Cultural Beliefs,Perceptions,and Experiences on Female Genital Mutilation Among Women and Men: A Qualitative Analysis

Abstract

The practice of female genital mutilation (FGM) is a deeply-rooted tradition that affects predominantly regions of Africa and Asia. Because of migration flows, FGM is an issue of increasing concern worldwide. FGM is now carried out in Europe, North America, Australia and New Zealand, and more specifically among immigrant communities from countries where it is common. This study aims to assess the experience, knowledge, attitudes, and beliefs related to FGM of migrant women and men from FGM-affected countries residing in Spain and the United Kingdom. A phenomenological qualitative approach was used. Participants (n=23) were recruited by using the snowball sampling technique until data saturation was reached. Data were collected through 18 open-ended interviews and a focus group. Of the 23 participants, 20 women had undergone FGM. The following five themes were generated from interviews: (a) FGM practice development, (b) knowledge about the practice, (c) reasons for performing FGM, (d) attitudes toward continuing or abandoning the practice, and (e) criminalization of FGM. The study here presented identifies a lack of information, memory, and knowledge about the practice of FGM and typology among women with FGM. The justification of the practice seems to be based on a multifactorial model, where sociocultural and economic factors, sexual factors, hygienic-esthetic factors, and religious-spiritual factors take on a greater role in the analysis of the interviews carried out. The participants practically unanimously agree to advocate the abandonment and eradication of this harmful traditional practice. The knowledge displayed in this study may provide a basis for improving awareness and healthcare in such collectives, aiming the eradication of this harmful traditional practice.

Keywords

female genital mutilation cultural beliefs migration women’s experiences qualitative research

Background

Female genital mutilation (FGM), also known as female circumcision or genital cutting, is a culturally determined practice, performed in 31 countries and predominantly in parts of Africa and Asia, affecting more than 200 million women and girls worldwide (UNICEF, 2020). FGM comprises all procedures that involve a partial or total resection of the female external genitalia or other injury to the female genitalia for cultural or other non medical reasons (WHO et al., 1997). The practice is recognized internationally as a violation of the human rights of girls and women and as an extreme form of gender discrimination, reflecting deeply entrenched gender inequality.

As FGM is practiced on young girls without consent, it is a violation of the rights of children. It also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death. The practice has devastating consequences for the health and quality the lives of women and girls both short and long terms (WHO, 2016).

FGM is carried out in the context of a community or a group and is legitimized through beliefs that vary depending on ethnicity and geographic location, and which offer a series of explanations for its justification and maintenance. These explanations are based on cultural, social, and community factors. Even within the same community, the reasons for carrying outFGM are not homogeneous. Furthermore, similar to the communities themselves, the justifications for FGM are not static and continue to be adapted in the emerging sociocultural context. Most of the time, FGM is done with the intention to provide benefit, not cause harm. Parents initiate this procedure with the aim of securing a marriage for their daughters, as being a wife and a mother is considered a woman’s livelihood, and not circumcising one’s daughter is equivalent to condemning her to a life of isolation (WHO, 1999). However, the practice of FGM continues because of social pressure on women to conform to social norms, peer acceptance, or fear of criticism despite its illegality as reported by Sakeahet al. (2019).

FGM is mainly concentrated in countries in the western, eastern, and north-eastern regions of Africa, along with the Middle East, and is practiced in some countries of Asia and Latin America. The rise in international migration has also increased the number of girls and women living in the diaspora populations (National FGM Centre, 2021; UNICEF, 2016), and this harmful practice is now widely carried out in Europe, North America, Australia, and New Zealand, and more specifically among immigrant communities from countries where FGM is common (European Parliament, 2019). Aside from girls and women living in diaspora communities, there is also evidence of the practice in non diaspora communities in Russia and Georgia.

Therefore, the migration of families from FGM-practicing countries has resulted in FGM becoming a global issue. Growing migration has increased the number of girls and women who have undergone FGM or who may be at risk of being subjected to the practice living outside their country of origin. This fact has caused women’s healthcare providers throughout the world to increasingly encounter women who have experienced this practice. In Europe, it is thought that over half a million women and girls have been subjected to FGM, and around 180, 000 are at risk in 13 countries alone (End FGM European Network, 2019).

The current manuscript presents results from part of a larger research project taking place within the doctoral thesis of the primary author in order to identify the knowledge, attitudes, and practice among frontline professionals, as well as knowledge, cultural beliefs, and experiences of migrant women and men from FGM-practicing countries residing in Spain and the United Kingdom with regard to this harmful practice.

