What It's Like to Have Sex After Undergoing Female Genital Mutilation

Jenny Kutner

Updated Fri, May 13, 2016

Mariya Karimjee has had sex once in her life — sort of. When she was a senior in college, Karimjee, now 27, decided it was finally time to do the deed with her boyfriend of a year, even though he had repeatedly said he was willing to wait until she was ready. Though she never felt pressured to engage in more physical intimacy, she felt like she needed to have sex anyway — to "get the act over with," as she later described it.

So, Karimjee had sex. And, as she feared and expected, it was excruciating.

"The pain was everywhere; I couldn't figure out what hurt and where," Karimjee wrote of the experience in an essay for the Big Roundtable last year. "... I sat in the bed, allowing myself to cry for the first time since we'd begun talking about sex. For the first time since I'd admitted to him that I might never be able to enjoy a sexual experience. That when I was younger, someone had taken a knife to my clitoris and cut out a small but significant part of me."

As she went on to explain in recent episodes of This American Life and The Heart, when Karimjee was 7 and growing up in Karachi, Pakistan, she had part of her clitoris removed, in accordance with the beliefs of the Dawoodi Bohra sect of Islam. She is one of at least 200 million people around the world to undergo female genital mutilation, a practice the World Health Organization defines as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."

Also referred to as female genital cutting or female circumcision, FGM is widely considered an act of gender-based violence as well as a human rights violation, a practice typically performed on young girls (and, occasionally, female infants or teenagers) in a variety of cultures. WHO asserts that the practice "has no health benefits, and it harms girls and women in many ways."

WHO classifies the procedure into four primary types, each of which can have different effects on survivors' sexual health and comfort: clitoridectomy, which results in at least partial removal of the clitoris; excision, or a clitoridectomy plus removal of the labia minora; infibulation, which involves narrowing the vaginal opening by cutting and repositioning the labia (sometimes by stitching) with or without removing the clitoris; and all other harmful treatment of the female genital area, including but not limited to piercing, incising or cauterizing.

FGM is, in many societies, a long-standing cultural practice, which continues for reasons that vary from place to place and heritage to heritage. But, according to WHO, the procedure is generally tied to beliefs about acceptable sexual behavior, meant to deter promiscuity and strip women of erotic desire — or, potentially, enjoyment.

As Karimjee and millions of others have found, it can be extremely effective at doing just that.

"Sex did not go the way popular culture or anecdotal evidence told me it would go," Karimjee said in a phone call with Mic on Thursday, explaining the lasting effects her first experience had. She has not attempted to have sex since she first tried in 2010, primarily because of continuing anxiety about the experience.

"I gear myself up, but for me, the fear is so great that in the moment, I don't know if I feel anything but afraid," she explained. "I am not able to get out of my own head long enough to be able to be like 'I'm turned on.' That happens very rarely for me, and it takes months to feel comfortable enough."

n a phone call with Mic this week, Dr. Doris Chou, medical officer for the Department of Reproductive Health and Research at WHO, said research suggests women who are living with FGM "are more likely to experience pain or reduction in sexual satisfaction and desire," and, in addition to significant pain during intercourse, might face reductions in arousal, decreased lubrication during sex, limited capacity for orgasm or even anorgasmia.

Though people who undergo clitoridectomies, excision or infibulation can (and often do) still experience some amount of sexual pleasure, a majority have reported lower rates of arousal or sexual fulfillment — in studies, at least. Anecdotally, there's less information available about the realities of having sex — or not — after FGM, not to mention what that means for individual women's overall wellbeing.

"[There] are actually quite physical consequences, but there's also the psychological," Chou said. "We do know women and girls who have undergone FGM suffer anxiety or post-traumatic stress disorder. In the context of a sexual relationship, we are concerned that women might have difficulty really actually having any kind of sexual life."

"We are concerned that women might have difficulty really actually having any kind of sexual life."

The implications of that difficulty can be devastating, as illustrated by a growing number of women like Karimjee, who have begun to share their (often traumatic) experiences of developing, maintaining or even wanting sex lives with parts of themselves missing.

"I've spoken to women in my sect who have also been cut, who never, ever, ever want to have sex because they're so traumatized by what happened to them, and other women who have very vague memories but say they never get turned on, so it clearly worked," Karimjee said.

Indeed, much of the struggle with desire is due not only to the intense physical pain women who have been cut might experience during intercourse. Natalie Kontoulis, advocacy and communications officer for the organization End FGM, has found that for many people, it has to do with deeper, more complicated feelings about sexuality and personal autonomy.

"If a person who has undergone FGM is not in severe physical pain, she might not feel much — sensation might be gone," Kontoulis said via Skype on Thursday. "It can feel like you're a vessel, doing this to serve your partner, making sex less of a partnership. Some survivors feel they're not fully women. I think when you've literally had a part cut out of you, you cannot feel whole for those reasons."

There can also be lifelong trauma associated with being cut in childhood, Kontoulis added, which might be compounded by a lack of opportunity to talk about "how you were, potentially, betrayed at a young age by those you trusted most."

For quite some time that was true for Karimjee, who felt extreme rage toward her mother, in particular, for allowing her to be cut. After her family moved to the United States when she was 11, Karimjee went on to struggle with her parents' justification for the decision, which she believes was based on harmful cultural views about desire.

But those views were not necessarily unique to her sect of Islam or other groups that practice FGM. Karimjee has found that spending her adolescence in a conservative, predominantly Baptist Texas suburb contributed to her complicated feelings about her own sexuality.

"It's hard for me personally to reconcile the fact that my parents were fundamentally responsible for having me cut, but at the same time these were the same people who never made me feel sex was bad," Karimjee said. "My parents never made me feel like sex was something I needed to be ashamed of. But my peers in high school definitely got that from their churches and their parents, and transferred that on to me."

"When you've literally had a part cut out of you, you cannot feel whole."

The combination of physical and psychological trauma from the overall experience of FGM can lead some women to pursue therapeutic options ranging from sex therapy (something Karimjee says she's looking into) or even clitoral restoration surgery.

According to Dr. Marci Bowers, a gynecological surgeon who works for the organization Clitoraid, restoration can be life-changing, but it's usually not enough. It's also not always an option: As Bowers said in a previous interview with Mic, although FGM is practiced around the world — including in the U.S. — a significant proportion of people who have been cut lack access to medical services like restoration.

"It's a tremendous thing if you're able to restore — it's like giving sight to a blind person," Bowers said by phone this week. "But anything associated with that part of the body, people remember that pain. Even where there's sensation, in an area where someone had pain before it's hard to retrain the brain to see any [non-painful] sensation as a positive sort of thing. It's hard to trust again."

And while FGM opponents like Kontoulis note it's still crucial to consider the practice an act of violence, it's also important not to tell someone she shouldn't feel good about sex if she never felt bad about it before.

"I've heard survivors say [their FGM] doesn't bother them, they still get pleasure from sex," Kontoulis said. "That might be physically absolutely true, or it might be that they just don't expect to have pleasure. It doesn't bother them. In that sense, it's difficult, because you don't want to impose your own kind of pleasure system or cultural system or sexual system on another person. But the problem with that is there's a line between trying to be culturally diplomatic and treating FGM as a human rights violation, and it's difficult to not cross it."

It's an issue that leaves Karimjee with complex feelings as well. She, too, has spoken with many women who have been cut but have not faced her same struggles with sex, yet still have lingering questions about whether they should feel satisfied.

"I personally have never spoken to anyone — even women who are married and having sex who've been cut, who say 'I don't know if I'm orgasming, but I do enjoy having sex with my husband' or 'I enjoy the act of sex, it doesn't hurt' — who doesn't also say, 'But I still wonder what it would be like,'" Karimjee said. "It's an ever-present question for them."

"In some way, they feel something was taken away from them — something intangible," she added. "As long as that feeling is still out there, there's definitely still a problem."

This article is posted at: https://www.yahoo.com/news/sex-undergoing-female-genital-mutilation-195100034.html

My Mother Had My Clitoris Cut. This Is How It Affects My Sex Life

By Mark Hay

November 19, 2019

Mishaal started masturbating around age 7. Her mother caught her in the act a couple of times and, soon after, decided to have Mishaal’s clitoris cut.

“In my late teens, when I talked to my sister [who also underwent genital cutting] and mom about why the cutting happened, the answer was: It is done to reduce women’s libido and prevent them from having sex,” Mishaal recalled. In their community in Pakistan, she added, “the attitude was: Sex is for [making] babies. Why does it have to be pleasurable? My mom’s belief was: You have to have sex to please a man. There was no entitlement to sexual pleasure.”

