FGM: New research highlights link between FGM/C and mental disorders

FGM: Female genital mutilation and other harmful practices

Health consequences of female genital mutilation

Female genital mutilation may cause mental health problems

This pilot study investigated the mental health of women following genital mutilation. A number of experts have in the past assumed that women undergoing genital mutilation would be more likely to develop psychiatric illnesses than women in the general population but there has been little research to confirm this belief.

The psychological impact of genital mutilation was assessed in 23 Senegalese women in Dakar who had undergone FGM, with 24 uncircumcized Senegalese women serving as comparison subjects. All participants were between the ages of 15 and 40 years, and they had an average length of education of 11.5 years. Twenty-one per cent of the subjects were married and 79% were single. The two groups of circumcised and uncircumcized women did not differ significantly in terms of age, education, marital status, or traumatic life experiences.

A neuropsychiatric interview and other questionnaires were used to assess the traumatization experienced and psychiatric illnesses. More than 80% of the entire group had already faced traumatic life experiences (usually the sudden death of a friend or family member). The age at which the circumcized women experienced FGM ranged between 5 and 14 years (the mean was 8.2 years). In no cases had local analgesics or narcotics been used.

All but one participant remembered the day of her circumcision as “extremely appalling and traumatizing”, the researchers say. More than 90% of the women described feelings of “intense fear, helplessness, horror, and severe pain” and over 80% were said to be “still suffering from intrusive re-experiences of their circumcision”. For 78% of the subjects, FGM was performed unexpectedly and without any preliminary explanation. The psychiatric diagnoses showed that almost 80% of the women who had undergone FGM met criteria for affective or anxiety disorders, with a high rate (30.4%) of post-traumatic stress disorder (PTSD), while only one of the uncircumcized women fulfilled the diagnostic criteria for an affective disorder.

The researchers conclude that female genital mutilation is “likely to cause various emotional disturbances, forging the way to psychiatric disorders, especially PTSD”. They state that the high rate of PTSD of more than 30% in the FGM group compares to the rate of PTSD of early childhood abuse (which ranges between 30% and 50%). Although FGM is part of the participants’ ethnic background, the researchers add, “the results imply that cultural embedment does not protect against the development of PTSD and other psychiatric disorders”. Those other psychiatric disorders are said to include “memory dysfunction” which other studies have shown to be present in traumatized persons.

“The alarmingly high rates of psychiatric disturbance among this group of circumcized women provide important evidence that researchers, as well as clinicians, have an obligation to focus more attention on the urgent needs of circumcized women” the researchers state.”


The distraction of comparing symptoms

“The concept of mental disorder is determined by many factors, including the historical context, cultural influence, level of scientific knowledge and capacity to carry out scientific enquiry, level of education in certain circumstances, as well as many others. In putting together a method of classification of mental disorders, the expert’s duty is primarily that of capturing and remaining faithful to the current level of knowledge in the subject, acknowledging that, in a matter of time, some or all the above factors could change to variable degrees, making what was clear as a mental disorder a few decades previously less clear in the next edition of the classification system.

In the earlier editions of the DSM, homosexuality was clearly categorized as a mental disorder and, by extension, a condition demanding or at least requiring medical treatment. In Western cultures, any suggestion that being gay or lesbian is anything but normal would now attract the wrath of society. The situation in Africa is quite the opposite, and many Africans still view gay and lesbian people as “mentally sick”, because their sexual orientation is against the order of nature. In this regard, one could view the Africans as “uncivilized” or as holding a cultural belief that may or may not change in the course of time, much as it did in Western countries.

A similar but opposite position holds with respect to the circumcision of women, a practice also described as female genital mutilation (FGM). There are still very strong pockets of Africans who practice FGM, presumably in part as a cure for what Victorian physicians would have called “clitoral orgasm”, a condition then requiring preventive surgery. Many Africans defend the cultural position with equal vigor to those who find it abnormal. *There are those who would consider it a mental aberration to mutilate the genitalia of young women and children.

Anorexia nervosa is one of the leading causes of morbidity and mortality in adolescent girls in Western countries. Crisp et al found a prevalence of one severe case in 200 girls in independent schools, while, among girls aged 16 years and over, the rate rose to one in a hundred for severe cases. In Africa, the condition is hardly known. Njenga and Kang’ethe reported on a study in Kenya and concluded that “in a cumulative period of 320 years of practice, Kenyan psychiatrists had seen twenty cases of anorexia nervosa”.

Hulley et al studied a sample of Kenyan and British female athletes and concluded that “the effects of cul- ture were clear, women in the UK were more dissatisfied with their weight and shape and demonstrated significantly more eating disorder cases and associated psychopathology compared with the Kenyan women”.

So, who is deluding who? Is refusal to eat food by “spoilt white girls a disease or simple foolishness?”. Trying to explain to the hungry African mother and child that there are girls who die in Western countries because they refuse to eat food goes beyond reason and logic and would not make sense as a mental disorder, and yet in the West, there is no room for such a discussion.

My Pain is My Pain; Your Pain is Your Pain — all children need care and love, and support through any mental health symptom, whether common in the developed or under developed countries. The adults of this world must TAKE ACTION to address all issues.

FGM is a horrific procedure practiced under unclean circumstances and in the west, our children are suffering from other issues that also must be addressed. The Women of our World must ‘unite’ and realize that our children are suffering at the hands of all the adults in this world that refuse to seek education, work for the motivation to change and think of their children’s wellbeing before their own.