Indirect estimates indicate that 15, 907 women and girls who have undergone FGM reside in Spain. Moreover, it is estimated that at least 70, 000 women and girls come from countries affected by FGM (Kaplan & López, 2017). In the Valencian Community, the number is estimated at almost 6, 000 women and 1, 500 girls between 0 and 14 years of age from countries affected by FGM, placing the Community as the fourth Spanish autonomous community with the largest population (Kaplan & López, 2017). This population comes mainly from Nigeria, Senegal, Guinea, Mali, and Cameroon.

In the United Kingdom, the prevalence of FGM varies regionally, and there are higher rates of women affected by FGM in cities with large populations of FGM-practicing communities. In 2011, it was estimated that 137, 000 women and girls were living with FGM in England and Wales and that a further 67, 300 girls under the age of 13 were at risk of the procedure. London has the highest national prevalence for any city with an estimated 2. 1% of women affected by FGM (Macfarlane & Dorkenoo, 2015).

Thus, FGM is a rising issue in western societies as a consequence of international migration. It is expected that the number of women with FGM in Europe would rise at quite a fast rate, and future flows are expected to be strongly geographically selective, involving mainly France, Italy, Spain, the United Kingdom, and Sweden (Ortensi & Menonna, 2017). Limited research has examined how migrant women and men residing in Europe think about this practice, experience the practice itself, and what are the motivating factors for performing FGM (Agboli et al., 2020; Ahmed et al., 2019; Gele et al., 2012; Johns dotter et al., 2009; Moxey & Jones, 2016; Thierfelder et al., 2005).

However, knowing the attitudes of practicing communities toward FGMis key for developing strategies to safeguard girls from FGM and to promote behavior change toward the abandonment of FGM, and this topic should be reinforced in future research (Larsson et al., 2018; Simpson et al., 2012). In Spain, there is little research about female and men experiences and attitudes surrounding the practice of FGM (Ballesteros-Meseguer et al., 2014; Jiménez Ruiz et al., 2014; Kaplan et al., 2013; Reig-Alcaraz et al., 2014), and concretely, there is no research to date that explores the practice in women and men from FGM-practicing countries residing in the region of Valencia.

To achieve success in preventing the continuation of FGM, it is necessary to understand the reasons underpinning the practice. Therefore, researching family and community factors underlying this tradition and exploring the perspectives and experiences of women affected by FGM would lead to a better understanding of the impact of the practice and help to achieve respectful and effective approaches for its eradication. In this regard, this study aims to assess the experience, knowledge, attitudes, and beliefs related to FGM of migrant women and men from FGM-affected countries residing in Spain and the United Kingdom.

Methods

Design

A phenomenological qualitative approach was chosen for data collection, as this method is particularly suitable for gaining insights into human experiences (Creswell, 2014). The method was informed by Husserlian philosophy which seeks to explore the same phenomenon through rich descriptions by individuals revealing commonalities of the experience (Husserl, 1962).

Participants

We included women and men aged 18 years and above from countries affected by FGM who had undergone FGM or had been in close contact with the practice, who were able to provide informed consent, and who spoke English or Spanish or had translation assistance available for the interview. A total of 23 participants were recruited, of whom 20 women had undergone FGM. We also included two men and a woman who had been in close contact with the practice since their wife and female relatives had been subjected to the practice. One of them led the awareness campaign in his country of origin and knew first-hand the situation of many girls and women in his community. These three participants were considered especially knowledgeable about the phenomenon studied and therefore were also included in the research. The sociodemographic characteristics and the FGM status of the study participants are shown in Tables 1 -3.

Purposeful sampling was used for the identification and selection of participants. This involves identifying and selecting individuals or groups of individuals that are especially knowledgeable about or experienced with a phenomenon of interest (Cresswell & Plano, 2011). The “snowball” sampling technique was chosen because of its suitability in providing forms of contact with populations or groups characterized as difficult to access or, as referred to in the literature, hard-to-reach populations (Atkinson & Flint, 2001; Johnston & Sabin, 2010) or hidden populations (Petersen & Valdez, 2005; Voicu & Babonea, 2011). Contact with the target population was made via key informants, African associations, and different public social institutions of the region of Valencia. Participants were approached by telephone and face-to-face.

The sampling was carried out mainly based on the criteria of accessibility and feasibility for the participants. We aimed to obtain a diverse range of participants in terms of age, marital status, educational level, socioeconomic level, and experience with FGM and geographical origin. In addition to being a purposeful and reasoned sampling, it was cumulative, sequential, flexible, and reflective as it was modified and expanded throughout the research process until data saturation was reached.