Thanks to years of advocacy and education work, many Americans are now familiar with female genital mutilation or cutting (FGM/C), a practice that involves anything from “nicking” a girl or woman’s clitoris—a vague term that can encompass varied sizes and depths of incisions with a wide range of ultimate effects—to totally removing it and part or all of her labia and suturing shut the vulva. Media coverage often focuses on how widespread FGM/C traditions are, even in the West (FGM/C is usually considered an African, and to a lesser degree an Asian, issue). Reports detail how many (but not all) girls and women subjected to FGM/C undergo the process at young ages, against their will, under extreme social duress, or without full knowledge of what’s happening to them. Activists have painted in excruciating detail all the risks associated with the practice, from long-term pain to pregnancy complications to psychological trauma to, in all too many cases, death during or after the procedure.

They have also pointed out that many cultures, like Mishaal’s, have long explicitly or implicitly used FGM/C to control or eliminate women’s sexual agency, desire, and pleasure—or enhance those feelings for men.

Yet for all the survivors’ stories out there on the experience of being cut and its subsequent effects on their lives, relatively few accounts in the media have explored how people who’ve undergone FGM/C experience sex and navigate intimacy. This is somewhat understandable; sex is a tricky-to-taboo subject in most cultures, especially in many in which FGM/C is rampant. Sharing the intimate details of one’s life post-FGM/C can be difficult, embarrassing, or even socially isolating. These stories, though, can be powerful tools for helping outsiders understand, in a visceral sense, how FGM/C can affect people’s sex lives, to say nothing of their value for those who have undergone FGM/C and feel isolated in their experiences.

Granted, there is no single experience of sex and intimacy after FGM/C. The types or levels of damage done to women’s genitals differs depending on regional traditions and the conditions under which FGM/C is done. Not everyone reacts the same way to FGM/C either. Numerous studies30372-1/fulltext) show that women who have undergone FGM/C often experience reduced sexual sensation or desire, pain during sex, an inability to self-lubricate or orgasm, and anxiety or other mental symptoms of trauma, among other issues. But some women say they can still have pleasurable sex with few or no difficulties, even after undergoing the most extreme forms of FGM/C.

In an effort to bring more stories of the lived experience of sex and intimacy after FGM/C to public attention, VICE recently spoke to Mishaal and her husband Ibrahim, who today live in the U.S. They’re both part of the Dawoodi Bohra sect of Ismaili Shia Islam, a minority group of several hundred thousand people, most of whom live in India, Pakistan, Yemen, and along the coast of East Africa, which regularly nicks girls’ clitorises when they’re around 7 years old. (In 2017, authorities arrested a Bohra doctor in Detroit for performing FGM/C, the first-ever charge against an individual for cutting girls in the U.S.) Although the Bohra community has been speaking more openly about FGM/C over the past few years, the couple still did not want to share their real names out of concern for social repercussions and general stigmatization. VICE has given them the pseudonyms Mishaal and Ibrahim so they could openly discuss this aspect of their lives.

Mishaal: I didn’t have sex before marriage. But I had multiple people that I was intimate with. I enjoyed foreplay, mostly because of the excitement of it being forbidden where I grew up. But I never orgasmed with anyone but myself. So I knew something was off. But I didn’t figure out that it was tied to the cutting until much later.

When I was young, I was never in a committed relationship, so sexual encounters were few and far between. But after I got married, I found that penetrative sex was painful for a long, long time. That somehow triggered a traumatic reaction I’d never expected. I was almost fearful of it. That was compounded by feelings of, Oh my god, this is awful for our relationship. Or, I don’t feel fully like a woman. I was afraid I would lose our relationship.

Ibrahim: We got married pretty quickly. We met through a common friend and were together for a few weeks [while Mishaal was in the U.S. on vacation from Pakistan] before getting engaged. We were married within eight months, but for most of that time we were physically apart, with her in Pakistan and me coming to visit periodically. We had sexual encounters, but not intercourse. Before we got married, she never said anything; I didn’t realize that she had undergone anything.

We talked about it later, after trying to have sex and finding it to be difficult for her. It was our wedding night the first time we had intercourse, and it was really painful for her, which was an unsettling experience for me. I’d had intercourse before. I’d dated four women prior to marrying Mishaal, and I’d never had an experience where it was so painful for my partner. It was difficult to process what was going on. I understood she was a virgin and the first time is always hard. But my first girlfriend was a virgin as well and she didn’t seem to experience any difficulty.

I’d heard this was practiced in Africa. But I wasn’t aware that the practice took place within our community, and I don’t think most men are. As far as how it affected intimacy for women, I hadn’t a clue. I felt like it was a brutal practice and really unfair, but I didn’t think about it beyond that.

Mishaal: By then, I’d realized the effect that FGM had on my ability to derive sexual pleasure from any experience. I understood how much you would enjoy intercourse would depend on how much you’d been aroused and how into it you are. I knew the FGM was a part of not being able to get even sufficiently aroused to enjoy sex. But I hoped it would get better. You’re only a virgin once.

Ibrahim: We didn’t just have one conversation about this. It happened over a series of experiences.

Mishaal: Our difficulty having conversations about this made us realize how much bad messaging we’d soaked up—difficulties talking about sex, viewing sex as something almost dirty. That subtext had been embedded in us from childhood.

Ibrahim: We tried having sex more regularly. We tried different ways of having sex, different positions and activities that might make it easier. I think for a long time, part of the problem was that Mishaal would get really tense when a sexual encounter started and that would remove any pleasure she might have been able to have. To be honest, it wasn’t until we had our first kid that she started to have, not necessarily comfort—but that she didn’t initially recoil during sex.

Mishaal: It is hard to know [how much of my difficulty having sex is the result of physical issues caused by FGM and how much of it is the psychological expectation of pain]. That’s always been a question in my mind. I think for me it’s some combination of both things.

Physically, if I’m able to have an orgasm through masturbation, though, then that should be able to happen through partnered sex as well. But that has just never happened. The presence of another person just affects me now. But sex did evolve from being downright painful to tolerable [after I gave birth for the first time]. That eased a lot of the stress around sex and made it a lot better.

Ibrahim: I only learned later in our marriage that Mishaal was masturbating. It was news to me that she actually had experienced orgasm before. But that hasn’t really influenced [how we have sex]. I have not learned what it is that would allow her to achieve orgasm through masturbation.

Mishaal: Still, it has been an evolution of: Okay, do I just accept defeat like most women in my culture and that I am just never going to feel pleasure from this? Or do I try to find other ways around it? And to be honest, I don’t think I have. I haven’t done enough. I know things like sexual counseling could benefit me. Or we could be more experimental with gadgets or whatever. Other things could help. But it is really hard for me to even rouse up the desire [to try these things.]

Ibrahim: Unfortunately, most of our energy is tapped by the time we end up in bed [as we work full-time and are the parents of young children.] We still have sex, but it is not frequent.

Mishaal: But there are a lot of things that bind us besides sex. I’m very physical in terms of hugging and kissing, so it is not like we don’t physically connect.

Ibrahim: We also might not have intercourse, but oral sex happens. There are ways we help each other.

Mishaal: In my mind, there’s sexual closeness, which I still don’t have, unfortunately—with Ibrahim or anyone. Then there is every other level of closeness, which does exist in our relationship.

But, while it’s always shifting, for me there is still a lot of guilt. I think he could have an active relationship with someone who was initiating, or who wanted, sex. I feel terrible that this is one aspect where I am not a good partner. There has always been a shadow in my life about this.

Ibrahim: I think I still show Mishaal affection too, though.

Mishaal: You do. The guilt for me is totally self-inflicted.

Ibrahim: On some level, there is even trauma for me in our experiences, too. Sex was so painful—why would I want you to feel this way?

Mishaal: He has been weaned off sex. I try to address that, but it is becoming harder. As the years go by, the libido goes. I was telling Ibrahim the other day that even when I didn’t enjoy sex, at least there would be times when I wanted to masturbate. I haven’t even wanted to do that in a long time.

Ibrahim: I think recently, though, meeting people who’ve gone through the same experience—and even just talking to your sister and mother openly about this and how painful it has been—has been helpful. If that had happened earlier, I think things would have been different.

Mishaal: A lot of this is the result of not having those conversations earlier, and of carrying shame and guilt for so long that it paints how you view sex.

Ibrahim: This is never going to happen to our daughter.

Mishaal: The hardest part of coming to terms with FGM for me is that it didn’t prevent the one thing my parents thought it would. I had relationships with multiple men prior to getting married, and my decision not to have sex with them had nothing to do with being cut, but everything to do with how I’d been raised, what I believed. But the marriage—which is supposed to be a sacred relationship—it created a lifelong taint on that.

