International Journal of

Environmental Research
and Public Health

Article
Female Genital Mutilation Consequences and Healthcare
Received among Migrant Women: A Phenomenological
Qualitative Study
Alba González-Timoneda 1, * , Marta González-Timoneda 2 , Antonio Cano Sánchez 3 and Vicente Ruiz Ros 1

1 Faculty of Nursing and Chiropody, University of Valencia, 46010 Valencia, Spain; vicente.ruiz@uv.es
2 Department of Obstetrics and Gynecology, University Clinic Hospital, 46010 Valencia, Spain;
mgonzaleztimoneda@gmail.com
3 Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; antonio.cano@uv.es
* Correspondence: alba.gonzalez@uv.es

Abstract: European healthcare systems are increasingly being challenged to respond to female genital
mutilation (FGM). This study explores the FGM experiences of migrant women coming from FGM-
practicing countries residing in a European host country. A qualitative phenomenological study was
carried out and 23 participants were included. Data were collected through 18 face-to-face open-
ended interviews and a focus group and were analysed using Giorgi’s four-step phenomenological
approach. Three main themes were derived: “FGM consequences”, “healthcare received” and



“tackling FGM”. Participants highlighted obstetric, gynaecological and genitourinary consequences


such as haemorrhages, perineal tears, caesarean delivery, risk of infection, dysmenorrhea, urinary
Citation: González-Timoneda, A.; tract infections and dysuria; consequences for sexuality, mainly, dyspareunia, loss of sexual interest
González-Timoneda, M.;
and decreased quality of sexual intercourse; and psychological consequences such as loss of self-
Cano Sánchez, A.; Ruiz Ros, V.
esteem, feelings of humiliation and fear of social and familial rejection. Women perceived a profound
Female Genital Mutilation
lack of knowledge about FGM from health providers and a lack of sensitive and empathetic care. Some
Consequences and Healthcare
women perceived threatening and disproportionate attitudes and reported negative experiences.
Received among Migrant Women: A
Phenomenological Qualitative Study.
Participants highlighted the importance of educating, raising awareness and improving prevention
Int. J. Environ. Res. Public Health 2021, and detection strategies. The findings disclose the need to improve training and institutional
18, 7195. https://doi.org/10.3390/ plans to address structural and attitudinal barriers to health equity across migrant families in their
ijerph18137195 host countries.

Academic Editor: Eleanor Holroyd Keywords: female genital mutilation; female circumcision; health consequences; women’s health;
nursing; midwifery; migration; health equity; qualitative research
Received: 27 April 2021
Accepted: 1 July 2021
Published: 5 July 2021

1. Introduction
Publisher’s Note: MDPI stays neutral
Violence against women is one of the most pervasive gender-based inequalities that
with regard to jurisdictional claims in
creates inequalities in many areas of the life of women and girls. These disadvantages pose
published maps and institutional affil-
serious threats to their welfare and the fulfilment of their rights [1]. The practice of female
iations.
genital mutilation (FGM) is a harmful traditional practice that involves partial or total
resection of the female external genitalia or other injury to the female genitalia for cultural
or other non-medical reasons [2]. The typology of FGM is shown in Table 1 [2]. FGM is
recognised internationally as a violation of the human rights of girls and women and as
Copyright: © 2021 by the authors.
an extreme form of gender discrimination that should be eliminated to achieve gender
Licensee MDPI, Basel, Switzerland.
equality and women’s empowerment. That is why the United Nations strives for its full
This article is an open access article
eradication by 2030, following the spirit of Sustainable Development Goal 5 [3].
distributed under the terms and
According to the latest United Nations Children’s Foundation (UNICEF) data, the
conditions of the Creative Commons
Attribution (CC BY) license (https://
exact number of girls and women affected by FGM globally remains unknown. However, at
creativecommons.org/licenses/by/
least 200 million of women and girls have undergone FGM and it is estimated that 68 million
4.0/). girls will undergo FGM before 2030 if action against this practice is not intensified [4,5].

Int. J. Environ. Res. Public Health 2021, 18, 7195. https://doi.org/10.3390/ijerph18137195 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 7195 2 of 17

Table 1. Types of female genital mutilation [2].

Type Description
Clitoridectomy
I This is the partial or total removal of the clitoris and in very rare cases, only
the prepuce.
Excision
II This is the partial or total removal of the clitoris and the labia minora with or
without excision of the labia majora.
Infibulation

III This is the narrowing of the vaginal opening through the creation of a covering
seal. The seal is formed by cutting and repositioning the labia minora or labia
majora, sometimes through stitching with or without removal of the clitoris.
Others

IV This includes all other harmful procedures to the female genitalia for
non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing
the genital area.