Data Collection

We carried out 18 face-to-face semi structured individual interviews and one focus group. The study was carried out in two stages: the first stage was conducted in London (United Kingdom) in January 2017, and the second stage was conducted in Valencia (Spain) from February to May 2017. The focus group was conducted in April 2017.

Two researchers were involved in carrying out the interviews. Although initially in-depth open-ended interviews were attempted, the language limitation in some cases, as well as the private and personal dimensions of the phenomenon studied and the consideration of the topic as a taboo, prompted the researchers to change to semi structured interviews containing open-ended questions.

Firstly, a few questions exploring the sociodemographic characteristics of the sample were undertaken. The following questions included women’s experiences and perspectives around different aspects of FGM such as knowledge about the practice, reasons for practicing it, or attitudes toward the continuation or abandonment of the practice. The participants chose the times and locations for the interviews. All narratives were, after obtaining consent, recorded in the audio format. In addition, nonverbal gestures and researchers’ observations were recorded in a field notebook.

The focus group was undertaken to encourage interaction between the participants and explore the discourse in a given social context, capturing social experience and the different opinions and contradictions following the Berengueraet al. (2014) approach. In the focus group, the individual point of view of the speech is more interesting: “listen in a group but speak as a singular interviewee” (Berenguera et al., 2014). Five Nigerian women coming from vulnerable social groups such as prostitution and trafficking agreed to participate. The focus group was open, nondirective and flexible, and offered the participants the freedom to answer or not to answer the questions. A second person who worked as a moderator was required for its implementation.

Ethical Considerations

Participants were given written and oral information about the study and signed a consent form prior to each interview. Participants received thorough information about the purpose of the research and confidentiality, such as that all person-identifying information that emerged during the interview would be anonymized in the transcript. They were also given information about how the recorded interviews were going to be stored and that these, together with their contact information, would be deleted once the study was completed. The authors emphasized in particular the right to withdraw from the study at any time. The participation was voluntary in all cases.

The study received approval from the Ethics Committee in Human Research of the University of Valencia, Spain.

Data Analysis

All interviews were transcribed verbatim, and the participants’ identities were protected using code numbers. Data analysis was conducted using Giorgi’s (1997) four-step phenomenological approach and occurred simultaneously with data collection: (a) reading the entire disclosure of the phenomenon as described by the participant to obtain a sense of the whole; (b) reading the transcripts again breaking down the whole through analysis into common elements; (c) transforming the language of the participants into a conceptual perspective of the experience, relative to the phenomenon of interest; and (d) combining and synthesizing these meaning units into a final general description that reflects the lived experience of the participants. Following this approach, the transcripts were read repeatedly to determine their wholeness, followed by a sentence-by-sentence analysis where common elements were extracted and restated in more general terms. Meaning units were identified and these were then coded. Subsequently, code groups or themes were formed along the way and adjusted as new codes emerged from data. The Atlas. ti v. 8. qualitative data analysis software was used for data analysis.

Together two authors concurrently and independently analyzed the narratives and interviews both as a whole and for meaning according to a phenomenological life world approach (Giorgi, 2009). Initial findings were conferred in a research team meeting and discussed until consensus was reached around themes and subthemes which added rigor to the data analysis. All the researchers agreed on the final thematic structure.

Rigor

In order to assess the research process developed in the framework of qualitative research, we have based our work on the general criteria described by Guba and Lincoln (1985): credibility, transferability, dependency, and confirm ability. The procedures used to ensure the rigor of our research were extensive field work, researcher and methodological (within method) triangulation, reflexivity, confirmation with participants as well as a thorough description of the context, phenomenon, participants, data collection tools, analysis strategy, and findings.

Results

Of the 23 participants, 21 were women and 2 were men. The mean age of the men interviewed was 50 years, whereas that of the women was 31. 8 years. All the participants came from countries affected by FGM: Mali, Somalia, Nigeria, Burkina Faso, Senegal, Cameroon, with the exception of one participant who came from Equatorial Guinea, but her family origins were Nigerian. The average residence time in the country of origin for women was 24. 6 years, whereas for men, it was 38. 5 years.

The following themes were derived from the interviews: (a) FGM practice development, (b) knowledge about the practice, (c) reasons for performingFGM, (d) attitudes toward continuing or abandoning the practice, and (e) criminalization of FGM. From these, several subthemes emerged, which are described below. Representative quotations from the participants are used in order to verify and validate the findings.