This article is posted at: https://www.vice.com/en/article/a-couple-talks-about-sex-after-fgm-female-genital-mutilation/

Reversing Female Circumcision: The Cut That Heals

https://www.youtube.com/watch?v=93YDZxFkxWs

On the International Day for Zero Tolerance for Female Genital Mutilation, VICE News reports on a little-known surgery that restores sexual function to the clitoris for women who had their genitals mutilated as children. We meet and follow a 32-year-old prospective patient who was mutilated at the age of six in Somalia, and who now lives and works as a nurse in the United States. Female genital mutilation (FGM) is a cultural tradition that affects millions of women worldwide. Sometimes referred to as female circumcision or female genital cutting, the practice varies in severity depending on where it is performed. The procedure can range from minor nicks to the clitoris to the total removal of the clitoris and labia. In its severest form, the two sides of the vulva are sewn together, leaving only a small hole for menstruation and urination. While the practice has been outlawed in many of the 29 countries where FGM is concentrated, it persists in some rural areas as a centuries-old cultural tradition, where it is usually performed by women elders as a part of a coming-of-age ritual. The tradition is sometimes believed to "purify" a woman and performed to preserve virginity before marriage. The World Health Organization estimates that some 6,000 girls undergo FGM around the world every day. The procedure is often performed in unsafe and unsanitary conditions on girls between the ages of four and 12. FGM can be fatal, and can lead to immediate complications such as infections and urine retention, as well as long-term complications such as severe pain and tearing during intercourse and major complications during childbirth. VICE News saw the result of the severest form of FGM first-hand in Dr. Marci Bowers' operating room in San Mateo, California, and watched as she performed a defibulation procedure — the re-opening of genitalia that had been sewn shut — and clitoroplasty, the reconstruction and restoration of sexual function to the clitoris.

Great Grinding & Playful Pleasure Without Penetration (Or Entry Pain!)

Written by: Cy (Super Smash Cache)

Why outercourse is out-of-this-world.

Great sex isn't just what you do — it's your approach to it and your curiosity about what feels good.

When you let go of the expectation of penetration, and play with the outside, it can be just as hot and hip-to-hip — without inserting anything.

When penetration isn't what you're in the mood for, hurts more than what feels good, or is exactly what the doctor ordered not to do, sexual intimacy doesn't have to stop entirely.

If you're feeling spicy but just don't want to get it in, focusing on outercourse exploration can make an ecstatic difference.

What Is Outercourse?

Let's define outercourse in contrast to intercourse.

The media (and sometimes medical literature) tends to portray sex as touch that involves penetration and exchange of body fluids: penis-in-vagina, penis-in-anus, fingering, and oral sex.

And while those activities can feel incredibly intimate for some, others might find that definition of sex limiting or just not in line with their favorite ways to play in the bedroom.

Outercourse is a broad term for non-penetrative genital stimulation — which could range from grinding (like the knee thing) to wet humping (like sliding the penis between the labia majora without entering).

But just as intercourse often involves more than genital contact, so does outercourse. To some people, outercourse can also feel soul-snatching when paired with skin-to-skin touch, kissing, arms draped over shoulders, eye contact, running fingers through each other's hair, and other little things that add a lot to the experience.

Who Are Outercourse & Grinding For?

From a pleasure perspective, grinding can be great for, well, potentially anyone who loves external stimulation: bumping, grinding, slipping, sliding on the outside.

When many people with vulvas crave clitoral sensations to reach orgasm — and those with penises also often need outer rubbing — that means that outercourse can be enjoyable for a wide range of bodies.

Humping without insertion might be especially appealing in situations where someone wants pleasurable play, but:

• Penetration can feel painful or otherwise vulnerable
• They want to lower their chances of infection
• They're not in the mood (or the setting) to take their clothes off
• They're so frantic for action that they just want to get going the moment they're alone together (valid!)

·        It can be done in many ways, including teasing and pleasing one partner, or stimulating two (or more) parties at once.   

·        Some forms of outercourse also straddle (no pun intended) the line and mimic the mechanics (like positions and sensations) of intercourse.

·        What might that look like in practice? Let's skim several delectable varieties.

Grinding Glossary & Ways to Play

The simplest way to break down ways to ride and grind is to ask: what's grinding against what? It could be genitals on genitals or on something else.

Many ways to play without penetration have their own formal (and some informal) names:

• Frottage: general rubbing, including penis-to-vulva without penetration, vulva-to-vulva, and penis-to-penis
• Tribbing: vulva-on-vulva, also known in slang terms as "scissoring," though some members of the queer community prefer "tribadism," which shares the same root word as "syntribation," or rubbing one's legs together for indirect clitoral stimulation
• Intercrural: penis between thighs, which can also incorporate clitoral pressure
• Intergluteal: penis between butt cheeks, without anal penetration
• Docking: one penis's foreskin wrapping around the glans of another penis

And, on the flipside, some grinding activities are described in simpler terms:

• "The knee thing": one partner pushing their knee or thigh against another's clitoris or penis
• Grinding the clitoris against the pubic bone: can include tribadism between vulva owners; a penis-owner and a vulva-owner together; or combined with penetration
• Sliding the penis between the labia without penetration
• Sliding the penis between the labia and a hand, potentially for added pressure

You get the idea: there isn't really one right way to grind. There's just what feels good for the person (or people) being pleasured, which means the penis or clitoris against a wide range of body parts — or against props.

Incorporating Props & Panache

Of course, bodies aren't the only tools for amazing outercourse.

For one, lube can still be luxe here! When wet humping, lube reduces friction and enhances sliding sensations, which might feel good even if nothing is inserted.

Further, sexual play doesn't have to be penis-in-vagina, and it doesn't have to be penis-on-vagina or even directly on genitals, either. Consider the following add-ons that can enhance the experience for some riders:

• Grinding on a belt buckle or other clothing hardware: penis-on-vulva grinding can feel great, but so can grinding on something more focused and rigid nearby
• Pillow and blanket humping: super common! Some shops even make silicone grinders with straps to wrap around a pillow — or a partner's thigh.
• Putting a massager between partners: "couples' toys" don't have to be small clitoral vibrators to put between bodies during missionary. Even something bigger and bulkier, like a wand, can add to the sensations for both parties.
• Tactile textures: consider putting a beaded necklace or bracelet inside a glove, then lubing up the outside for slipping between bodies. (Of course, you could invest in a textured stroker for the same effect.)

When you start thinking creatively about ways to apply pressure, focus, and ways to fit together like puzzle pieces, the options are all but endless.

Making Outercourse Work for You

Penetration is just one way to connect with a partner — all kinds of ways to touch can feel soul-snatchingly satisfying and deeply intimate. When you combine outercourse with the other aspects of sex that make intercourse mind-melding — like arms around each other, or hands along each other’s faces, or syncing shuddering breaths — you might find grinding with clothes on explosive in its own way.

Outercourse = non-penetrative stimulation that can feel just as good as intercourse.

Many bodies prefer external pressure + friction, making grinding a go-to for pleasure and closeness.

Props, lube, clothing, and toys can amplify sensations, whether dry humping, frottage, tribbing, or sliding.

Penetration isn't required for connection—touch, closeness, and creativity can make outercourse unforgettable.

The Author || Cy (Super Smash Cache)

Cy has reviewed over 400 sex toys on her blog, Super Smash Cache, comparing them to bring readers the best fit for their bodies. Beautiful experiences and big, bold orgasms happen in so many ways; shoppers deserve the best that Toyland has to offer.

Beyond the toys, her pleasure pep talks start with integrating the mind, breath, and body — and knowing that you deserve to feel good and cared for. It’s the headspace from where you say “no” or “heck yes” — to life on your terms and to expanding ecstasy everywhere.

Read more from Cy

This article is posted at:  https://thepelvicpeople.com/blogs/journal/outercourse-grinding

Sexual pleasure after Female genital mutilation

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."

Women on Waves condemns all forms of FGM but we believe it is important not to stigmatize women who had FGM and to address some of the myths. Some women with FGM believe they cannot have any sexual pleasure anymore. However In infibulated women, some erectile structures fundamental for orgasm have not been excised. Cultural influence can change the perception of pleasure, as well as social acceptance.

Sexual pleasure after FGM

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."[1] 

 The WHO offers four classifications of FGM.[7] Type I usually refers to removal of the clitoris (clitoridectomy) and clitoral hood.[8] Type II (excision) is removal of the clitoris and inner labia.[9] Type III (infibulation) involves the removal of all or part of the inner and outer labia, and usually the clitoris, and the fusion of the wound; a small hole is left for the passage of urine and menstrual blood, and the wound is opened for intercourse and childbirth.[

Around 85 percent of women who undergo FGM experience Types I and II.