FGM is mainly concentrated in 130 countries in the western, eastern and north-eastern
regions of Africa, along with the Middle East and is practised in some countries of Asia and
Latin America with wide variations in prevalence [6]. Nevertheless, not all ethnic groups
living in these countries practice FGM, nor do all the ethnic groups that practice it follow
the same procedure. The kind of FGM carried out varies mainly according to ethnicity [7].
FGM is carried out during infancy with most girls cut before the age of 15. In others, it
takes place at the time of marriage, during a woman’s first pregnancy or after the birth of
her first child [5,7].
Thus, although the practice is originally characteristic of certain areas, this local
phenomenon has been globalised and spread around the world through the different
migratory movements. Therefore, FGM and its harmful consequences are affecting a
growing number of women and girls among migrant communities in Europe, North
America and Australia [5]. According to the 2011 census, around 600,000 women and
young females have experienced FGM in Europe and it is considered that 190,000 young
girls are at risk of FGM in 17 European countries alone [8]. In the United Kingdom (UK),
it was estimated that 137,000 women and girls were living with FGM in England and
Wales in 2015 [9]. In Spain, it is estimated that almost 70,000 women and girls come
from countries affected by FGM [10]. The Valencian Community is the fourth Spanish
autonomous community with the largest population from countries affected by FGM;
mainly from Nigeria, Senegal, Guinea, Mali and Cameroon [10].
It is expected that the number of women with FGM in Europe will rise at quite a fast
rate and future flows are expected to be strongly geographically selective, involving mainly
France, Italy, Spain, the UK and Sweden [11]. This fact has implied that healthcare systems
in European countries are increasingly being challenged to respond to the care of affected
communities.
The practice is painful and traumatic and its performance is often unhygienic or
carried out by non-expert practitioners who have little knowledge of the anatomy of the
genitourinary system of women and lack the ability to respond to adverse events. FGM
has consequences that undermine the health and well-being of girls and women, revealing
a remarkable situation on the global women’s public health agenda [12,13]. The effects
of FGM depend on several factors, including the type performed, the expertise of the
practitioner, the hygiene conditions under which it is performed, the amount of resistance
and the general health condition of the girl/woman undergoing the procedure [12].
Immediate complications include severe pain, shock, haemorrhage, tetanus or infec-
tion, urine retention, ulceration of the genital region and injury to adjacent tissue, wound
Int. J. Environ. Res. Public Health 2021, 18, 7195 3 of 17

infection, urinary infection, fever and septicaemia. Haemorrhage and infection can be
severe enough to cause death. Long-term consequences include complications during
childbirth, anaemia, the formation of cysts and abscesses, keloid scar formation, damage to
the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse), sex-
ual dysfunction, hypersensitivity of the genital area and increased risk of HIV transmission,
as well as psychological effects [12].
In addition to the physical and psychological impact of FGM, the associated complica-
tions are usually not the primary problems for women who arrive as refugees or migrants.
They are very likely to come from conflict zones where they experience poverty, malnutri-
tion, health problems, lack of educational opportunities and restricted access to health care
services [14]. This fact discovers a variety of cultural realities for health professionals that
have led to face new care challenges. Furthermore, migration can create or increase vulner-
ability due to multiple factors such as low socioeconomic status, language, cultural barriers,
or lack of knowledge about healthcare rights and accessibility. This vulnerability can be
notable during the period surrounding motherhood, when these women normally tend to
attend for the first time the healthcare system. Almeida et al. reported, in migrant women,
lower levels of access to health care and poorer birth outcomes than non-immigrants or
English-speaking immigrants [15].
Evans et al. suggests that care and communication around FGM can pose signif-
icant challenges for women and other healthcare providers [16]. Several studies have
explored the knowledge and attitudes of healthcare professionals regarding the practice of
FGM in western countries evidencing a profound lack of knowledge about the practice of
FGM [17,18]. Evidence also indicates that women affected by FGM do not receive appro-
priate healthcare due to cultural barriers and lack of knowledge and capability to provide
competent transcultural care by healthcare professionals [17,18].
Nonetheless, limited research has examined how women and men experienced the
practice of FGM and its consequences, as well as the healthcare received within the Spanish
national public health system [19–22]. Furthermore, there have been no studies to date that
examine the experience of women affected by FGM when receiving healthcare in the region
of Valencia, although evidence indicates that healthcare providers are not knowledgeable
about FGM despite being a problem present in the Valencian community [23,24].
To address this need and considering that FGM may act as an element of discrimination
and a condition for health inequalities in contexts where the practice of FGM is unknown
and ignored, the aim of this study was to gain in-depth experiential knowledge about the
experiences regarding FGM of migrant women coming from FGM-practicing countries
residing in their European host country.

2. Materials and Methods

2.1. Design
A qualitative study design with a phenomenological approach was chosen. Phe-
nomenology was selected on the basis of its relevance to research individual lived experi-
ences, meaning-making and interpretation of one’s experience or perception. This method,
developed by Husserlian philosophy [25], aims to explore the same phenomenon through
rich descriptions of individuals revealing common features of the lived experience. For
Husserl, to understand a phenomenon, whatever the purpose, it is not possible to ignore
the experience of the person who lives the phenomenon [25].

2.2. Participants
A total of 23 participants were included in the study. For the selection of the partici-
pants a purposeful sampling strategy was used, which implies identifying and selecting
individuals or groups of individuals that are especially knowledgeable about or expe-
rienced with a phenomenon of interest [26]. The sampling was based on a profile that
comprised a set of selection criteria: women and men 18 years of age and older coming
from countries where FGM is practiced, who had undergone FGM or had been in close
Int. J. Environ. Res. Public Health 2021, 18, 7195 4 of 17

contact with the practice, who were able to provide informed consent, who spoke English or
Spanish or had translation assistance during the interview. Of the 23 participants recruited,
20 women had undergone FGM. We also included the two men and a woman that had
been in close contact with the phenomenon studied since their wife and female relatives
had FGM performed and they had lived closely the FGM consequences.
Contact with the target population was made through key informants. Key informants
were local community leaders who were located via community health agents, local
associations of migrants and social organizations and services. Key informants were
asked if they wanted to participate in the study if they met the inclusion criteria. Key
informants also served as gatekeepers since they were trusted sources that controlled access
to the target population. Using the snowball sampling technique, they contacted potential
participants and asked them for the first time if they would agree to the study. This
technique was chosen because its suitability provides forms of contact with populations
or groups characterised as difficult to access or, meant in the literature, as hard-to-reach
populations [26,27] or hidden populations [28,29]. Participants who agreed to be contacted
by the researchers were approached by telephone and face-to-face. In addition to being
an intentional and reasoned sampling, it was cumulative, flexible and reflective as it was
expanded throughout the research process until data saturation was reached.