FGM Practice Development

Most of the women agree that the practice is mostly predominantly carried out by elderly women who dedicate themselves, assuming the role of cutters within the community. These women, who inherit this role from mothers to daughters, do not have adequate anatomical knowledge nor adequate surgical training. The performance of the practice by men, barbers, healers, or relatives, as it is known in certain communities, has not been detected.

“They are grandmothers who do it” (I8VW).

“Her grandmother has been doing this work for more than 40 or 50 years” (I15VM).

“Doctors don’t. In my country (Burkina Faso) they are older people” (I11VW).

However, some women referred to the concept of medicalization of FGM. We have recognized a clear difference between Somali women residing in London and the rest of the women, where the first were mutilated by a doctor and not by a non-healthcare professional:

“So, she called the doctor” (I1LW), “It was a doctor, in the city” (I4LW), “It was a doctor, a man” (I5LW).

We have also found differences between the most rural and the most urban areas. Those families with the most economic means moved to cities to carry out the practice by qualified medical professionals.

“The man who was doing it was a doctor, so he didn’t cut us like other people from outside the city from the rural area. There is horrible, there’s no local anesthetic, there’s nothing, type III […]. Any no-experienced woman could be doing it, whoever…” (I2LW).

“In Mali they make the group and go to the forest and the mothers stay out there and the children are cut off and then they are let out to see their mother. There are boys and girls” (I12VW).

Other women, on the other hand, reported that the person who carried out the practice, whether it was a doctor or an older woman, went to their own home or a family member’s house to carry it out.

“Yes, the doctor came to my house. There was not only me, we were four girls at the same place, in my house” (IL2W).

“It wasn’t at my house; it was at my grandmother’s house. My mother sent me there and I did not know or have any idea what they were going to do to me… and I remember when she took me to the bathroom…” (I 16 VW).

All the interviewees agreed that FGM is performed at a very early age. The modal age of FGM was 6 years, but ranged from less than a week to 12 years old; 7 women could not recall the age when they were cut. Thus, most of the participants only had vague memories of the moment of FGM. During the focus group, when we asked if they remembered when the practice was performed, all the women laughed:

“Childhood, we were children (they laugh in group)” (IG).

“So, normally it takes place as soon as possible…. They are old enough to understand but not old enough to be too late to say no, and understand that is wrong and fight it. But we didn’t thought it was wrong, because everybody was doing it. It was our culture. You don’t realize until you grow up and see the problems” (I2LW).

“You never know if you are cut, you are a baby […] you don’t know what is happening” (I13VW).

Regarding the hygienic-sanitary conditions, mainly those women who were genitally mutilated by a medical trained professional received local anesthesia prior to the practice, it was done under aseptic conditions and antibiotic prophylaxis.

“So, she called the doctor. I had local anesthetic, it was a type one” (I1LW).

“I was lucky because I was in the city and it was the doctor who did the thing. I got an injection for the pain and antiseptic to try not to have an infection” (I2LW).

“After the local anesthetic no pain, just to get the anesthetic was very painful” (I4LW).

In contrast, in rural areas where mutilation was carried out by older women in the community, the means were scarce. FGM was performed with sharp objects such as special knives, scalpels, or blades; anesthetics and antiseptics were not usually used, and there was no possibility of receiving analgesia and antibiotic therapy as reflected in the following accounts.

“They have a way to sterilize the knives (…) they do it to you and then they tell you how to clean the girl” (I6VW).

“Without any hygiene, you know. Anything can happen in that process” (I9VW).

“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 girls who die from hemorrhages…” (I14VW).

In most of the reports collected, post-FGM care is carried out by the family itself, in accordance with the accounts described previously:

“Sometimes when they cut everything, then the portions are sewn together…. When the wound is healing and they are cleaning it, they try that the skin does not stick so much…. They clean it making a bigger hole with the finger […]. Women who cure it normally will not have the same as those who do it by cleaning it (she makes movement with the drag index vertically) from top to bottom” (I14VW).

“… she told me that the tradition was to use the soil from the entrance of the house… she spread it with karite oil […]they don’t have the right medicines to heal it” (I15VM).