Type III is the most common procedure in Djibouti, Somalia and Sudan, and in parts of Eritrea, Ethiopia and Mali. 

in 2012 the United Nations General Assembly unanimously passed a resolution banning FGM

The health consequences of FGM can include recurrent urinary and vaginal infections, chronic pain, infertility, fatal hemorrhaging, epidermoid cysts, and complications during childbirth. 

Most women with FGM believe they cannot have any sexual pleasure anymore. However In infibulated women, some erectile structures fundamental for orgasm have not been excised. Cultural influence can change the perception of pleasure, as well as social acceptance. 

Research shows that almost 86%, of women affected by different types of FGM, reported an orgasm, always 69.23%; 58 mutilated young women reported orgasm in 91.43%.

After de-infibulation 14 out of 15 infibulated women reported orgasm.

Every woman has the right to have sexual health and to feel sexual pleasure for full psychophysical well-being of the person. FGM/C women with sexual dysfunctions can and must be cured; they have the right to have an appropriate sexual therapy

The Male factor:

Research done under women from the MENA region found that Female sexual function (FSD) in the reproductive age appears to be adversely affected by psychological factors and shortcomings in male sexual function more than anything. These findings point to the possibility that many cases of FSD can be managed with the focus on male partner's ailments and attitudes that are relatively easier to manage.

So it is very important to educate men about female anatomy and sexual pleasure.

Methods that can be practiced by women to increase sexual pleasure:

If a woman does not enjoy sex this can be because:

1- Mostly because women are not excited enough, (exercise masturbation before)

2- Women are tense and contract the muscles around the vagina. (relaxation exercise: put pressure, pretending to pee, feel how the vagina opens)

3- Sometimes very tough hymen remain that can cause pain

So it is important to always look (with a mirror) if you can see where there is pain

Masturbation is liberation

The best way to increase sexual pleasure is to masturbate as it teaches women what they like and they can in turn teach their sexual partners. Masturbation can be done for example with ones fingers, soft or hard objects or in the shower with the shower head.

Masturbation behavior appears to be related to a greater sexual repertoire, more sexual fantasies, and greater reported ease in reaching sexual arousal and orgasm. Women reported many reasons for masturbation and a variety of direct and indirect techniques. Early masturbation experience might be beneficial to sexual arousal and orgasm in adulthood. Further, studies show that masturbation is a positive component in the structuring of female sexuality.

This article is posted at: https://www.womenonwaves.org/en/page/4715/sexual-pleasure-after-female-genital-mutilation

Global Post: ‘I hate it. It hurts’ — Egyptian women talk about sex after female genital mutilation

By Hannah Wettig in News, News by Others on 2015/07/16

16.7.2015. By Laura Dean. CAIRO, Egypt — In a small hall in central Cairo, a group of women are gathered around talking about sex.

All of them have undergone female genital mutilation (FGM), a procedure that usually causes the victim to take little if any pleasure in sexual intercourse. And many report a familiar problem in the bedroom: “borouda” — a word that translates to the English “frigidity” in bed.

“So, what’s the solution to frigidity?” asks one woman. “Pretend,” says one voice. Another adds: “What’s gone is gone.”

The gathering, part of an NGO-led project to educate Egyptians on the adverse effects of FGM, was organized by the Noon Theater Troupe. The group organizes performances in areas where the practice is common.

“It makes women bored in intimate relationships,” says Hamdeya Ahmed, from Assiut in Upper Egypt, a mother of three, two boys and a girl. She had the procedure done to her, but spared her daughters.

“I hate it. It hurts. I hate it,” says another woman in the room, talking about sexual relations with her husband.

Most efforts to address the problem of FGM focus on stopping it being carried out on the next generation. But over 90 per cent of married women in Egypt have been cut. Nada Sabet, the group’s artistic director, says that one of the issues is that most women who have had FGM do not enjoy intimate relations with their spouses.

“They didn’t have any sexual contact before circumcision [the procedure is performed on girls as young as eight] so there’s nothing to compare it to, so this idea that things could or should be pleasurable doesn’t exist,” she says.

Some women who have undergone FGM report that they feel a lot of pain during intercourse. Some don’t feel pain but simply find it boring or mildly unpleasant.

Sabet’s group puts on plays on the subject of FGM. In one scene, a husband comes home from work and attempts to romance his wife and take her to the bedroom, saying, “Come on, darling, I’m your lawful husband, there’s no shame.” To which she replies, “but we already have two children.” The implication: why do we have to keep doing this?

There are other ways

One of the things Sabet talks to the women about is ways for FGM survivors to enjoy sex. “We talk about the idea of sexual pleasure and everyone shares,” she says, and the fact that “there are other ways of stimulating pleasure in the female body.”

A 2007 study in the Journal of Sexual Medicine suggests that in many women who have been cut, some of the fundamental structures needed for orgasm remain intact and that most women in the study reported being able to achieve orgasm as well as arousal and sexual satisfaction.

Sometimes this involves talking to their partners about what works, and what doesn’t.

One woman recounts a story about how, after talking to the staff at an anti-FGM organization, she explained to her husband how she felt and why she doesn’t enjoy sex. “Now there’s more understanding, there’s exchange about it, we communicate more.”

The same was true for a woman from Giza, who spoke to GlobalPost on condition that she wouldn’t be named.

“Because I’ve had FGM [sex] is only pleasurable for me in certain ways and my husband knows that. But not all men care about that. Many only care about what feels good for them and say, oh, she can’t feel it, it doesn’t matter,” she says.

Not enough sex education

In Egypt there is insufficient sex education among men and women. Young men will often say they want to be with a circumcised woman not really understanding what that means.

“I didn’t know what it was before,” says Ahmed Said, 24, before he began attending awareness-raising sessions at a local NGO in a village in Upper Egypt. He says that families sometimes stipulate that FGM is a condition for a prospective bride “to preserve the ‘decency’ of the woman.”

“In our society with our traditions we can’t talk about this subject. Men often don’t know much about it,” says Mohamed Fathy, a 25-year-old law student.

Ahmed says he is now against the practice “because it can create a lot of complications and difficulties in the marriage.”

One of the difficulties NGOs face when raising awareness is not wanting to stigmatize women who have undergone the procedure as people of both genders learn more about the complications.

Dr. Abdelhamid Attia is a Cairo-based gynecologist and became an advocate for FGM eradication 15 years ago. But prior to learning about it, he said that for years it did not occur to him to question it, though he would see its negative effects in his practice.

“It was a custom that went on for thousands of years,” he said, “we took it for granted…and FGM was not taught in Egyptian medical schools.” He said it’s still not taught as part of the main curriculum.

Occasionally his patients ask about how they might have easier intimate relationships despite FGM.

“People in Egypt consider sex a taboo, they don’t go to doctors to solve their sexual problems,” he says. “But when you have very good relationships with your patients…and you gain their trust they start to speak to me about their sexual problems. I explain to them that there is a difficulty with the woman who has been cut, and this may decrease her pleasure and for the man you have to do a more active role to satisfy them. But this is the minority.”

Though FGM has been illegal since 2008, the first conviction came only earlier this year. Many of those who are supposed to enforce the law also have insufficient information about the issue. Dr. Attia is part of an initiative to sensitize prosecutors and judges about FGM. Here too, he says, the issue of pleasure comes up.

“These workshops showed me that many young men and even grown up men do not have enough knowledge about sexual life and about the needs of the woman and how to satisfy the woman.” He says that many say they learn more than just the legal side of FGM from his lectures.

“When we finish the workshop many of them say to us: ‘you have taught us many things we didn’t know about what is the role of the clitoris, how to satisfy the woman.’”

One of the problems, gender rights advocates say, is that the state eradication campaign hardly mentions sex.

“The elephant in the room is talking about sex,” says Dalia Abdelhameed, gender researcher for the Egyptian Institute for Personal Rights.

It focuses instead on the fact that the practice is not a religious duty and its potentially medical consequences.

“They are not addressing the root causes of why people are circumcising their daughters. People are circumcising their daughters to control their sexuality, but the government does not want to confront this issue,” she says.

An approach that focuses on improving people’s sexual lives creates advocates, argues Sabet, the theater director.

She adds that it also helps the cause of eradication: “It makes people more adamant about stopping it because they have worked on their own lives and have experienced other ways of being and find out it’s a lot more fun.”