2.3. Data Collection

All eligible participants who were approached agreed to be part of the study. Data
were collected through 18 face-to-face open-ended semi-structured interviews and a focus
group. The study was carried out in two stages: the first stage was carried out in London
(United Kingdom) in January of 2017 and the second stage was carried out in Valencia
(Spain) from February to May 2017. The focus group was conducted in April 2017 in
Valencia. The study was carried out in two stages based on the criteria of convenience-
relevance and the sufficiency of the sample, which were also considered to facilitate the
research process and the scope of the saturation principle.
First, a few questions exploring the sociodemographic characteristics of the sample
were undertaken. The following general questions included women’s experiences on
FGM, its consequences and the healthcare received. The participants chose the times
and locations for the interviews: participants’ home, workplace or a cafe or a garden
close to their homes. Two researchers were involved in carrying out the interviews. The
researcher’s credentials, occupation and training were informed to participants prior to
data collection. All narratives were, after obtaining consent, recorded in audio format. Field
notes were written after each interview to detail observations that could not be captured via
the audio recording. The duration of interviews sessions ranged between 11 and 58 min.
The focus group was conducted to stimulate the interaction between the participants
and to explore the discourse in certain social context, capturing the social experience
and the different opinions and contractions following Berenguera approach [30]. The
focus group included five Nigerian women coming from vulnerable social groups such as
prostitution and trafficking who agreed to participate. They were contacted through a local
women’s support association. The focus group was open, non-directive and flexible and
offered the participants the freedom to answer or not the questions posed to them. For the
implementation of the focus group, a second person was required to act as moderator.

2.4. Ethical Considerations

All participants received oral and written information about the purpose of the study,
voluntary participation, guaranteed confidentiality and the right to discontinue at any time
without any adverse effects. All participants signed a written informed consent prior to
each interview. All interviews were coded prior to their transcription to guarantee the
confidentiality of the participants. Approval was obtained from the Ethics Committee in
Human Research of the University of Valencia, Spain.
Int. J. Environ. Res. Public Health 2021, 18, 7195 5 of 17

2.5. Data Analysis

Data analysis was conducted according to the four-step phenomenological approach
of Giorgi [31] and took place concurrently with data collection. The first step was data im-
mersion; interviews transcripts and field notes were thoroughly read and digital recordings
were also carefully listened to obtain a sense of the whole described by the participants. All
interviews were transcribed verbatim by the lead researcher protecting all the participants
identities using code numbers. The second step involved dividing narrative data into
concepts which required the extraction of individual meaning units or conceptualisations.
This was possible by re-reading the transcripts again breaking down the whole through
analysis into common elements. Together two authors independently analysed the nar-
ratives and interviews both as a whole and for meaning. To facilitate the management
and grouping of qualitative data, the Atlas.ti v.8. qualitative data analysis software was
used [32]. The third step consisted in organising, analysing and transforming the lan-
guage of the participants into a conceptual perspective of the experience, relative to the
phenomenon of interest. This step saw the emergence of themes and the authors worked
collaboratively to discuss the emerging themes and resolve any differences. In the final
step, themes and sub-themes were combined into a final general description that reflected
the lived experience of participants. All researchers agreed on the final thematic structure.

2.6. Rigour
To assess the rigour of the research process developed in the framework of quali-
tative research, we have based ourselves on the general criteria described by Guba and
Lincoln: credibility, transferability, dependency and confirmability [33]. Specific strategies
to attain trustworthiness were used as recommended by Guba and Lincoln [33]. Firstly,
to obtain credibility, data are presented as verbatim quotes and explained by the authors’
interpretation to illustrate the richness of the data. In addition, the data, researchers and
methods were triangulated. The member check strategy was also performed with one
participant who agreed to reviewthe returned transcript. Secondly, to facilitate transfer-
ability to other settings, detailed descriptions of the context, the sample, the participants’
perspective and the phenomenon itself have been produced in order to allow readers to
make informed judgements about similarity between contexts. Thirdly, to check depend-
ability, data collection tools and analysis strategy and findings are thoroughly described.
Finally, the researchers used reflexivity about their own position on the topic to ensure the
confirmability of the data.
This study has been reported in line with the Consolidated Criteria for Reporting
Qualitative Research (COREQ) guidelines to enhance the quality and transparency of the
study [34].

3. Results
From the 23 experiences collected, 20 women had undergone FGM, of whom 14 had
been mothers. The mean age of the men interviewed was 50 years, while that of the
women was 31.8 years. All the participants came from countries affected by FGM: Mali,
Somalia, Nigeria, Burkina Faso, Senegal and Cameroon, except for one participant who
came from Equatorial Guinea and was included in the study since she had close contact
and knowledge about FGM. The detailed sociodemographic characteristics and the FGM
status of the study participants are shown in Tables 2 and 3.
Int. J. Environ. Res. Public Health 2021, 18, 7195 6 of 17

Table 2. Sociodemographic and FGM characteristics of participants (individual interviews).