We did not find excessive references regarding the recovery time needed after FGM, since many of the participants did not remember how the practice was carried out. In communities where infibulation is practiced, girls have their legs tied for immobilization for 10 or 14 days, thereby allowing scar tissue to form. This fact is reflected in the words of one interviewee:

After it was done I recovered the next day. But my brother who was older than me -he was 6 years older than me-, had a lot of experience back home. When the FGM was done back home (Somalia) for the girls who had type III they wouldn’t move around for the next four or five days having their legs tied together. So when he saw me walking around he said to my mum ‘Oh, mum, nothing has been done for her. This is not the right way, the doctor didn’t do anything for her’, so I had it re-done (I1LW)

Regarding the decision to cut, different testimonies have been collected without reaching consensus. Most of the time, it is women who take the initiative to mutilate the girls. Male involvement within societies that practice FGM is generally less, since the practice is considered “a women thing”:

“No, no, no! An older woman in the family! Grandma or aunt … it depends. For example, your father’s sister or your grandmother…. They decide” (I8VW).

The decisions made in the female sphere, however, are sometimes endorsed by men, as some of the interviewees narrate. The pressure of a society with a clear masculine dominance pushes women to make the decision to mutilate their daughters or their closest relatives. We also see how under some circumstances, some parents, neither the mother nor the father, are even informed of the moment of the FGM.

“It is the father who says to his wife, look, this is the girl's turn…” (I6VW).

“We didn’t know when the practice was going to happen” (IG).

“I think it is culture’s pressure, because I think that FGM will come because of the machismo, because men dominate women…” (I14VW).

“Most do it without father’s consent…” (I15VM).

“Because they do it by surprise too…. I have little sisters, I can take them and bring them to wherever FGM is done…. Like doing them a favor” (I16VW).

However, the payment for the performance of genital mutilation is compulsory in any case:

“Yes, you have to! Even if it’s local women, they are cheaper than the doctors. When is a doctor you have to pay more for them, for the local anesthetic and all of that” (I2LW).

Nevertheless, some of the participants indicated that they themselves demanded FGM in an attempt to be socially accepted among their peers. These reports relate how the fear of social rejection, marginalization, and the desire to belong to a group are causes of FGM in some cases.

“I thought every woman had it, I thought that was the normal as every single woman…. I was normal” (I1LW).

“Actually, because everybody was having this, I was the one who was pushing my mother to do it. I wanted to be same as the others. We thought we were growing up” (I2LW).

“We were around fouror five girls, one of them was a bit older around 13 or 14 years old because she didn’t have parents; she grown up with her grandparents. We ashamed to become like that girl, we wanted that (FGM) at an earlier age than that girl” (I2LW).

“I asked my parents every day, do it please! because all my friends had it. I asked them every morning. My dad didn’t want, and I asked my mum. My dad never supported the practice” (I4LW).

“As I had friends who were a little older than me … they were going to be cut and I asked mom … me too!” (I12VW).

One describes how the FGM rite was perceived as a moment of celebration and joy where the family offered gifts to her before the practice was performed:

“It was explained to me but, for a 6-year-old girl, I thought I was doing something very good, I had to please my parents, to please everyone. I was given plenty of gifts, gold, jewelry, which is hardly praised in our culture” (I1LW).

Knowledge of the Concept of FGM

All participants knew about the practice of FGM since they had been subjected to the practice or they have heard about the practice from family and friends. Some participants stated that a small part of female genitalia is cut during FGM, whereas others indicated that a large part is cut or even there is a complete cut. However, the great majority of participants did not know about the type of FGM they had experienced, even after a visual picture of typology was showed to participants.

“It was just the top and then it is like a stopper, so that I cannot have relations with any man” (I8VW).

“A very small cut at the top” (I13VW).

“I don’t know the grade, but I know they cut my entire clitoris (…) Yes, all together, I only had a little hole for everything. Yes, it is a grade III” (I14VW).

“The mutilation that my wife has is the one that cuts only the clitoris, it is not stuck” (I15VM).

Table 1.

Sociodemographic Characteristics of Participants (Individual Interviews).