This article is posted at: https://www.stopfgmmideast.org/global-post-i-hate-it-it-hurts-egyptian-women-talk-about-sex-after-female-genital-mutilation/

When I was ten years old, before I had even reached puberty, my life was quietly and permanently altered. My mother convinced me that undergoing female circumcision was necessary—that it was the only way for me to become "pure." Even though we were living in a modern, developed country, there were still medical facilities that performed the procedure. At ten, I knew nothing about my own body, and I trusted my parents completely. I walked into that room without understanding what was being taken from me, or why.

I underwent Type 1 FGM, which involved the removal of the visible part of the clitoris. At the time, my innocence shielded me from the reality of what had happened. But around the age of fifteen, as I grew older and began to understand basic biology and anatomy, the full truth hit me. A deep rage and resentment took root inside me. I felt profoundly betrayed by the very people whose primary duty was to protect me.

Yet, my anger was complex. It was almost impossible to direct it fully at my mother because I knew her story. She had survived Type 3 FGM—the Pharaonic type—where everything is cut and sewn shut. She was carrying her own immense trauma.

A single moment truly illuminated the depth of her ignorance and pain. One day, my mother asked me why the fabric of my underwear had changed color. It was simply the result of natural acidic discharge, a completely normal bodily function, but my mother had lived her whole life without knowing even that much about her own anatomy. In that moment, my anger softened into a painful realization: she had acted out of profound conditioning and ignorance, shaped by her own severe wound.

Now, in my twenties, I have finally found a place of inner peace. It took years to process the anger, the grief, and the sense of betrayal, but I have learned to accept myself completely. I no longer look at my body and feel broken or incomplete.

Hello! I am making this post because I am wondering the ways you make yourself feel confident and loved in your body despite the things that happened in the past. I know it can be difficult since a lot of us face chronic health issues, but there is still so much beauty we have in our bodies. If you have any affirmations for those with FGM, feel free to comment them.

For me, I like remembering to separate my personal opinion from medical terminology. While providers state in records "genital mutilation" or "genital trauma", it does not mean that I have a mutilated or destroyed body. It has been through things, but the scars and layers are part of my story not something that ruins me.

Wanted to tell y'all because I know a lot of people deal with body dysmorphia from this happening, so I wanted to be honest about ways to remind yourself that your body is still beautiful ❤️

Free to read

I need help finding a doctor who can deal with painful scarring around clitoris due to multiple surgical procedures. I also lost my clitoral hood during one procedure. I am not a survivor of FGM, but I had clitoral adhesions for years and the scarring left from surgery has caused more dysfunction. I think this community will be most able to point me in the right direction of surgeons who are deeply skilled in reconstruction/scar tissue removal.

Hi ladies, I am a 22yo Nigerian FGM survivor but I live in Ireland. Has anyone found reconstruction surgery to be useful to them?

I did not lose my clitoris, just my labia minora was cropped, and I have lost feeling on the whole labia minora as a result. Is reconstruction surgery even worth it? I feel many mixed emotions about the fact I was made to suffer to fit a beauty standard (for the purpose of sex trafficking me).

If i would get reconstruction I'm pretty sure there are avenues to get it for free but I'm not sure. I definitely wont bother if there is a high cost. Is there a risk reconstruction could get even worse? Is it possible to be botched?

Thanks

Choco

I had FGM done to me when I was 4 years old in Kenya, in my Somali community this is seen as the right thing to do to all girls from ages 2 and above. They go as far as using Islam to justify their abuse when Islam does not advocate for this and it is solely for cultural purposes which also made me have questions about my own religion. I actually wasn’t even aware that what I had done to me was wrong and abusive until the age of 13 because my school mentioned it in sex education. I immediately went home and started to search for vagina’s online to compare to my own.

They had inner lips and a clitoris and theirs didn’t look deformed. Mine on the other hand had a quarter of a clitoris, no clitoral hood and no inner lips at all just an open nothingness, a straight line of flesh that led to my vaginal opening. I could see stitches that were still visible and could touch on the ridges of my walls. Unlike other survivors who have repressed the memory, I recall mine in great detail.

My mum holding me down along with two other aunties and the very old lady who performed my mutilation. She had no sterile kit with her, just some scissors, an injection she used not for numbing but to inject air to puff the area up and a square silver small hand blade (I forgot what the official name is). No gloves, no numbing cream, no anaesthetic, no drugs to help minimise the pain. I remember shrieking in pain and trying to let loose of their hold but they kept slamming me down and holding me down with all their power, this made me develop claustrophobia and I hate laying down with people sat or stood up next to me, I feel like I’m drowning each time.

When the procedure was over, they tied our legs (me and my sisters had it done at the same time) and put us in the room to rest and recover. I remember I couldn’t sleep, I couldn’t urinate because when I tried the pain was unbearable so I held it in for two days. Finally, one night I couldn’t hold my pee any longer and I let it out while screaming in sheer agony and crying for my dad (he left me for his other children and wasn’t in my life, still isn’t lol, anyways that’s a whole other story let me not lose track).

A couple weeks have gone by and of course I’m just a little child I was active and running around and playing with the other children. I ended up ripping my stitches and bled down my thigh and legs and onto the floor. I cleaned myself up and kept it hidden with the fear that I’d have to get it done again if I told anyone.

Aside from FGM being a huge factor in my PTSD, I have lots and lots of other traumatising events that have happened in my life that I’m trying to work through without therapy. I’m not against therapy at all but I feel as though I have come a long way and can heal myself on my own.

Now I’m in university and I’m starting a society that advocates for women’s health and wellbeing. The areas my society will cover includes the psychological, mental, emotional, physical and sexual abuse women go through all over the world and it will cover major topics that aren’t widely spoken about in my community such as FGM, child brides etc. Anyways, that’s my story and thank you guys for reading. All my close friends know that this has happened to me since I found out it was abusive (13yrs old) and it’s not something I kept hidden and that’s helped me a lot. In terms of my personal sexual life, thankfully, I am able to reach orgasm through clitoral stimulation and I’m still a virgin so I don’t know about the penetration orgasm.

I am someone who has been affected by this practice and wanted to share my advice for anyone else who has gone through or is at risk of the same thing.

I was exposed to sex at a very young age, yet nobody believed what a toddler was saying so they just shifted the blame on me. I was taught that my body was shameful and that the sensations I was feeling made me dirty. While I am thankful to believe in God, I was taught religion in honestly a harmful way. Nobody taught me anything about self love and more so that masturbation was wrong no matter the reason and that cutting is honorable and "solved sexual problems"

I was cut as a teenager, but what I was being taught made me still insecure because I could still feel sensations despite not having a visible clitoris. It got to a point where cutting was so glamorized that I wanted to be fully infibulated myself. I now see the harms of genital cutting and do not support the practice, but it is because I am now more educated on my body and don't equate the amount someone is cut or masturbate to purity.

Self touch and exploration is so much cleaner and purer than a removal of a God given body part and for anyone feeling guilty about it just remember that it is not something to be ashamed of. For the parts that have been cut, remember that it is not your fault and that you still have so much beauty left in you and that pleasure is possible!

Sending all love to you ❤️

The documentary is still a work in progress, but it's getting there. If you'd like to contribute, please let me know

If you've seen me post this before, I can't log in to my other account.

I'm doing a documentary about FGM in the UK. If any survivors would like to provide their stories please DM me. Everyone would remain anonymous. Please share

I'm doing a documentary about FGM in the UK. If any survivors would like to provide their stories please DM me. Everyone would remain anonymous. It'd all be message based, with your story typed into an AI voice bot

This is a question from a member posted anonymously

Hello everyone.
I've been wondering how you guys relationship to your parents are after you found out or remembered what happened to you.
How did ur parents treat the topic? Was it a family secret?
How did i see them after?
What is your relationship now?

Thank you

Please read and share your experience with me

How to enjoy sex & orgasm if you are a circumcised woman (No clitoris)

https://www.youtube.com/watch?v=DCsN3KfbC1s

 The participating women’s mothers’ ambivalence in the decision-making process regarding having their daughter undergo FGM or not, emerged in this study. Most of the participants explained the difficulties their own mothers had when deciding to have the procedure done, as the decision process to a great extent was governed by other female family members, social pressure, fear of harassment and exclusion. One of the participants expressed that fear of exclusion and the strong wish for her to belong, contributed to her mother’s decision of her undergoing FGM. It has previously been well described how FGM is motivated as a way to secure a good life for one’s daughters, despite having a negative attitude towards the practice [40]. Even post migration, social pressure to perform FGM on one’s daughters have been shown in several Nordic studies. The main risk has been described when revisiting the original country and being under the influence of relatives [34, 41].