Years Out Age of

Place of Type of
Number Sex Age Profession Ethnicity Residence of Country FGM FGM
Origin FGM
of Origin (Years)
Kismaayo, Yes (in
I1LW Woman 28 Midwife - London 22 I 6
Somalia Italy)
Health
Kismaayo, II-III
I2LW Woman 43 Care - London, 17 Yes 6–7
Somalia (Pharaon)
Assitant
Health
Mogadishu, II-III
I3LW Woman 44 clinic - London 5 Yes -
Somalia (Pharaon)
assistant
Mogadishu,
I4LW Woman 28 Housewife - London, 12 Yes III (oni) 9
Somalia
Mogadishu,
I5LW Woman 36 Housewife - London, 13 Yes II 5–6
Somalia
I6VW Woman 43 Senegal Catering - Valencia 9 No - -
I7VM Man 47 Cameroon Catering Bamileke Valencia 16 - - -
Dakar,
Woman 35 Hospitality Wolof Valencia 11 No - -
I8VW Senegal
Dakar,
* sister Senegal
- - France - Yes Uncertain 12
in law (originally
from Guinea)
I9VW Woman 39 Nigeria Hospitality Ibu Valencia 11 No - -
Bata,
Woman 40 Ecuatorial Hospitality Fang Valencia 18 No - -
I10VW
Guinea
* female
Nigeria - - - Yes Uncertain -
relative
Uagadugú,
Cleaning
I11VW Woman 43 Burkina Mossi Valencia 10 Yes I 1
staff
Faso
I12VW Woman 34 Mali Housewife Bambara Valencia 8 Yes Uncertain 3–4
Edo,
I13VW Woman 31 Housewife - Valencia 5 Yes Uncertain <1
Nigeria
Technical
staff in
I14VW Woman 29 Kayes, Mali Mandike Valencia 8 Yes III 1 week
Founda-
tion
Seasonal
I15VM Man 53 Malí Bambara Valencia 7 - -
worker
* his
44 Malí - Bambara Valencia 3 Yes Type II -
wife
Bamaku, Fulani
I16VW Woman 28 Student Valencia 8 Yes Uncertain <7
Mali (Peul)
I17VW Woman 25 Kayes, Mali Housewife Valencia 2 Yes Uncertain 1 month
Rural area,
I18VW Woman 26 Housewife Valencia 1 Yes Uncertain 1 month
Mali
* Wife and female relatives who had FGM performed. I8VW, I10VW and I15VM included because had been in close contact with the
phenomenon studied.I: interview: V: Valencia; L: London; W: woman; M: man.

Table 3. Profile of participants included in the focus group.

Interview Age Country of Origin Years out of Country of Origin Marital Status FGM, Type
IG1VW 19 Nigeria 2 Single Yes, uncertain
IG2VW 19 Nigeria 5 Single Yes, uncertain
IG3VW 31 Nigeria 4 Single Yes, uncertain
IG4VW 22 Nigeria 1 Single Yes, uncertain
IG5VW 24 Nigeria 3 Single Yes, uncertain
I: interview; G: Grupal; V: Valencia; W: woman.

Three main themes were derived from narrative data: (a) FGM consequences, (b)
healthcare received and (c) tackling FGM. From these, several sub-themes emerged, which
are described below (Table 4). Representative quotations from the participants are used to
verify and validate the findings.
Int. J. Environ. Res. Public Health 2021, 18, 7195 7 of 17

Table 4. Themes and subthemes emerging from the data.

Theme Subtheme
Obstetric consequences
Genitoruinary complications
Pain
Consequences of FGM Sexual complications
Psychological and social consequences
Lack of insight
Men’s consequences
Unacquainted professionals
Lack of detection and information
Healthcare received
Stigmatizing and over-inquisitive attitudes
Offering reversal or deinfibulation
Education and awareness
Speaking up
Tackling FGM
Improving prevention
Penalization

3.1. Consequences of FGM

In this category, the following subthemes were derived: “obstetric consequences”,
“genitourinary consequences”, “pain”, “sexual complications”, “psychological and social
consequences”, “men’s consequences” and “lack of insight”. In general terms, both short
and long-term consequences were described. The severity of complications depends on the
type of FGM that has been performed, types II and III being the most intrusive: “The bigger
the grade is, the more complications are” (I1LW). Other factors, such as the girls’ prior
health or the conditions in which the practice is carried out, also influence the consequences
of the procedure.

3.1.1. Obstetric Consequences

Regarding obstetric consequences, the most frequently mentioned were postpartum
haemorrhage, perineal tears, pain, caesarean delivery and the risk of infection. Infertility,
preterm birth, shoulder dystocia and even death were also mentioned (Table 5). Serious
complications such as the death of girls and women due to postpartum haemorrhages were
discussed. Of the fourteen women who had undergone FGM and had been mothers, 46%
ended the pregnancy by an elective caesarean section or by an urgent caesarean section
due to failed induction of labour.

Table 5. Obstetric and gynaecological consequences of FGM.

Obstetric-Gynaecological Complications
“I started working in a maternity ward ( . . . ) when a pregnant woman arrived for birth it was a disaster ( . . . )
two women in front of me lost a lot of blood . . . ” (I15VM)
Postpartum haemorrhage “Two girls from my town, 18 and 22 years old died in childbirth ( . . . ) in my town there isn’t a blood bank, there
is nothing at all, if your wife has a problem with childbirth you have to take the woman by bicycle to the nearest
maternity hospital, which is 8, 10, 20 km away from town . . . “ (I15VM)
“It was very painful, that’s what I always say. I asked the midwife then how many stitches I had, but they could
Perineal tears
nou be counted. They gave me a lot of stitches inside and outside” (I14VW)
“There are many complications for women ( . . . ) first, there are many hygienic infections” (I8VW)
Infection
“Strong pain ... but also if you are unlucky you get an infection...” (I6VW)
“The problem was with my third baby ( . . . ), to get him out they forced his arm . . . the midwife squeezed a lot
Arm palsy
and his arm ended up broken. He has arm paralysis” (I11VW)
Preterm birth “They were very preterm; they were born at 23 weeks” (I16VW)
Infertility “Yes, yes, we were trying for a while, with the second insemination I got pregnant” (I16VW)
“When you are pregnant . . . labour is usually very difficult, there are even girls who die giving birth” (I8WM)
Death
“At times there are girls who bleed a lot and sometimes they die” (I11VW)
Int. J. Environ. Res. Public Health 2021, 18, 7195 8 of 17

