Serious life events and associated PTSD in Gambian girls exposed to female genital cutting.

Introduction: Poor mental health, such as post-traumatic stress disorder (PTSD), has been reported after female genital cutting (FGC). However, data documenting adverse consequences of FGC have insufficiently considered confounding factors, such as other traumatising events. Here, we examined the extent to which FGC versus other serious life events disturbed Gambian girls subjected to FGC. We additionally assessed the prevalence of PTSD and the extent to which it was attributed to FGC versus other serious life events. Methods: We conducted a cross-sectional study with a community-based sample of 12 years-old Gambian girls who had been subjected to FGC (N = 125). Using structured interviews, we assessed serious life events and probable PTSD related to the event that the girls cited as bothering them the most. Results: Most of the girls reported several serious life events in addition to FGC, such as witnessing violence, experiencing violence or assaults, death of a close relative, and being exposed to natural disasters or serious accidents, for an average 4.5 events per girl. Around one-sixth of the girls (16.8%) stated that FGC was the event that currently bothered them the most, whereas the majority (75.2%) emphasised other experiences. The girls who said they were most troubled by other events reported more impaired daily functioning than those most bothered by FGC. Overall, we found a prevalence of probable PTSD of 19.2%. Of 24 PTSD cases, one was attributed to the experience of FGC, and the remaining 23 were attributed to other events. Conclusion: Our findings indicate that FGC is less important than other serious life events in explaining high rates of PTSD in Gambian girls. Associations established in the field between FGC and adverse mental health must be interpreted with caution because girls who have undergone FGC may be severely exposed to other traumatising events.

Factors associated with general practitioners' routines and comfortability with assessing female genital cutting: a cross-sectional survey.

BACKGROUND: Female genital cutting (FGC) may cause a series of health problems that require specialized healthcare. General practitioners (GPs) are gatekeepers to specialized healthcare services in Norway. To refer girls and women subjected to FGC to appropriate services, GPs need to assess whether the health problems reported by these patients are related to FGC. However, we do not know to what degree GPs assess FGC as a potential cause of the patients' health problems. We also know little about the GPs' patterns of training and knowledge of FGC and their effect on the GPs' assessment of FGC as a potential cause of health problems. METHOD: We employed a cross-sectional online survey among GPs in Norway to examine: 1) patterns of received training on FGC, self-assessed knowledge, and experiences with patients with FGC-related problems and 2) the association between these three factors and the GPs' assessment of FGC as a potential cause of patients' health problems. A total of 222 GPs completed the survey. Data were analysed using binary logistic regression, where we also adjusted for sociodemographic characteristics. RESULTS: Two-third of the participants had received training on FGC, but only over half received training on FGC-related health problems. Over 75% of the participants stated a need for more knowledge of FGC typology and Norwegian legislation. While the majority of the participants assessed their knowledge of FGC medical codes as inadequate, this was not the case for knowledge of the cultural aspects of FGC. Female GPs were more likely to have experience with patients with FGC-related health problems than male GPs. Among GPs with experience, 46% linked health problems to FGC in patients unaware of the connection between FGC and such health problems. GPs were more likely to assess FGC as a potential cause of health problems when they had experience with patients having FGC-related problems and when they assessed their knowledge of FGC typology and FGC-related medical codes as adequate. CONCLUSION: To improve their assessment of FGC as a potential cause of patients' health problems, GPs should receive comprehensive training on FGC, with particular emphasis on typology, health problems, and medical codes.

Religion, Health, and Life Satisfaction Among Somali and Gambian Women in Norway.

This article describes and analyses the religious justifications for the life satisfaction reported by two groups of Muslim women. Approximately, twenty Somali women and twenty Gambian women, living in Norway, who had experienced trauma and pain due to female genital mutilation/cutting as well as other traumas and hardships, were interviewed. While the Somali women adhere to conservative Islam and try to cope with their life through endurance and patience, the Gambians belong to a Sufi tradition and verbalise their dissatisfaction in order to receive help from Sufi saints. Therefore, there are two religious codes, here called emotionologies, within the Muslim tradition that have different impacts on the expression of life satisfaction and women's ways of coping with pain and suffering.

Health workers and Sub Saharan African women's understanding of equal access to healthcare in Norway.