Anorexia nervosa in fact raises many questions regarding its cause and origins. Is it primarily genetic, or is it a social construct of a search of thinness as required of females in Western societies, or is it a combination of both? Should we conclude that pursuit of a cultural belief, such as the belief that to be thin is good, is evidence of a mental disorder because it causes mortality and morbidity? How much is the desire for a thin body “normal” and how much of the same is abnormal, and who decides anyway? Are these cultural or biological conditions? The issue of dimensional and categorical systems of classification comes sharply into focus. The African is however clear! When food is available, one must eat to the full!

Historically, the African were believed to function as “lobotomized Europeans“, because of a smaller brain, and the desire to free himself from French colonialist rule was evidence of a mental disorder, a “fact” taught in French Universities in the 1960s. Few if any psychiatrists would now believe “the facts” as stated above, but in the 1950s and 1960s, these were the facts as understood by well educated, well meaning men and women of science. It is therefore with this knowledge that we must approach the subject of mental disorders with caution and humility, as we could, in a generation or two, be viewed much as Carothers is now viewed by many.

That said, however, we must pick up the courage of our conviction and do what man has done through the years, which is to create order from chaos, which is, after all, the whole purpose and function of a classification system. Our duty to posterity, therefore, is to use the best available tools, to carry out the ordering process and, even if we get it “wrong” in the eyes of the next generation, we will be able to stand firm and tall in the knowledge that no system of classification will remain unchanged for all time. It therefore stands to reason that the concept of what is and what is not a mental disorder is a dynamic one, which will change from time to time, from culture to culture and, as in the case of homosexuality, from generation to generation.”

References
1. Crisp AH. Palmer RL. Kalucy RS. How common is anorexia nervosa? A prevalence study. Br J Psychiatry. 1976;128:549–54.[PubMed]
2. Njenga FG. Kang’ethe RK. Anorexia nervosa in Kenya. East Afr Med J. 2004;81:188–93.[PubMed]
3. Hulley A. Currie A. Njenga F, et al. Eating disorders in elite female distance runners: effects of nationality and running environment. Psychology of Sport and Exercise. 2007;8:521–33.
4. Carothers JC. Frontal lobe function and the African. J Ment Sci. 1951;97:12–48.[PubMed]
5. Fanon F. London: Penguin Books; 1963. The wretched of the earth.

The age of the performance (of female genital mutilation) varies across and within countries.

Most of the operations occur before the end of childhood (mainly between 4 and 10 years). The medical consequences have been broadly investigated. However, there has been hardly any research to qualify and quantify the impact on psychological health.

Case studies mention phobias, depression, and sexual disorders. Nonetheless, it has been ignored that female genital mutilation, representing a violation of someone’s physical intactness, can be classified as a psychological trauma according to DSM-IV and a potential cause of posttraumatic stress disorder (PTSD).

Hence, the purpose of the study was to explore the relationship between female genital mutilation and psychiatric illnesses, especially PTSD. Despite the infliction of long-lasting somatic harm on most individuals, the fact that female genital mutilation is culturally embedded may represent a protective factor against the emergence of PTSD.

In a subsidiary analysis, we also investigated whether or not the presence of PTSD is accompanied by declarative memory dysfunctions (deficits in active recall of previously encoded information), which are often found in other traumatized groups.

New data out of Iraq shows what many psychologists suspected though little research has confirmed: Girls who have undergone female genital mutilation/cutting (FGM/C) are more prone to mental disorders, including post-traumatic stress disorder (PTSD).

Results of the research – conducted by Jan Ilhan Kizilhan of the University of Freiburg, an expert in psychotraumatology (psychotherapy for people who have suffered extreme trauma) – were published in the April-June 2011 edition of the European Journal of Psychiatry.

Kizilhan found “alarmingly high rates” of PTSD (44 percent), depression (34 percent), anxiety (46 percent) and somatic disturbances (mental disorders whose symptoms are unexplainable physical illnesses – 37 percent) among a group of 79 circumcized girls in the Kurdistan region of northern Iraq, aged 8-14, who did not otherwise suffer any traumatic events.

These rates were up to seven times higher than among non-circumcised girls from the same region and were comparable to rates among people who suffered early childhood abuse.

Last year, shortly after receiving the results of the research, Kizilhan said, the Kurdish parliament in northern Iraq banned FGM/C.

He told IRIN he hopes the results will also lead to more and better treatment of PTSD among girls who have undergone FGM/C, using special techniques which include the family in the process as much as possible.

The existence of FGM/C in the Middle East is less known than in Africa. Estimates of the prevalence of FGM/C in Iraqi Kurdistan vary wildly depending on the province, but surveys have indicated the overall figure could be around 40 percent. The region is home to five million people, but has just 13 psychologists and only one with expertise in psychotherapy, Kizilhan said.

There is help through education, as the following example displays.

Animators Raise Awareness About Dangers of Female Genital Mutilation
One animator, Mr. Teka Bataga, shares his experience with the campaign:

“Last week a friend and neighbor of mine told me he is planning to circumcise his one-year-old daughter. I told him, soberly and after choosing the right moment for our discussion, about the disadvantages of this harmful practice. We, the animators, were lectured on this subject.

I told my friend and neighbor: FGM is often performed in poor sanitary conditions by traditional practitioners with immediate and long-term health consequences. Immediate complications include excruciating pain, shock, urine retention, ulceration of the genital regions and injury to the adjacent tissue. Other complications include blood poisoning, infertility and obstructed labor and more.

Then my friend and neighbor remarked, “I was about to kill my only daughter. Thank you for such valuable information. As of today I will be a campaigner against FGM too.”


References

1. Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. American Journal of Psychiatry 2005; 162:10001002.

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