3.1.2. Genitourinary Complications

Multiple allusions were also made to bleeding secondary to FGM itself, also associated
with the significant risk of traumatic wound infection.
“In my country (Mali) they usually do FGM to babies of a week or days of life.
There are not so many means to do it. Likewise, they cut 20 girls using the same
knife, so there are many infections. There are also girls who die from hemorrhages
. . . ” (I14VW)
“There are many complications ( . . . ) first, there are plenty hygienic infections”
(I8VW)
“Bleeding... Her family was healing her, at home! Not in a hospital” (I9VW)
In addition, to wound infections caused by FGM, women also refer us to other gen-
itourinary complications such as repetitive urinary tract infections: “Yes, many (urine
infections), as a child and now” (I12VW)

3.1.3. Pain
Moreover, the pain is a symptom that appears associated with most complications’ sec-
ondary to FGM. We have found references to it both when urinating (dysuria), having sex
(dyspareunia), related to menstruation (dysmenorrhea) or related to birth or gynaecological
examination (Table 6).

Table 6. Quotations related to pain associated to the practice of FGM.

Pain
“I was lucky because I never had problems with my periods, the man who was doing it was a
Dysmenorrhea
doctor, so he didn’t cut us like other people from outside the city” (I2LW)
“The first time I went for a wee it was very painful. I didn’t want to go to toilet, I was holding my
Dysuria wee . . . I was crying I will never forget that moment” (I2LW)
“Bad things, pain for wee at the beginning. After 2 weeks, it was normal” (I5LW)
“Period problems, having sex is very painful . . . ” (I2LW)
Dyspareunia
“She has 3 children but with her husband during intercourse she is always screaming” (I8VW)
“I didn’t feel it, but they say that when you are giving birth there are women who find it much
more difficult ( . . . ) it hurts more when giving birth ( . . . ) They say that there are births that last
longer and are harder” (I11VW)
Pain during birth
“I have explained to him the inconveniences that women have when giving birth because they see it
the opposite of the ones here; they think that women who are not mutilated at the time of giving
birth they will suffer a lot, but it is totally the opposite” (I14VW)

3.1.4. Sexual Complications

Regarding the consequences on sexuality, dyspareunia, the decrease or absence of
erotic desire, the decrease in the quality of sexual relations and anorgasmia were mainly
mentioned: “Then, when you get married it is very difficult to feel pleasure” (I1LW), “She
is suffering because she does not have the desire to have sex” (I9VW).

3.1.5. Psychological and Social Consequences

Regarding psychological consequences, the participants did not explicitly describe
suffering from anxiety and depressive disorders, post-traumatic stress, or reminiscences of
the moment of the cut. However, we can find verbatims of clear components of psychosocial
affectation such as loss of self-esteem, feelings of humiliation and fear of social rejection
and dishonour of the family.
“I had to please my parents, I had to please everyone. I was given plenty of gifts,
gold, jewellery, which is hardly praised in our culture” (I1LW)
Int. J. Environ. Res. Public Health 2021, 18, 7195 9 of 17

“Because a girl who is not mutilated, people call them ‘bilákoro’, it’s like . . . if
you are dirty, you are not welcomed . . . ” (I15VM)
“It is a party, the day of FGM comes and then the whole family gets prepared. It
is said that the girl’s crying defines the courage of the family” (I15VM)

3.1.6. Lack of Insight

Finally, we have also found different testimonies from women affected by FGM who
report not having suffered any associated complications. Two participants expressed:
“There are no complications after female circumcision” (IG); “It didn’t affect my sex life and
it didn’t affect my pregnancy. I would have loved to have my clitoris hanging, but it’s not
there which is fine, no problem! Sex life it’s OK! I cannot complain! (Laughs . . . )” (I1LW)
Many women do not perceive the consequences and complications as a cause of FGM,
since they understand that they are “common and normal in women”. Therefore, they do
not perceive the need to seek support, help or assistance in the face of a problem, since they
consider it as something intrinsic to the nature of women.
“If they have severe FGM types, they have lots of problems such as infection,
difficulty with bleeding like periods problems. However, they do not seek much
help because they think that is normal for every woman, the more they are
educated the more help is seek. Yes, but I do not think they will be coming in
numbers. Only the ones who knows better” (I1LW)
There is also a belief in some communities that if something bad happens, the existence
of a “higher being” is what determines the final result as reported by one participant:”It is
something normal in life. For example, when girls die during the FGM procedure, people
think that God has made the decision and it happens because it must happen. It is the
same for women who die giving birth. They do not associate it with mutilation” (I14VW)

3.1.7. Men’s Consequences

Some of these consequences also affect men. For I2LW interviewee, men do not
suffer any consequence: “I don’t know the men, I don’t think they have problems” (I2LW).
However, other participants suggest the opposite: coping with the fear of losing virginity
on their wedding night, frustration, or decreased quality of sexual relationships.
“A lot of pressure comes also from men, but I think in my culture lots has changed,
and men are stepping back, and they don’t want to go through that trouble ( . . . ),
when a woman who is FGM type III comes to them, and they have to open their
vagina with their own genitalia” (I1LW)
“There are men who do not want to sleep with the woman that day, but there are
others who force her wives because they have to do so ( . . . )” (I14VW)
“Women do not have pleasure when they have sex and this generates many
frustrations, for men too, so they do not feel satisfied in bed and then the problem
begins. They go with other women . . . ” (I14VW)

3.2. Healthcare Received

From this theme, four subthemes were derived: “unacquainted professionals”, “lack
of detection and information”, “stigmatizing and over-inquisitive attitudes” and “offering
reversal or deinfibulation”.