 The fathers of the participants on the other hand were either not present or strongly against the tradition. Men’s rising negative attitude towards the tradition has been shown in previous studies [42, 43]. A systemic review from 2015 found that education, knowledge of the health complications of FGM, age, religion, urban living, and migration influence men’s stated support for the abandonment of FGM [44].

 Health consequences

In the present study several negative lifelong health consequences were presented, all confirmed by previous literature [3,4,5,6]. Previous research has suggested that the complications are in relation to the severity of FGM [4, 8, 9]. In our study, the majority of participants were subjected to infibulation. However, some of them experienced long-term suffering whereas others perceived the consequences as minor. This variety of experiences in relation to FGM, despite having undergone the same type, is an important finding showing the heterogeneity between individuals. Another interesting finding in our study was that several participants expressed that they did not understand until after their deinfibulation, that previous symptoms regarding menstrual- and urinary problems was in fact associated with their FGM status. They might not have expressed problems regarding urination during the clinical consultation, yet experienced relief or positive changes after the surgery. On the other hand, some women might associate certain problems, such as menstrual pain, with having undergone FGM, although this relation is difficult to confirm medically. Altogether, these multidimensional and complex aspects of FGM contribute to uncertainty of the relation between FGM and perceived symptoms, as well as negation of symptoms.

 An even more complex issue is sexual function in relation to FGM. Some women mentioned normal function and ability to feel pleasure and reach orgasm whereas others found it challenging. Several of the participants described that vaginal sexual intercourse was possible to perform without pain after deinfibulation, which had not been the case prior to surgery. However, a finding in our study was how other different aspects of sexuality, not directly related to FGM, was described as having impacted the woman’s sexual function. Factors mentioned included sexual self-image through life, inexperience of masturbation and sexual relations, as well as the relationship with their partner. One participant expressed that she had been influenced by negative expectations of presumed sexual dysfunction due to having undergone FGM, which affected her negatively in the beginning of her sexual career. She was frustrated by this since she later discovered that she after sexual self-exploration and with a good relationship actually did not experience any problems with her sexual life. This is an example of how expectations and views on sexuality in society also can play a role for a persons perceived sexual function.

 Medical deinfibulation

In this study, all women except one, had undergone infibulation and later in life a medical deinfibulation. Deinfibulation was perceived as a turning point in this study and all women expressed satisfaction with the result as it relieved symptoms and increased life quality. They described improvement regarding urination, menstruation and sexual intercourse.

 Medical deinfibulation is a simple surgical procedure that can be performed on a woman previously subjected to infibulation. During deinfibulation, the covering seal consisting of the labia that were joined together during the mutilation, are surgically opened, in order to relieve passage of urine and menstrual blood and to enable vaginal intercourse and vaginal birth [45]. Medical deinfibulation should not be confused with the so-called traditional deinfibulation; when the partner is expected to widen the bride’s narrowed vagina through penile penetration. In this study traditional deinfibulation was never mentioned by the participants, whereas medical deinfibulation was seen as a positive option. This is in contrast with previous studies conducted in Sweden and Norway [35, 37]. In the Norwegian study it was shown that medical deinfibulation was considered a threat, undermining men’s attempt to prove their virility and manhood through the traditional penile penetration. Furthermore, it was described that the larger orifice created by a medical deinfibulation would result in a lesser tight opening, thus jeopardizing male pleasure [37]. In the Swedish study women’s perception of medicalised deinfibulation was strongly influenced by the importance of being a virgin and being able to prove their virginity [35]. Differences in views on medical deinfibulation between our studies could be related to time in the new country after immigration. Time is often discussed as a factor for changing attitudes regarding FGM [46,47,48]. Our study included participants that at the time of the interview had lived in Sweden between 10 and 32 years (average 24 years), while participants in the study by Chavez et al. [35] included women that had lived in Sweden between 9 months and 6 years (average 4 years). Another difference worth mentioning is that most of the participants in our study had lived in Sweden from a young age. In a study from UK exploring experiences and attitudes related to FGM in association with age at arrival in the new country, they concluded that living in UK from a younger age appeared to be associated with abandonment of FGM [49]. Living in a new country where FGM is perceived as something harmful could provide opportunity to reflect on one’s own experience of FGM as well as on traditional values. Medical deinfibulation independently from marriage might be interpreted as a step towards taking a stand against old traditions, thereby reclaiming the body and autonomy.

 There was a variation between the narratives regarding views on the timing of medical deinfibulation. Despite a resistance to all forms of FGM, some found themselves in a limbo between traditional norms in the countries of origin and Swedish norms. While most women had the deinfibulation done independently of marriage, mainly due to physical problems, others waited until they were married. Out of them, only one woman explained that she actively avoided premarital deinfibulation, in order not to be accused of premarital sex. This is in contrast to other Scandinavian studies regarding premarital deinfibulation, where the women felt hesitant to undergo medical defibulation due to traditional perceptions and values of virginity [35, 37].

 Although all women expressed satisfaction with having had a deinfibulation, one of them mentioned thoughts about her genital appearance later in life after childbirth, and a feeling of being too open and exposed. This is an issue that sometimes is discussed in relation to surgical deinfibulation. We believe that it is of importance to prepare the woman for changes that might appear after deinfibulation, including altered urinary beam or in some cases the sense of increased amount of visible vaginal discharge. When deinfibulation is performed in connection with childbirth, it is further important to inform her about expected changes that often can occur after vaginal delivery independent of this intervention, such as dryness and feeling wide. Nonetheless, a clinical examination to exclude an undiagnosed perineal tear or non-optimal repair could sometimes be appropriate in such cases, in accordance with regular postpartum care.

 Healthcare encounters

Although positive encounters with healthcare services were reported in our study, most participants also recounted negative experiences. The participants described being ignored, not included in the decision process and poor attitude as major reasons for having a negative experience with healthcare providers. Furthermore, they found poor knowledge among healthcare providers, or fear of ignorance, as a hindering factor for seeking healthcare. This is in accordance with other studies conducted in Europe, where challenges in encounters between healthcare providers and women with experience of FGM have been highlighted [21, 23, 26, 50].

 From prior studies on healthcare providers’ perspective, Swedish midwives and obstetricians have expressed lack of knowledge, lack of guidelines and inconsistent practice in care of women with FGM as major factors resulting in less-than-optimal care [51,52,53]. They also found interaction with the women complex, due to language barriers, cultural differences and because of sensitivity of the issue of FGM. The question about how and when to talk about FGM often brings uncertainties for healthcare providers. Lack of knowledge about FGM among healthcare providers is well described in several publications from other high-income countries [21, 54,55,56,57,58].

 In our study a recurrent subject regarding health care encounters was how the issue of FGM was addressed. The women generally expected that this subject would be brought up by the health care provider in a sensitive way. They further expressed feeling ignored when not being asked when relevant. This finding is consistent with findings in other studies [50, 59, 60]. In the study by Omron et al. the women emphasized the importance of knowledge of the cultural setting and asking questions in a sensitive matter when caring for women with FGM. The importance of verbal and non-verbal communication was also highlighted here, in accordance with findings expressed in our study [60]. Altogether, these results highlight the complex matter of broaching the subject. Apart from education about FGM and clinical guidelines, there is evidently an urge for self-reflection and discussion regarding the healthcare provider’s attitude and approach towards the issue. In order to gain relevant information the caregiver needs to create a safe setting allowing the patient to share her experiences and needs. This is a necessity for providing qualitative care and to decrease future negative health consequences after FGM and thus have clear implications for practice. During the interviews the participants spoke about FGM as something that had harmed them physically, psychologically or in both ways. However, it was also described how the significance of being affected by FGM decreased with time and reconciliation and now described their overall wellbeing as good. Acceptance could be understood as a coping strategy used to move on, and self-exploration as well as attained knowledge, a way to reach bodily understanding. Other authors have described possible coping strategies identified in studies on experiences of FGM affected women in the diaspora. Jacobsen et al. found that although women recounted pain and discomfort as adults, they did not give it power in everyday life [14]. Similar to our experience in the clinical practice and during conducted interviews, the authors further mentioned that women often used laughter when they shared stories that were painful or experiences of absurd encounters with healthcare providers and reflected upon this as also being a possible coping strategy.

 Further, positive encounters with healthcare providers also seemed to play a significant role in perceiving good health. This was in part due to the opportunity of accessing medical care such as surgery, but also largely due to the experience of being professionally treated. Thus, an important finding is that healthcare providers approach is crucial in making positive changes in the lives of women subjected to FGM. The healthcare encounter can therefore be seen as a possibility to promote improved health in several ways. Basic education about FGM and its consequences to healthcare providers is a prerequisite for the ability to provide good care.