Interview	Sex	Age	Place of Origin	Ethnicity	Residence	Family Status	Years Out of Country of Origin	Profession	Religion
I1LW	Woman	28	Kismaayo, Somalia	−	London, UK	Married	22	Midwife	Muslim
I2LW	Woman	43	Kismaayo, Somalia	−	London, UK	Married	17	Health Care Assitant	Muslim
I3LW	Woman	44	Mogadishu, Somalia	−	London, UK	Single	5	Health clinic assistant	Muslim
I4LW	Woman	28	Mogadishu, Somalia	−	London, UK	Married	12	Housewife	Muslim
I5LW	Woman	36	Mogadishu, Somalia	−	London, UK	Married	13	Housewife	Muslim
I6VW	Woman	43	Senegal	−	Valencia, Spain	Single	9	Catering	Christian
I7VM	Man	47	Cameroon	Bamileke	Valencia, Spain	Single	16	Catering	Protestant
I8VW	Woman	35	Dakar, Senegal	Wolof	Valencia, Spain	Married	11	Hospitality	Christian
I8VW			Dakar, Senegal (originally from Guinea)	−	France	Married	−	−	−
I9VW	Woman	39	Nigeria	Ibu	Valencia, Spain	Married	11	Hospitality	Christian
I10VW	Woman	40	Bata, Equatorial Guinea	Fang	Valencia, Spain	Single	18	Hospitality	Christian
I10VW			Nigeria	−	Valencia, Spain	−	−	−	Muslim
I11VW	Woman	43	Uagadugú, Burkina Faso	Mossi	Valencia, Spain	Married	10	Cleaning staff	Muslim
I12VW	Woman	34	Mali	Bambara	Valencia, Spain	Married	8	Housewife	Muslim
I13VW	Woman	31	Edo, Nigeria	−	Valencia, Spain	Single	5	Housewife	Christian
I14VW	Woman	29	Kayes, Mali	Mandike	Valencia, Spain	Divorced	8	Technical staff in Foundation	Muslim
I15VM	Man	53	Mali	Bambara	Valencia, Spain	Married	7	Seasonal worker	Christian
I16VW	Woman	28	Bamaku, Mali	Fulani(Peul)	Valencia, Spain	Married	8	Student	Muslim
I17VW	Woman	25	Kayes, Mali		Valencia, Spain	Married	2	Housewife	Muslim
I18VW	Woman	26	Rural area, Mali		Valencia, Spain	Married	1	Housewife	Muslim

Note. I = interview; V = Valencia; L = London; W = woman; M = man.

Italics denote the characteristics of the women’s experience related by the participants.

Table 2.

FGM Characteristics of Participants (Individual Interviews).

Interview	FGM	Type of FGM	Name of FGM	Age of FGM (Years)
I1LW	Yes (in Italy)	I		6
I2LW	Yes	II-III(Pharaon)		6-7
I3LW	Yes	II-III (Pharaon)		−
I4LW	Yes	III (Oni)		9
I5LW	Yes	II		5-6
I6VW	No	−		−
I7VM	−	−		−
I8VW	No	−		−
	Yes	Uncertain		12
I9VW	No	−		−
I10VW	No	−		−
	Yes	Uncertain		−
I11VW	Yes	I	Ablation	1
I12VW	Yes	Uncertain	Circumcision	3-4
I13VW	Yes	Uncertain	Circumcision (French)	<1
I14VW	Yes	III	Bolokoli	1 week
I15VM	−*Her wife	−*Type II	Sili-ji	−
I16VW	Yes	Uncertain	Circumcision	<7
I17VW	Yes	Uncertain	Excision	1 month
I18VW	Yes	Uncertain	Excision	1 month

Note. FGM = female genital mutilation; I = interview; V = Valencia; L = London; W = woman; M = man.

Italics denote the characteristics of the women’s experience related by the participants.

Table 3.

Profile of Participants of the Focus Group.

Interview	Age	Country of Origin	Years Out of Country of Origin	Marital Status	FGM, Type	Name of FGM
IG1VW	19	Nigeria	2	Single	Yes, uncertain	Circumcision
IG2VW	19	Nigeria	5	Single	Yes, uncertain	Circumcision
IG3VW	31	Nigeria	4	Single	Yes, uncertain	Circumcision
IG4VW	22	Nigeria	1	Single	Yes, uncertain	Circumcision
IG5VW	24	Nigeria	3	Single	Yes, uncertain	Circumcision

Note. FGM = female genital mutilation; I = interview; G = group interview; V = Valencia; W = woman.

Reasons for Performing FGM

A wide range of reasons for performing the practice of FGM emerged from the interviewees (Table 4). Although the reasons may vary between communities, they share commonalities such as tradition, ensuring the girl or the woman a status in the community, improving marriage opportunities, chastity, purity, and family honor. Where women depend heavily on men, financial need can also be a powerful reason for undergoing FGM. Nearly all participants decoupled FGM from their religion, since although the practice can be found among Christians, Jews, and Muslims, none of the sacred texts prescribe FGM.

Table 4.

Reasons for Conducting FGM.