3.2.1. Unacquainted Professionals

The lack of knowledge about FGM of different professionals perceived by women
emerged, for example, when they underwent gynaecological examination or received
childbirth care.
Int. J. Environ. Res. Public Health 2021, 18, 7195 10 of 17

“I knew that the way they looked at me meant that they had no knowledge of
what had happened to me ( . . . ) When we talk between us, the ignorance of
professionals comes up” (I14VW)
The interviewee I8VW experienced an unpleasant situation in consultation, when
the midwife made an unfortunate comment, thus demonstrating a lack of sensitivity
and information about FGM and its approach: “The midwife found it very rare that
performing a cervical smear would hurt so much and she told me: ’if the penis has fit there,
it shouldn’t hurt so much’. I explained to her why it was so painful for me. Ashamed she
apologised” (I8VW)

3.2.2. Lack of Detection and Information

Participants reported that healthcare providers failed to detect FGM and its conse-
quences. Practically all the women interviewed in Valencia reported that no professional
asked them if they had undergone FGM at any time during their pregnancy or any other
health visit: “No, no... they didn’t tell me anything about it, nobody” (I11VW), “No, no
one has never asked me this” (I12VW). Some participants suggested that although some
professionals may be knowledgeable about the practice, they do not ask because of em-
barrassment and a lack of skills to handle the situation: “I think they do know but they
don’t ask, they may be ashamed . . . ” (I17VW). This fact has an impact on the information
provided and, consequently, the quality of care for these women, girls and families. On the
contrary, all women who gave birth in a hospital in the British Health Care System were
asked during pregnancy about FGM: “But when I was doing my booking, they asked me if
I had FGM done” (I1LW), “During my first pregnancy they kept asking me if I had been
circumcised” (I4LW).

3.2.3. Stigmatizing and Over-Inquisitive Attitudes

Another important aspect to highlight is the stigma. To avoid stigmatization of
different cultures and groups, professionals should demonstrate respect for different
cultures and their ritual practices, which is wholly compatible with showing a frontal
rejection of FGM. Professionals should avoid issuing blaming judgments to these women,
since, as I1LW interviewee described, “she did not choose to be mutilated”. Statements
from healthcare providers such as, “we have to refer you to social services” during the
first pregnancy consultation were construed as very offensive, even more so for this
specific interviewee, who as a midwife knew the action plan perfectly, but did not agree
with the way in which the professionals had decided to act and communicate. This
participant stated:
“But when I was doing my booking, they asked me if I had FGM done. I said yes,
and they said that if I had a girl, they would have to refer me to social services
. . . for child protecting issues. This was quite offensive because I don’t want
anyone else what I have been through” ( . . . ). “It wasn’t my choice; it wasn’t me
going to the doctor and saying: ‘I want FGM to be done on me’ ( . . . ). Instead of
judging women, professionals should raise awareness, provide education and
emotional support if women’s been traumatised” (I1LW)

3.2.4. Offering Reversal or Deinfibulation

Four of the participants were offered a reversal of FGM intrapartum which was
accepted by two of them. These women who were offered a reversal attended the British
healthcare service.
“I was in labour and the doctor came and told me that he will open before the
baby came. I refused because I didn’t want it. But at the end I had caesarean
not because pf the FGM but because the baby was stuck somewhere. With my
second baby I also had caesarean” (I2LW)
Int. J. Environ. Res. Public Health 2021, 18, 7195 11 of 17

“They said to me: ‘You can’t deliver your baby unless we open you’. And I chose
to be opened the day of delivery. I didn’t want to have a reversal in pregnancy, I
wanted everything at the time of delivery, all together” (I4LW)
None of the Spanish participants were offered a reversal during pregnancy. One
Spanish participant requested surgical reconstruction, but she found that professionals did
not always know the procedure to follow. Information on the possibility of undergoing
reconstructive surgery was obtained in this case by friends, women in the same situation
and the media (internet): “I requested it. I heard of it from a friend ( . . . ) I looked it up
in ‘YouTube’, I looked for information so I found out what could be done ( . . . ) After
asking different professionals, I found a midwife who referred me to the specialist doctor”
(I14VW)

3.3. Tackling FGM

Under this main theme, the subthemes “education and awareness”, “speaking up”,
“improving prevention” and “penalization” were derived.

3.3.1. Education and Awareness

Participants emphasised the education and awareness of women and men -as a
fundamental component in the practice maintenance-, both in current countries of residence
and in countries of origin with prevalence of FGM.
“Oh God! Education, education, education. I can’t say it enough! And also
educating men here but also back home” (I1LW)
“To avoid this practice, women must go to school ( . . . ) When a woman is not
educated, she cannot think, she cannot defend herself ( . . . )” (I9VW)

3.3.2. Speaking Up
Furthermore, many of the participants emphasised the idea of speaking up about
the practice and showing support for its eradication. Two of the interviewees described
that after several years in Spain, they returned to their places of origin to publicise the
consequences of FGM and work with the community towards its eradication, trying to
generate action for social change.
“I explained to my mother the inconveniences and I have succeeded to prevent
my daughter and nieces from FGM. It is possible! If there is a will, there is a way.
I didn’t know that I could convince my mother either” (I14VW)
“When I went back to my country, I gave a talk about FGM ( . . . ) at first, I looked
as if I was no longer African, my mind had changed a lot” (I14VW)
“I have also held a meeting with all the women in my town ( . . . ) Now I can say
that 80% of the women in my town have abandoned the practice” (I15VM)

3.3.3. Improving Prevention

Another aspect that emerged during the interviews was the prevention of FGM in
girls. Several quotes demonstrate that girls, despite residing in Europe, continue to be at
risk of FGM when they travel to their country of origin: “One day I was talking to my
mother, and she told me that she was waiting for my daughter to cut her clitoris with the
others . . . ” (I14VW).