This article describes and analyzes conceptions of equal access to healthcare by health workers and Sub Saharan African women living in Norway. The main objective of the study was to find out if there is equal access to healthcare as understood by both the provider and receiver side of healthcare. The two sides have different positions from where to observe and judge the services given, which can give a broader understanding of the healthcare system. Do Sub Saharan African women find healthcare services unjust and discriminating? Do health workers share conceptions of access held by these women? This study used a qualitative fieldwork research design. One hundred interviews were done with health workers and 55 interviews were done with Somali, Gambian and Eritrean women who all had experienced female genital mutilation/cutting (FGM/C). The study found a mismatch in the conceptions of access to healthcare between health workers and the women. Health workers did not believe there was equal access to healthcare and were critical of how the system functioned, whereas the women trusted the system and believed there was equal access. However, both sides had corresponding views on the following challenges facing the healthcare system: little time available to identify symptoms, difficulties in navigating the system, difficulties in getting referrals, and some negative adjudication by some health workers. Bourdieu's concepts of field, habitus and hysteresis, and candidacy theory were used to analyze the collected data. It was concluded that health workers and the women based their experiences of healthcare on differing cultural frames and expectations. The women seemed to base their assessments of healthcare on previous experiences from their home country, while health workers based their understanding from experiences within the system.

The association between physical complications following female genital cutting and the mental health of 12-year-old Gambian girls: A community-based cross-sectional study.

BACKGROUND: Female genital cutting (FGC) involve an acute physical trauma that hold a potential risk for immediate and long-term complications and mental health problems. The aim of this study was to examine the prediction of depressive symptoms and psychological distress by the immediate and current physical complications following FGC. Further, to examine whether the age at which 12-year-old Gambian girls had undergone the procedure affected mental health outcomes. METHOD: This cross-sectional study recruited 134 12-year-old girls from 23 public primary schools in The Gambia. We used a structured clinical interview to assess mental health and life satisfaction, including the Short Mood and Feeling Questionnaire (SMFQ), the Symptom check list (SCL-5) and Cantril's Ladder of Life Satisfaction. Each interview included questions about the cutting procedure, immediate- and current physical complications and the kind of help and care girls received following FGC. RESULTS: Depressive symptoms were associated with immediate physical health complications in a multivariate regression model [RR = 1.08 (1.03, 1.12), p = .001], and with present urogenital problems [RR = 1.19 (1.09, 1.31), p < .001]. The girls that received medical help following immediate complications had a lower risk for depressive symptoms [RR = .73 (.55, .98), p = .04]. Psychological distress was only associated with immediate complications [RR = 1.04 (1.01, 1.07), p = .004]. No significant differences in mental health outcomes were found between girls who underwent FGC before the age of four in comparison to girls who underwent FGC after the age of four. CONCLUSION: Our findings indicate that the immediate and long-term complications following FGC have implications for psychological health. Only a minimal number of girls received medical care when needed, and the dissemination of health education seems crucial in order to prevent adverse long-term physical and psychological health consequences.

A system analysis of the mental health services in Norway and its availability to women with female genital mutilation.

BACKGROUND: This article explores mental health services in Norway and their availability for women subjected to female genital mutilation/cutting (FGM/C). The article focus on the system of communication and referrals from the perspective of health workers, and aims to identify bottlenecks in the system, what and where they are to be found, and analyze how different mental health services deal with Sub Saharan African (SSA) women in general, but in particular with respect to FGM/C. METHOD: The study was conducted in Oslo, Norway, using a qualitative fieldwork research design, with the use of purposeful sampling, and a semi-structural guideline. One hundred interviews were done with general practitioners (GPs), gynecologists, psychologists, psychiatrists, midwives and nurses. ANALYSIS: A system analysis is applied using socio-cybernetics as a tool to identify the flow of communication and referrals of patients. FINDINGS: The study shows that borders of subsystems, silencing mechanisms, regulations and "attitudes" of the system can lead to women with SSA background having difficulty getting access to the specialist services. High standards for referral letters, waiting lists, out pushing to the lower levels, insecurities around treatment and deference rules silencing mental health issues during consultancies, have a negative impact on the accessibility of services. Consequences are that mental health problems due to FGM/C are under-investigated, under-referred, and under-treated and a silenced problem within the mental health services for women. CONCLUSION: A better integration of subsystems at the specialist level with the GP scheme is necessary, as well as providing competence on FGM/C to the different levels. It is also important to strengthen and integrating the services at the Municipal level and provide information to SSA women about the low threshold services.

Sexual norms and the intention to use healthcare services related to female genital cutting: A qualitative study among Somali and Sudanese women in Norway.