Subthemes	Quotations
Culture and tradition	“She had it done, her mother had it done, her mother’s sister had it done, and it was continuously not stop” (I1LW). “But we didn’t think it was wrong because everybody was doing it. It was our culture. You don’t realize until you grow up and see the problems” (I2LW). “In a family that believes in FGM, all the girls that are born are circumcised. It is tradition, there is no option” (I8VW). “Whether you want it or not, they have to do it to you” (I10VW).
Hygiene and esthetical appeal	“But if they take your clitoris away you are good girl, that you know, you are clean. It’s also another thing they say. Women who have it done they look much cleaner than the others” (I1LW). “If a woman is not mutilated, it is as if she is dirty” (I7VM). “Because a girl who is not mutilated, people call them ‘bilákoro’, it’s like… if you are dirty you cannot come with us…” (I15VM).
Prevent illnesses or bad luck	“Some other think that if she is not cut and that girl becomes pregnant (…) if the clitoris touches the baby's head at the time he’s born, then the boy will go crazy” (I15VM). “If you are working in the field, and your wife brings you food there (…) if that woman touches you without cutting the clitoris, enters the rice field, the rice dries, the potato dries, the field will not produce well, it's bad luck for your cultivation…” (I15VM).
Chastity and virginity	“Men can marry four women and mutilated women do not usually reveal themselves much, because look, if I am married to a man, then if that man is going to marry another, I cannot do anything; I cannot do anything because I do not like having a sexual relationship with this person either, because having FGM, sexual relations are very painful… so why would I go find another man?” (I14VW). “People believe that a girl who is not mutilated is a girl who can play outside her marriage” (I15VM). “It’s done so that the woman does not have so much desire” (I17VW). “We think it’s something they do to prevent girls from having sex” (IG).
Marriage opportunities, prerequisite to marriage	“They cut it off and they put a thing that works as a stopper so she cannot have sex with any other man (…) it stays there until the day they get married. But then on the wedding’s day they take it away to hand her over to the husband” (I8VW). “And that has to be opened before the relationship … With the knife!” (I14VM). “On the day of the wedding, we accompany the wife and the husband to the bedroom, and there is an old woman who stays at the door to watch and says if the girl is virgin or not” (I15VM). “The husband must open that… firstly he tries with the penis, if it does not open with the penis, he tries with anything else” (I15VM). “I thought that if a woman was not mutilated, she could not have children” (I16VW).

Note. FGM = female genital mutilation; I = interview; V = Valencia; L = London; W = woman; M = man; G = group interview.

“No, but it’s cultural thing and then it immigrated with the religion but it’s not part of the religion” (I1LW).

“Well, I think that is more culture than religion, because in my country (Mali) there are Christians, non-believers, Muslims, but everyone does it, so I would not associate it with religion” (I14VW).

“Muslim, they do it; but we also do it” (IG).

Attitudes Toward Continuing or Abandoning the Practice

Essentially, the positioning of the study participants was against the realization and continuity of the practice of FGM (Table 5). Whereas in some cases, the consequences of FGM on the health of girls and women are mentioned as the main reason why the practice should be eradicated, in other participants, the knowledge of current legislation and the possible punitive consequence are the pretext of this position against the continuity of the practice.

Table 5.

Positioning About the Practice.

Subthemes	Quotations
Against FGM	“It should be stopped” (I1LW) (I2LM). “I’m not allowed to touch my daughter!” (I2LW). “No, no. I hope they stop that” (I4LW). “It must be eradicated!” (I9VW) (I11LW). “One day talking to my mother she said she was waiting for my daughter be to cut with the other girls in Mali, and I said to my mum, what are you saying?” (I14VW). “I believe that this practice has to be eradicated […] There is a will there is a way! I didn’t know that I could convince my mother either”(I14VW). “Neither does my husband; he says it to me, I love you very much, but if you do, I denounce you” (I17VW).
Pro FGM	“But even today my sister-in-law thinks that FGM must still be continued even though all the inconveniences that she has experienced. She is afraid that her daughters will not keep their virginity until the day of their marriage in a country where everything is permitted” (I8VW).

Note. FGM = female genital mutilation; I = interview; V = Valencia; L = London; W = woman; M = man.

Criminalization of FGM

Almost all participants knew the current legislation in the United Kingdom and Spain. Some also told us how the legislation in their respective countries of origin is changing.

“I’m not allowed to touch my daughter!” (I2LW)

“Now there is a law, up to three years in prison and a fine for women who do it in Senegal” (I8VW).

