Rapport fra Kunnskapssenteret - Systematisk oversikt

Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/C): a systematic review of quantitative studies

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Berg RC, Denison E, Fretheim A. Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/C): a systematic review of quantitative studies. Rapport fra Kunnskapssenteret nr. 13 – 2010. ISBN 978-82-8121-350-0 ISSN 1890-1298.

Female genital mutilation/cutting (FGM/C) is a traditional practice that involves "the partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non-therapeutic reasons." FGM/C is practised in more than 28 countries in Africa and in some countries in the Middle East and Asia. Although limited data exist, it is speculated that FGM/C is practised by immigrant communities in a number of other countries, including Australia, Canada, France, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The practice of FGM/C is rooted in social conventions within a frame of psycho-sexual and social reasons such as control of women’s sexuality and family honour which is enforced by community mechanisms.

FGM/C is recognized as a harmful practice which abrogates human rights. It is prohibited by law in several African and Western countries. The current WHO classification describes four types of FGM/C: Type I, clitoridectomy , involves partial or total removal of the clitoris and/or the prepuce. Type II, excision , involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III, infibulation , involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type IV, other , involves all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization. There is great variation in prevalence, reflecting ethnicity, tradition and sociodemographic factors. Countries with very high prevalence, over 70%, include Egypt, Ethiopia, Mali, and Somalia. FGM/C is associated with several health risks such as severe pain, bleeding, shock, infections, and difficulty in passing urine and faeces. Caesarean section, blood loss, and increased perinatal mortality are associated birth risks. Non-medical consequences from FGM/C are less clear.

We asked the following question: What are the psychological, social and sexual consequences of FGM/C?

We searched systematically for literature in the following scientific databases: African Index Medicus, Anthropology Plus, British Nursing Index and Archive, The Cochrane Library (CENTRAL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects), EMBASE, EPOC, MEDLINE, PILOTS, POPLINE, PsychINFO, Social Services Abstracts, Sociological Abstracts, and WHOLIS. We also searched in databases of international organisations that are engaged in research concerning FGM/C, manually in reference lists of relevant reviews and studies included in this systematic review, as well as communicated with experts engaged in FGM/C related work. We searched for studies that used the following study designs: systematic reviews, cohort studies, case-control studies, and cross-sectional studies.

Two of the authors independently assessed studies for inclusion according to pre-specified criteria and considered the methodological quality of the studies using checklists. We summarized the study level results in text and tables and calculated effect estimates (relative risk and mean difference).  We also performed meta-analyses to estimate effect, using Mantel-Haenszel random effects meta-analyses for dichotomous outcomes and inverse variance random effects meta-analyses for continuous outcomes. We applied the instrument GRADE to assess the extent to which we could have confidence in the effect estimates.

We identified 3,669 publications and after having assessed titles, abstracts, and articles in full text we included 17 studies that fulfilled the inclusion criteria. All included studies were observational comparative studies (15 cross-sectional studies and 2 case-control studies) that compared women who had been subjected to FGM/C with women who had not been subjected to FGM/C. We failed to obtain two potentially relevant records, despite extensive retrieval efforts.

We arrived upon a final decision of low study quality for ten of the 17 studies, moderate quality for five and high quality for two. In our assessment, using the GRADE instrument, the quality of the evidence was very low with regards to documenting a causal relationship between FGM/C and psychological, social and sexual consequences. Collectively, the studies involved a total of 12,755 participants from nine different countries. One study was from Israel, one was from Saudi Arabia, while the remaining fifteen studies were from countries in Africa: Central African Republic, Egypt, Gambia, Ghana, Nigeria, Senegal, and Sudan.

Four studies reported on psychological consequences. Study level results suggested that women with FGM/C may be more likely than women without FGM/C to experience psychological disturbances (have a psychiatric diagnosis, suffer from anxiety, somatisation, phobia, and low self-esteem). However, our meta-analyses for anxiety, somatisation, depression, and hostility failed to reach significance and were marred by high heterogeneity. We were unable to draw solid conclusions concerning psychological consequences. Only two studies, both of low study quality, included some measure of social consequences of FGM/C and we were unable to draw any conclusions. Concerning sexual consequences, several studies were sufficiently similar to warrant pooling of effect sizes in meta-analysis for the outcomes pain during intercourse, satisfaction, desire, initiation of sex, orgasm, reporting clitoris as the most sensitive area of the body, and reporting the breasts as the most sensitive areas of the body. Compared to women without FGM/C, women with FGM/C were 1.5 times more likely to experience pain during intercourse (RR= 1.52, 95%CI= 1.15, 2.0). The pooled effect estimate from two studies suggested that women with FGM/C experience significantly less sexual satisfaction (St.mean diff= -0.34, 95%CI= -0.56, -0.13). Women with FGM/C were twice as likely to report that they did not experience sexual desire (RR= 2.15, 95%CI= 1.37, 3.36). These meta-analysis results were supported by other study level findings. The results of the remaining meta-analyses were marred by high heterogeneity and the results were inconclusive. Collectively, the results provide evidence that women with FGM/C are more likely to experience pain during intercourse, reduced sexual satisfaction and reduced sexual desire than women without FGM/C, but the low quality of the body of evidence precludes us from drawing conclusions regarding causality.

The psychological, social and sexual consequences of FGM/C is an under-researched and neglected issue. The low quality of the body of evidence precludes us from drawing conclusions regarding causality, and the evidence base is insufficient to draw solid conclusions about the psychological and social consequences of FGM/C. However, our results substantiate the proposition that a woman whose genital tissues have been partly removed is more likely to experience increased pain and reduction in sexual satisfaction and desire. Future studies investigating the consequences of FGM/C should compare clearly defined groups that differ by the extent of FGM/C, whereby classification is based on gynaecological examination. Multi-centre, comparative studies which apply a methodology that increases the likelihood of equivalency of exposed and unexposed groups of women and standardized data collection, are preferable.