3.3.4. Penalization
Some interviewees proposed dealing with FGM by penalizing and prosecuting the
practice. However, they also state that this is not always effective because although the
performance of FGM may be punishable by law, the law is not always fulfilled: “Yes, yes,
in my country it is prohibited. They do it, but it is prohibited. But it may be that one day it
will end” (I11VW).
Int. J. Environ. Res. Public Health 2021, 18, 7195 12 of 17

4. Discussion
In the present study, the experiences of women and men from FGM-affected countries
were investigated via qualitative analysis and assigned to three main themes. As discussed
in the interviews, the consequences of FGM are complex and affect different spheres of
women’s and men’s lives along with their families. With regards to the consequences for
women’s health which are described in our study, participants highlight both obstetric and
gynaecological consequences and complications such as postpartum haemorrhage, perineal
tears, completion of caesarean delivery, infertility, risk of infection and dysmenorrhea;
genitourinary complications such as urinary tract infections and dysuria; consequences
for sexuality, mainly dyspareunia, decreased or absent erotic desire, decreased quality
of sexual intercourse and anorgasmia; and psychological consequences such as loss of
self-esteem, feelings of humiliation, fear of social rejection and family disgrace, which
coincide with several synthesis studies [13,35–37]. Death, as a major complication and
consequence of FGM, was also referred to by several participants.
Although the consequences for women’s health appear to be the most predominant,
socioeconomic consequences and those affecting men were also described by interviewees.
Direct economic consequences on women and their families can originate fundamentally
from the development of infections secondary to FGM that require expensive treatment, or
the development of other complications that can lead to disability. In the long run and in
certain contexts, this situation could lead to direct economic dependence on the husband or
father [38]. In addition, the practice of FGM and the associated ceremony, can cause high
costs that lead to family debt.
In many communities, FGM is a cultural requirement for girls who go into adulthood
to acquire a certain social position and belong to a group. FGM is an important brand of
social identity and not conforming to this can lead to social consequences, such as bullying,
ridicule, social stigma, exclusion from the adult community, community events and social
support, discrimination by peers, social rejection, loss of social status, increased isolation
due to lack of marital capacity and family shame, as well as exclusion of the whole family
from the social acceptance and welfare system of the community, as demonstrated by
participants [38,39].
Regarding the consequences for men, those most mentioned included the pursuit of
pleasure outside of the relationship, the fear of causing pain with penetration, or unsatis-
factory sexual intercourse, as described previously [21,40,41].
Notwithstanding the health and social consequences acknowledged by most partic-
ipants, we also found reports of women who did not associate any complications with
the practice. In this way, Reig-Alcaraz [22] demonstrate a lack of self-awareness about
the health implications for women who have undergone FGM. Our findings agree with
previous research where Somali women expressed their feelings as: “It is normal” or “I
am normal” [42,43]. For these women, there is no other way of being a woman and no
other way of experiencing sexual intercourse and, motherhood, etc. They do not perceive
the need to seek support, help or assistance, since FGM is commonly deemed intrinsic
to a woman’s nature. Furthermore, a lack of education and misinformation about their
own health accentuates this situation, which explains why women with a higher level of
education advocate more strongly for the abandonment of the practice [44].
Regarding the healthcare received, the experiences of the respondents are varied.
However, we observe clear differences between those residents in London and those inter-
viewed in Valencia. For many of these women, their first contact with the health services in
their host country is when they are pregnant [45]. During pregnancy, none of the women
interviewed in Valencia reported that they were asked about FGM, even though having
undergone FGM makes it more likely to experience obstetric complications [36] and special
care is needed because the long-term health problems of FGM are in many cases irreversible.
The impact of FGM during the birthing process should be sensitively discussed and a plan
of care should be agreed to reduce fears about how the births will be managed [46]. All
women, regardless of their country of origin, should be asked in their first pregnancy
Int. J. Environ. Res. Public Health 2021, 18, 7195 13 of 17

