11, no. 5, pp. JE01-JE05.
Andro, A, Cambois, E & Lesclingand M 2014, âLong-term consequences of female genital mutilation in a European context: self-perceived health of FGM women compared to non-FGM womenâ, Social Science and Medicine, no. 106, pp. 177-184.
Asekun-Olarinmoye, EO & Amusan, OA 2008, âThe impact of health education on attitudes towards female genital mutilation (FGM) in a rural Nigerian communityâ, European Journal of Contraception & Reproductive Health Care, vol. 13, no. 3, pp. 289-297.
Babalola, S, Brasington, A, Agbasimalo, A, Helland, A, Nwanguma, E & Onah, N 2006, ‘Impact of a communication program on female genital cutting in eastern Nigeria’, Tropical Medicine and International Health, vol. 11, no. 10, pp. 1594-1603.
Baillot, H, Murray, N, Connelly, E & Howard, N 2018, âAddressing female genital mutilation in Europe: a scoping review of approaches to participation, prevention, protection, and provision of servicesâ, International Journal for Equity in Health, vol. 17, no. 1, p. 21.
Charles Sturt University 2019, Literature review: traditional or narrative literature reviews. Web.
Dalal, K, Kalmatayeva, Z, Mandal, S, Ussatayeva, G, Lee, MS & Biswas, A 2018, âAdolescent girls’ attitudes toward female genital mutilation: a study in seven African countriesâ, F1000Research, vol. 7, p. 343.
Elliott, C, Creighton, SM, Barker, M-J & Liao, L-M 2016, âA brief interactive training for health care professionals working with people affected by âfemale genital mutilationâ: initial pilot evaluation with psychosexual therapistsâ, Sexual & Relationship Therapy, vol. 31, no. 1, pp. 70-82.
Feldman-Jacobs, C & Ryniak S 2006, Abandoning female genital mutilation/cutting: an in-depth look at promising practices. Web.
Galukande, M, Kamara, J, Ndabwire, V, Leistey, E, Valla, C & Luboga, S 2015, âEradicating female genital mutilation and cutting in Tanzania: an observational studyâ, BMC Public Health, vol. 15, no. 1, pp.1-10.
Gebremicheal, K, Alemseged, F, Ewunetu, H, Tolossa, D, Maâalin, A, Yewondwessen, M & Melaku, S 2018, âSequela of female genital mutilation on birth outcomes in Jijiga town, Ethiopian Somali region: a prospective cohort studyâ, BMC Pregnancy and Childbirth, vol. 18, no. 1, pp. 1-10.
Graamans, EP, Zolnikov, TR, Smet, E, Nguura, PN, Leshore, LC & Have, ST 2019, âLessons learned from implementing alternative rites in the fight against female genital mutilation/cuttingâ, Pan African Medical Journal, vol. 32, no. 59, pp. 1-12.
Johansen, R, Ziyada, MM, Shell-Duncan, B, Kaplan, AM & Leye, E 2018, âHealth sector involvement in the management of female genital mutilation/cutting in 30 countriesâ, BMC Health Services Research, vol. 18, no. 1, p. 240.
Kandala, NB, Ezejimofor, MC, Uthman, OA & Komba, P 2018, âSecular trends in the prevalence of female genital mutilation/cutting among girls: a systematic analysisâ, BMJ Global Health, vol. 3, no. 5, p. e000549.
Khosla, R, Banerjee, J, Chou, D, Say, L & Fried, ST 2017, âGender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standardsâ, Reproductive Health, vol. 14, no. 1, p. 59.
Knipscheer, J, Vloeberghs, E, Van, D & Van, D 2015, âMental health problems associated with female genital mutilationâ, BJPsych Bulletin, vol. 39, no. 6, pp. 273-277.
Koski, A & Heymann, J 2017, âThirty-year trends in the prevalence and severity of female genital mutilation: a comparison of 22 countriesâ, BMJ Global Health, vol. 2, no. 4, p. e000467.
Masic, I, Hodzic, A & Mulic, S 2014, âEthics in medical research and publicationâ, International Journal of Preventive Medicine, vol. 5, no. 9, pp. 1073-1082.
Mohammed, ES, Seedhom, AE & Mahfouz, EM 2018, âFemale genital mutilation: current awareness, believes and future intention in rural Egyptâ Reproductive Health, vol. 15, no. 1, pp. 1-10.
Movsisyan, A, Dennis, J, Rehfuess, E, Grant, S & Montgomery, P 2018, âRating the quality of a body of evidence on the effectiveness of health and social interventions: a systematic review and mapping of evidence domainsâ, Research Synthesis Methods, vol. 9, no. 2, pp. 224-242.
Norwegian Knowledge Centre for the Health Services 2009, Effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting. Web.
Odukogbe, AA, Afolabi, BB, Bello, OO & Adeyanju, AS 2017, âFemale genital mutilation/cutting in Africaâ, Translational Andrology and Urology, vol. 6, no. 2, pp. 138-148.
Pastor-Bravo, MD, Almansa-MartĂnez, P & JimĂ©nez-Ruiz, I 2018, âLiving with mutilation: a qualitative study on the consequences of female genital mutilation in womenâs health and the healthcare system in Spainâ, Midwifery, vol. 66, pp. 119-126.
Rouzi, A, Berg, R, Sahly, N, Alkafy, S, Alzaban, F & Abduljabbar, H 2017, âEffects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional studyâ, American Journal of Obstetrics and Gynecology, vol. 217, no. 1, pp. 1-62.
Rural Health Information Hub n.d., The health belief model. Web.
Smith, H & Stein, K 2017, âHealth information interventions for female genital mutilationâ, International Journal of Gynecology & Obstetrics, vol. 136, suppl. 1, pp. 79-82.
United Nations Population Fund & United Nations International Children’s Emergency 2014, UNFPA-UNICEF joint programme on female genital mutilation/cutting: accelerating change. Web.
United Nations Population Fund & United Nations International Children’s Emergency 2016, 2016 annual report of the UNFPAâUNICEF joint programme on female genital mutilation/cutting: accelerating change. Web.
Van Rossem, R, Meekers, D & Gage, AJ 2016, âTrends in attitudes towards female genital mutilation among ever-married Egyptian women, evidence from the Demographic and Health Surveys, 1995-2014: paths of changeâ, International Journal for Equity in Health, vol. 15, p. 31.
Waigwa, S, Doos, L, Bradbury-Jones, C & Taylor, J 2018, âEffectiveness of health education as an intervention designed to prevent female genital mutilation/cutting (FGM/C): A systematic reviewâ, Reproductive Health, vol. 15, no. 1, pp. 1-14.
World Confederation for Physical Therapy 2017, Policy statement: female genital mutilation. Web.
World Health Organization 2018, Female genital mutilation. Web.