BACKGROUND: Female Genital Cutting (FGC) is a traditionally meaningful practice in Africa, the Middle East, and Asia. It is associated with a high risk of long-term physical and psychosexual health problems. Girls and women with FGC-related health problems need specialized healthcare services such as psychosexual counseling, deinfibulation, and clitoral reconstruction. Moreover, the need for psychosexual counseling increases in countries of immigration where FGC is not accepted and possibly stigmatized. In these countries, the practice loses its cultural meaning and girls and women with FGC are more likely to report psychosexual problems. In Norway, a country of immigration, psychosexual counseling is lacking. To decide whether to provide this and/or other services, it is important to explore the intention of the target population to use FGC-related healthcare services. That is as deinfibulation, an already available service, is underutilized. In this article, we explore whether girls and women with FGC intend to use FGC-related healthcare services, regardless of their availability in Norway. METHODS: We conducted 61 in-depth interviews with 26 Somali and Sudanese participants with FGC in Norway. We then validated our findings in three focus group discussions with additional 17 participants. FINDINGS: We found that most of our participants were positive towards psychosexual counseling and would use it if available. We also identified four cultural scenarios with different sets of sexual norms that centered on getting and/or staying married, and which largely influenced the participants' intention to use FGC-related services. These cultural scenarios are the virgin, the passive-, the conditioned active-, and the equal- sexual partner scenarios. Participants with negative attitudes towards the use of almost all of the FGC-related healthcare services were influenced by a set of norms pertaining to virginity and passive sexual behavior. In contrast, participants with positive attitudes towards the use of all of these same services were influenced by another set of norms pertaining to sexual and gender equality. On the other hand, participants with positive attitudes towards the use of services that can help to improve their marital sexual lives, yet negative towards the use of premarital services were influenced by a third set of norms that combined norms from the two aforementioned sets of norms. CONCLUSION: The intention to use FGC-related healthcare services varies between and within the different ethnic groups. Moreover, the same girl or woman can have different attitudes towards the use of the different FGC-related healthcare services or even towards the same services at the different stages of her life. These insights could prove valuable for Norwegian and other policy-makers and healthcare professionals during the planning and/or delivery of FGC-related healthcare services.

Cultural protection against traumatic stress: traditional support of children exposed to the ritual of female genital cutting.

This study explores the factors addressed in folk psychology in The Gambia for protecting the girl-child from the potential traumatic stress of female genital cutting (FGC). The type and quality of the psychological care was analyzed and compared with research on traumatic stress and principles for crisis and trauma intervention. Thirty-three qualitative indepth interviews were conducted with mothers who had supervised their daughters' FGC, women who had been circumcised, and professional circumcisers. The findings indicate that the girls have largely managed to handle the potentially traumatic event of FGC. The event is placed in a meaningful system of understanding, and the stress is dealt with in a traditional way that to a great extent follows empirically-based and evidence-based principles of crisis intervention. However, the approach tends to be culturally encoded, based on the local cultural belief system. This puts circumcised individuals in a potentially vulnerable position if they are living outside the homeland's supportive cultural context, with consequences for psychological and culturally competent FGC health care in exile.

Internalizing knowledge and changing attitudes to female genital cutting/mutilation.

The process of paradigmatic attitudinal change has been analyzed by the use of multimethods and multileveled internalization theories. Forty-six informants (a network of activists and a group of Gambian women) have described their change of attitude to female genital cutting. This study shows that internalizing a packet of information as adults, that contradicts an old schema of knowledge internalized as children, can be experienced as epistemologically very painful. Activists in Norway who have changed their attitude to FGC have got information from different educational institutions, from seminars and conferences, from work as interpreters in hospitals, and from discussions among families and friends. Information can be received, listened to and subsequently discarded. In order to design FGC-abandonment campaigns, the importance of the internalization process in order for the individual to make an attitudinal change must be understood.

Meaning-making of female genital cutting: children's perception and acquired knowledge of the ritual.

How do girls who have undergone female genital cutting understand the ritual? This study provides an analysis of the learning process and knowledge acquired in their meaning-making process. Eighteen participants were interviewed in qualitative indepth interviews. Women in Norway, mostly with Somali or Gambian backgrounds, were asked about their experiences of circumcision. Two different strategies were used to prepare girls for circumcision, ie, one involving giving some information and the other keeping the ritual a secret. Findings indicate that these two approaches affected the girls' meaning-making differently, but both strategies seemed to lead to the same educational outcome. The learning process is carefully monitored and regulated but is brought to a halt, stopping short of critical reflexive thinking. The knowledge tends to be deeply internalized, embodied, and morally embraced. The meaning-making process is discussed by analyzing the use of metaphors and narratives. Given that the educational outcome is characterized by limited knowledge without critical reflection, behavior change programs to end female genital cutting should identify and implement educational stimuli that are likely to promote critical reflexive thinking.