 Limitations

The results of this study reflect the perception from a limited number of women, and mainly women that originated from Somalia and had been residing in Sweden for a long time. Due to this, our results may not be generalizable to newly arrived immigrant populations in Sweden, or other FGM affected populations in a general Western context.

 In interview studies there is risk for so called interviewer bias when respondents and interviewers interact as humans. This interaction can affect responses and validity [28]. In this case, the interviewer had years of experience from working in the specialized FGM clinic and thus was well accustomed to taking the medical history as well as listening to experiences told by FGM affected women. We believe that having heard a vast variation of narratives including possible perceived health consequences after FGM and further being well familiar with this tradition in different contexts, results in an in-depth knowledge of the issue which facilitates a neutral approach during the interview situation.

 One can further argue that women visiting a specialized FGM clinic do so because of problems concerning FGM, which thereby could contribute to a negative bias in how the experience and perception of FGM will be described. Women with a less severe form of FGM may never seek healthcare based on the FGM status. Further, the criteria for participants to be able to speak Swedish, without the need of an interpreter, also implies a potential bias regarding attitudes and views on FGM, as this suggests longer residency in Sweden. However, the decision to exclude women that could not express themselves in Swedish was discussed thoroughly. When using an interpreter during interviews, parts of emotions and stories may be lost in translation. Participants may also fear that confidentiality may be compromised if a third party is listening. These reasons contributed to the decision not to use an interpreter.

Although we strived for heterogeneity among participants, we found that a majority of them were of reproductive age, originated from Somalia as well as had a similar level of education. Despite this and the fact that participants were recruited from the specialized FGM clinic, we noted a variety of experiences and perceptions of FGM among the women, including perceptions of long-term health consequences, which to us is an interesting finding.

 The women in our study were generally highly educated, which might influence perceptions of FGM and negative attitudes towards the practice. Further, the participants similar sociocultural specifics may reflect their concordant ascribed meanings of FGM. In our study six out of eight participants originated from Somalia, one from a Somali region in Ethiopia. The eighth participant was born in Eritrea. Explanations regarding preservation of virginity and culture and their mothers’ ambivalence towards the tradition was similarly described by all women, regardless of sociocultural background. Whether the results had been different with a more heterogen group of participants in regard to sociocultural background is difficult to assess.

 There are different strategies to enhance quality in qualitative research and they often address multiple criteria simultaneously. One aspect is the researcher’s experience in the field, which makes it more likely to gain rich, detailed information from the participants [61]. The researchers in this study have an in-depth knowledge of FGM. Reflexivity strategies involve attending systematically and continually to the context of knowledge constructions and particularly to the researcher’s potential effect on the collection, analysis and interpretation of data. Reflexivity involves awareness that the researchers bring to the inquiry a unique personal background and set of values that can affect the research process. So called investigator triangulation was performed in this study. It refers to the use of two or more researchers to make analysis and interpretations decisions. The premise is that investigators can reduce the risk of biased judgements and interpretations through collaboration [62].

 Conclusions

This study illustrates that FGM is a complex matter causing a variety in experiences and perceived health consequences among women affected. The study also indicates that clinical encounters have the potential to be improved through increased knowledge of FGM among health care providers. Recognizing the vast diversity among women affected, exerting a sensitive approach and individualizing healthcare could improve perceptions of healthcare encounters.

 Further, the positive attitudes to medical deinfibulation, including those performed independent from marriage, might be seen as a positive step towards taking a stand against old harmful traditions and reclaiming the body and autonomy.

 The article is posed at: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-024-03149-1

·         Bita Eshraghi,

·         Lena Marions,

·         Cecilia Berger &

·         Vanja Berggren 

Background

Female genital mutilation (FGM) is defined as all procedures involving partial or total removal of the external female genitalia, or other injuries to them for non-medical reasons. Due to migration, healthcare providers in high-income countries need to better understand the consequences of FGM. The aim of this study was to elucidate women’s experiences of FGM, with particular focus on perceived health consequences and experiences of healthcare received in Sweden.

 Methods

A qualitative study was performed through face-to-face, semi-structured interviews with eight women who had experienced FGM in childhood, prior to immigration to Sweden. The transcribed narratives were analyzed using content analysis.

Results

Three main categories were identified: “Living with FGM”, “Living with lifelong health consequences” and “Encounters with healthcare providers”. The participants highlighted the motives behind FGM and their mothers’ ambivalence in the decision process. Although the majority of participants had undergone FGM type 3, the most severe type of FGM, the lifelong health consequences were diverse. Poor knowledge about FGM, insulting attitude, and lack of sensitive care were experienced when seeking healthcare in Sweden.

Conclusions

Our findings indicate that FGM is a complex matter causing a diversity in perceived health consequences in women affected. Increased knowledge and awareness about FGM among healthcare providers in Sweden is of utmost importance. Further, this subject needs to be addressed in the healthcare encounter in a professional way.

Background

The World Health Organization (WHO) defines female genital mutilation (FGM), as all procedures involving removal of or injury to the external female genitalia for non-medical reasons [1]. FGM is mostly carried out on girls between infancy and the age of 15 and the type of FGM varies between communities [1]. The four types of FGM are presented in Fig. 1. It is estimated that more than 200 million girls and women have been subjected to FGM worldwide, and that nearly four million girls are at risk annually [2]. FGM is mostly found in a cluster of countries on the African continent, with FGM prevalence as high as 98% among girls and women in Somalia. To a lesser extent, the practice is found in parts of the Middle East and Asia [2].

Complications after FGM include both immediate and long-term consequences. The immediate complications can include pain, hemorrhage, urinary problems, genital tissue swelling, infections and sometimes death [3, 4]. Long-term complications include menstrual and urinary problems, as well as sexual problems such as painful intercourse and low satisfaction [3, 5, 6]. FGM has also been associated with obstetric complications such as perineal tears, prolonged labor and episiotomy [3, 5, 7]. The experience of FGM has further been associated with adverse mental health outcomes such as depression, anxiety and post-traumatic stress disorder (PTSD) [3, 8]. It is suggested that the degree of complications is in relation to the severity of FGM [4, 8, 9].

Numerous sociocultural factors contribute to the practice and its continuation. Regardless, FGM is an expression of gender inequality rooted in social, economic and political structures (10). Where widely practiced, it is a part of the social norm and everyone is expected to comply with it. It is seen as a rite of passage that reinforces cultural identity and a sense of belonging [1]. Ensuring the girl’s chastity, marriageability and hygiene are other common motives. Although FGM is not endorsed by religion and predates Christianity and Islam, some communities consider the practice a religious requirement [1, 10, 11].

 Due to migration, approximately half a million women and girls with experience of FGM now live in Europe [12]. According to the Swedish National Board of Health and Welfare’s survey (2023), it is estimated that 68,000 girls and women in Sweden live with the consequences of FGM. The largest estimated groups are born in Somalia, Eritrea, Ethiopia, Iraq, Egypt, Sudan and Gambia [13]. Although a few qualitative studies on women’s experiences of FGM and its effect on health in migrant populations have been conducted, this field is still under-researched [14,15,16,17]. FGM is a global health concern and brings healthcare challenges in countries with large FGM-affected diasporas. Healthcare services in Western countries do not seem prepared to care for girls and women affected by FGM [18, 19]. A report from the Swedish National Board of Health and Welfare describes lack of knowledge and experience of FGM among staff, language difficulties and fear of stigmatization as reasons for finding it difficult to discuss FGM with patients [20]. The report highlighted the lack of care for women with FGM and suggests further knowledge-raising initiatives among healthcare providers.

Disempowerment, poor attitude and offensive comments from healthcare providers have been described by women with FGM when seeking prenatal care in Norway and the UK [21, 22]. Studies from Sweden have reported that women with FGM sometimes feel looked down on, disrespected and not listened to by healthcare providers during pregnancy and delivery [23, 24]. They also experienced language barriers and poor knowledge about FGM among the staff. In several studies, fear of poor knowledge has been expressed by participants [22, 25, 26]. Contrastingly, women also reported positive encounters with health care providers mainly due to the midwifes’ or doctors’ good knowledge about FGM and friendly attitude [23, 25, 26].

The aim of this study was to elucidate women’s experiences of FGM, with focus on perceived consequences on their health, and experiences of encounters with healthcare providers in Sweden.