visits whether they have undergone FGM and this information must be recorded [36]. The
detection of FGM was a causal finding during gynaecological examinations or during the
birthing process in all cases attending the Spanish healthcare system.
In Spain, the study participants perceived a profound lack of knowledge about FGM
by healthcare providers as evidenced in regional studies [24,47] that coincide with other
European research [17,18]. In Valencia, less than a quarter of primary healthcare profession-
als correctly identified the typology of FGM, five percent correctly reported the countries
where the practice is prevalent and only a third of the professionals were able to detect
cases at risk of FGM [24]. Thus, most health providers do not know enough about FGM and
are therefore uncertain of how to adequately deal with it. Moreover, participants reported
a lack of information received during pregnancy and childbirth, as documented in other
western countries [48]. In addition, interviewees reported negative experiences during
vaginal examinations because professionals presented facial and verbal expressions denot-
ing significant lack of knowledge in relation to the modification of the external genitalia.
This fact has also been described in prior research [20,47,49].
Similarly, when requesting information on reconstructive surgery in Spain, there
were severe difficulties in locating the appropriate information and referrals, as described
in previous research [20]. This fact highlights the need for easily accessible educational
resources and evidence-based guidelines to enable health professionals to reduce structural
inequities and optimise health for women and girls who have undergone FGM.
On the other hand, women residing in the United Kingdom emphasised the high level
of awareness and knowledge of healthcare providers. Based on the interviews with the
participants, the professionals who attended them during their antepartum visits, labour
and postpartum period, were fully aware of the established protocols and guidelines for
action. Moreover, all women who gave birth in a hospital in the British Health Care System
were asked during pregnancy about FGM. Despite this, women still felt discriminated
against at times due to the stereotyping of healthcare providers and their insensitivity
toward FGM. Interviewers also described a lack of understanding of cultural differences,
perceiving the concerns of health professionals in relation to FGM as disproportionate. For
example, some women perceived shaming and even threatening attitude in relation to
the continuity of the practice of FGM for future newborns, without even having explored
maternal intention in relation to the continuity or abandonment of the practice. In this
sense, the experiences of migrant women collected by qualitative studies in countries with
a large migrant population from countries affected by FGM reinforce a worrying lack of
empathic care and sensitivity [45,46].
Finally, throughout the participants’ discourse, different strategies and actions to
improve healthcare for women and girls affected by FGM as well as the prevention and
eradication of the practice of FGM emerged. Participants highlighted the importance of
educating and raising awareness among women and men both in their hosts countries and
countries of origin [50–53]. Participants also mentioned the impact of speaking up and
making FGM known globally. There are increasingly more initiatives to empower girls and
parents to reject this harmful practice, pushing for deeper transformation in the community.
However, empowerment and education come together.
Our findings also support a previously demonstrated need to improve prevention
and detection strategies [21,47,50,54]. To build a relationship of trust with communities
affected by FGM, healthcare providers must have an accurate understanding of the cultural
background surrounding this practice, a working knowledge of the different types of FGM
procedures that may be encountered and an awareness of both the acute and long-term
complications. Asking routinely about FGM may encourage open communication and
facilitate more positive experiences [43].

Limitations
This study has certain limitations that require to be acknowledged. Firstly, one of the
major limitations was searching for the study participants. When using the “snowball”
Int. J. Environ. Res. Public Health 2021, 18, 7195 14 of 17

technique, one of the possible biases involves the oversampling of a network of peers [27].
In addition, individuals who share economic or social activities and who present similar
characteristics may end up having a greater representation in the sample [29]. To minimise
this bias, multiple snowballs starting from different key informants were used, attempting
to expand the scope of the research beyond a single network. Another limitation of this
sampling method is that participants may hesitate to provide names of other people who
have undergone FGM and on occasions, asking for it may have raised ethical problems for
the participants. For this reason, key informants initially contacted potential participants.
Those who agreed to receive the study information and to be contacted by the researchers
were those who were ultimately approached for their participation in the study.
Secondly, because the nature of the subject can be very sensitive, it is possible that
some of the interviewees have not been able to express their feelings and experiences with
total spontaneity and freedom. Finally, it was also considered that participants may not
have been completely truthful in some of the aspects discussed, because, among other
reasons, FGM is a harmful practice punished both in the United Kingdom and in Spain.

5. Conclusions
The current study identifies health and social issues in migrant women and men
affected by the practice of FGM from their own perspective. Migrant women residing
in Spain perceived a profound lack of knowledge about FGM from healthcare providers
and consequently stressed that the information received was insufficient. The findings
also illustrate that sometimes participants encountered negative attitudes when accessing
healthcare services in their host countries and for certain participants the language used by
health care providers was seen as frightening or humiliating. Some women’s experiences
suggest a concerning absence of sensitive and empathetic care and a more woman-centred
and human rights-based approach is recommended.
Our findings disclose the need to improve training and institutional plans to address
structural and attitudinal barriers to health equity across migrant families in their host
countries. This study may contribute to making visible this unknown practice among
health providers and may serve as a basis to formulate strategies aimed at strengthening
the care of women and girls affected by FGM from a comprehensive, respectful, cultural and
gender perspective, while also being effective in eliminating the physical and psychological
consequences of FGM and reducing health inequalities for migrant women and girls.
Trying to deal with the crisis of violence against women this study provides insights
from the perspective of women who have been affected directly by the issue, through
the discussion of personal experiences related to the provision of care. It also offers
a broad and holistic understanding about the phenomenon studied, which can inform
professionals about the realities of the practice of FGM. Such insights are vital to provide
women-centred care, particularly for women and girls from vulnerable groups whose
voices are often unheard.

Author Contributions: Conceptualization, A.G.-T., A.C.S. and V.R.R.; Data curation, A.G.-T. and
M.G.-T.; Formal analysis, A.G.-T. and M.G.-T.; Investigation, A.G.-T. and M.G.-T.; Methodology,
A.G.-T., A.C.S. and V.R.R.; Supervision, A.C.S. and V.R.R.; Writing—original draft, A.G.-T.; Writing—
review and editing, A.G.-T., M.G.-T., A.C.S. and V.R.R. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by Ethics Committee in Human Research of the University of
Valencia, Spain (26 June 2016).
Int. J. Environ. Res. Public Health 2021, 18, 7195 15 of 17

Informed Consent Statement: All participants received oral and written information about the
purpose of the study, voluntary participation, guaranteed confidentiality and the right to discontinue
at any time without any adverse effects. All participants signed a written informed consent prior to
each interview.
Acknowledgments: The authors would like to thank all the women and men who participated in
this study for their time and for revealing their stories.
Conflicts of Interest: The authors declare that there is no conflict of interest.

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