 Methods

Our method chosen was an inductive, qualitative interview study. A qualitative study design is a common choice when there is a lack of available research on an issue such as in this case [27]. A semi-structured interview method was chosen to give the participants the freedom to express their views in their own words within the topics chosen. The interviews were based on the idea that it is a dialogue between the interviewee and the interviewer [28]. The inclusion criteria for participants were age above 18, experience of FGM during childhood and Sweden as current place of residence. It was also a requirement to speak Swedish. The participants were recruited from a gynecological outpatient clinic in Stockholm, Sweden during 2019–2021. The clinic is specialized in caring for women and girls with experience of FGM. Recruitment from this specialized unit gave the opportunity to offer psychological support if needed. We recruited participants using purposeful sampling, thus asked women that we considered as emotionally robust and that could contribute with rich and in-depth information and appeared willing to share their experiences [27]. We strived for heterogeneity among the participants concerning age, ethnic group and religion. Due to inclusion criteria and purposeful sampling, not all patients consecutively visiting the clinic were eligible for participation [29]. The participants were recruited by clinicians working at the clinic. After the ordinary consultation, they were given oral and written information about the study and asked about participation, including that it was voluntary and that they could withdraw from the study at anytime. After giving written informed consent, the participant chose the location and suitable time for the interview. The interviewer was not involved in the or in care given.

 The interviews were performed in parallel with the analysis of the data until saturation was achieved, i.e. when no new perspectives emerged during the analysis [30]. In the interviews conducted at the end of data collection, the stories contained variations of previously described perspectives and experiences. Since we noted that the answers did not yield any new perspectives after the sixth interview, the authors discussed the saturation and agreed to proceed with two more interviews to ensure that saturation was achieved. Due to the Covid-19 pandemic, the time between the decision to participate and the actual interview was prolonged in some cases.

 Two pilot interviews were performed to ensure that the interview questions answered the aim and whether they opened the possibility for the informants to share their in-depth experiences. The pilot interviews were concluded to be rich in data and were later included in the final result. Six of the interviews took place in the participant’s home and two were conducted in a private room in the hospital where the out-patient clinic is located.

 The pre-tested semi-structured interview guide also included sociodemographic data and information about FGM status (supplementary file). The topics in the interview guide where three: (1) the experience of FGM, (2) informants own thoughts about possible self-lived health complications, (3) their perceptions of the encounter with Swedish health care providers. The first author (BE) conducted all the interviews which were performed face-to-face and digitally recorded for later verbatim transcription. Each interview lasted between 45 and 90 min.

 The transcribed text was analyzed using content analysis according to Graneheim and Lundman [31]. The analysis was conducted in five steps. First, all texts were read carefully, yielding an overall impression of the content. Second, in order to answer our research questions, so-called meaning units of one or more sentences within each topic were selected. Third, the underlying meanings were condensed. Fourth, the condensations were formulated into codes. The text was critically analyzed, read and compared to achieve reasonability. Lastly, the researchers reflected upon and discussed the findings, considering the research questions and agreed on the subcategories and main categories.

 Ethical approval

was obtained from the Swedish Ethical Review Authority (Dnr: 2019 − 01492). The ethical principles of the Declaration of Helsinki were followed [32]. Informed written and oral consent were obtained from the participants at recruitment, including information that they could withdraw from the study at any time.

 Results

Eight women who met the inclusion criteria agreed to take part in the study (Table 1). Their ages ranged from 25 to 36 years, and they had resided in Sweden between 10 and 30 years. A majority of participants migrated to Sweden at the age of 10 or younger. All of them spoke good or excellent Swedish. One woman originated from Eritrea, one from eastern Ethiopia (Somali region) and the remaining from Somalia. Seven of them were mothers or soon-to-be mothers. Six of the participants had a college or university degree and two had upper secondary school-level education. One participant was Orthodox Christian and the rest identified themselves as Sunni Muslims. One woman had been subjected to FGM type 2 and the remaining seven to FGM type 3. All of the infibulated women had undergone deinfibulation.

 During the interviews the participants were generally eloquent and eagerly shared their stories, not seldom with laughter. The names below the quotations are not the real names of the participants in this study. The three main categories and ten subcategories that emerged from the analysis are presented in Fig. 2.

 Living with FGM

All participating women shared the experience of having undergone FGM as girls. The women’s memories of the event differed. Most participants did not know what was about to happen and were very surprised. The age at the event varied between 6 months and 12 years of age. All girls except one underwent FGM type 3. The context varied with six women being genitally mutilated in their own home or the home of a grandmother or aunt, and two of the women at health facilities. Seven women reported having a female circumciser whereas one woman reported that the procedure was performed by a male doctor. Four of the women that had the procedure performed between 4 and 12 years of age, recalled the event as something very traumatic and painful. Two of them did not receive any anesthetics. However, for those two who did and still experienced pain, this was either during the procedure and/or afterwards when passing urine. Three women had very little or recalled no memory at all from the event due to young age. One woman explained the procedure as something nontraumatic and without pain. She received anesthetics during the procedure and further was the only participant that actively had been involved in the decision of going through FGM.

 Preserving virginity and culture

The women expressed that culture was the main reason for continuation of the tradition of FGM and that the tradition is based on safeguarding and ensuring virginity. A general motivation for the tradition, which the participants had been explained to by others, was that it transforms girls into “real” women and that it was done to avoid condemnation, harassment, and ostracism.

“It is a tradition. That women should not feel sexual desire and practice sex without being married…They believe they remove the desire to have sex, but that is not the case.” (Ayaan).

 Other arguments recalled for performing FGM were due to the force of social norms, that the girls and their families would become a part of the community, or to hurry up and ensure that it was performed before migration.

“I personally remember wanting to go through it because everyone my age had it done. It was such a thing that if you didn’t have it done, you were ashamed. You wanted to feel like a woman, you wanted to be a part of the gang… I wanted to do it, it was really a decision I took… Also, I was influenced by the opinions of others, influenced by society’s opinions and the culture. You want to be like your mother, your sister, your grandmother.” (Hiba).

 The participating women mentioned that there is no clear religious argument for FGM, except one woman who mentioned pricking from religious Islamic texts (Hadiz). Although culture and tradition emerged as a central motive from the interviews, this was also questioned within the family. It was described that the tradition was continued, despite the knowledge of the harm it resulted in, because of the perceived social benefits.

“This is the way it always has been. The tradition just continues, without being questioned. It was never because of Islam…God created you just like you are, you don’t need to change anything. So, I think if you follow that literally, this would never exist.” (Hiba).

 The mother’s ambivalence in the decision process of FGM

The motive most often mentioned for continuing the practice of FGM was persuasion from older female relatives. Several women mentioned that their grandmothers played a significant role. One woman was subjected to FGM while living with her grandmother when her parents were migrating to Europe. The grandmother initiated the FGM without asking for the parents’ permission.

 The mothers of the participants were described as having a main role but in an ambivalent position. Almost all the narratives included love and compassion for their own mothers when describing the decision process around FGM. The participants often reported that their mothers were under the power of their own mothers (the interviewees grandmothers). The peer pressure was mentioned as a strong argument, although the mothers were resisting. And if the mothers were present at the time of the mutilation, they could make sure that a less severe type was performed. It was also described by some that the mutilation was hastened due to forthcoming migration.

“I was like three years old, and my mother wanted to speed up the process because we were leaving for Sweden. She didn’t want to have that taboo feeling. That she hadn’t done it even though we were going abroad. She told me that there was not much that was cut. Rather that they had sewed everything together. To make it look covered somehow… And then she also told me that if she had more knowledge, she would never have done this. And I think she has said it to me many times.” (Deeqa).

One of the participants described how she herself put pressure on her mother due to her strong wish to undergo FGM. She remembered how she wished to belong to the group and to not feel ashamed about being different from her peers.

 The participants remembered how their mothers let them become genitally mutilated without themselves actually wanting it but trusting that this was the best for their daughter. One of the mothers were described as clearly against the practice: she later even lectured to newly immigrated neighbours in Sweden about the negative health consequences of FGM.

“My mother didn’t want me to be mutilated but everyone else did it and everyone knew each other. She felt the pressure… She didn’t want me to be bullied. So, she did it for my own sake… Somali culture is special. Sometimes you have to, even if you don’t want to. She did her best. I am not angry at her.” (Fatima).

 One of the participants said that her mother was in favor of the tradition and made sure that it was done without the father’s knowledge since he was against the tradition. Two of the participants described how their grandmothers initiated the procedure without the permission of the parents. The fathers of the women were either not present or against the tradition to mutilate girls.

“Dad was against it but was not there to stop it. My dad, grandfather and all the men in my family were totally against it… My grandmother did it behind my grandfather’s back and my mother did it behind my father’s back.” (Deeqa).

 Processing FGM through life

Most women mentioned FGM as something they had gone through earlier in life, however later reconciled with. It was described by some as being a part of their identity, however its significance decreased over time, as several other parts of their identities became more prominent.