“You are not allowed to do FGM in this country, you are not allowed to practice in this country, and you are not allowed to practice on UK citizens abroad, under the age of 18…. I’m not sure, or 16, I think” (I1LW).

“Yes, I know, 10 years in prison!” (IL4W).

“Yes, Spanish law condemns FGM. Yes, it is illegal in Spain” (I7VM).

“I told him that this is not done here (Spain) … if you do it, they put you in jail here” (I16VW).

Discussion

Despite the fact that the women interviewed came from different countries of origin, this study showed that FGM is mainly performed by elderly women coinciding with Ballesteros-Meseguer et al. (2014) and Reig-Alcaraz et al. (2014) in similar studies carried out in Murcia, Spain. The practice was carried out in their countries of origin except for one of them, who was subjected to FGM twice, in Italy. The EU tackles FGM in various ways in its internal and external actions, and there are at least 50 criminal court cases of FGM in Europe, and most of them took place in France in the 1980s and 1990s (Mestre i Mestre, Johnsdotter, 2019).

Regarding the age at which the practice was carried out, all the interviewees agreed that it was carried out during their childhood before menarche, although most women did not remember with certainty the age at which they were subjected to the practice. FGM is usually performed on girls between the ages of 4 and 15 (UNAF, 2013; WHO, 2016). However, it has recently been stated that the majority of girls were mutilated before the age of 5 (UNICEF, 2016). This could be based on the assumption that “the younger the child, the less resistance” or that the healing capacity of girls is foreseeably greater at a younger age (Kaplan, 2013; Touray & Piniella, 2013).

FGM was considered to be a “female thing, ” and this study reveals that women or grandmothers decide to do FGM with the belief that a mutilated woman will be more feminine, cleaner, honorable, and beautiful (Little, 2003). The participants agree with Kaplan et al. (2013) that although men do not play an active part in decision-making, it does not mean that they do not have the power to influence it. We also agree with Jiménez Ruiz (2015) when he affirms that the power of men in societies where FGM is routinely carried out influences in an invisible and silent way the decision to cut or not to cut. Thus, the decision-making process about cutting or not cutting seems to be very complex, and several factors are involved. However, the obligatory nature of the practice does not entail an understanding of what actually happens in the mutilation process. Men generally know little or nothing, since it is part of the feminine sphere, and a large part of the women do not remember their mutilations and only assist in carrying them out in certain circumstances (Touray & Piniella, 2013).

Also surprising are the stories of women where it is evident that they themselves had to beg their parents to carry out the practice:

“I asked my parents every day” (I4LW), “I was the one who was pushing my mother to do it. I wanted to be same as the others” (I2LW).

Jacobson et al. (2018) also recorded stories of women who requested to be mutilated and eagerly awaited the day of FGM. Both in Somalia and in other countries, social pressure and the desire to belong seem to have played an important role (Ballestros-Meseguer et al., 2014; Jacobson et al., 2019; Jiménez Ruiz, 2015).

For the women interviewed, FGM is “something you must go through” and the testimonies collected in our study about the secrecy surrounding the performance of the practice coincide with those referenced by other researchers (Ballestros-Meseguer et al., 2014; González-Henao, 2011; Jacobson et al., 2018). We see how FGM is considered by many of our participants to be a taboo subject, and they themselves declare that they do not speak about it in their family or social circle. On one occasion, the women interviewed told us that they had never shared their stories of FGM before. On the other hand, the participants spoke of a community silence regarding not being told what would happen during FGM or the benefits obtained from not carrying outFGM. This coincides with the WHO report (1999), where it is reflected how girls are sometimes made to swear to keep silent about the practice, pain, and associated techniques.

Many women revealed feelings of terror, humiliation, and pain. Ballesteros-Meseguer et al. (2014) highlighted that this fact may favor the climate of submission and silence in relation to FGM. However, during the interviews with Somali women living in London, we were impressed by the presence of laughter in the narratives of their personal stories about FGM. This fact is also mentioned by Jacobson et al. (2018) in their study of Somali women residing in Canada.

On the practice itself and aftercare, we agree with Reig-Alcaraz et al., (2014) regarding the little literature found in this regard. Somali women’s reference to the received pre-FGM ceremony is highlighted, which coincides with that described by Touray and Piniella (2013). From the participants’ verbatims, we observed how the practice is normally carried out with razor blades, scissors, or any sharp object, and how post-FGM healing and recovery are carried out in most cases by the family itself, fundamentally by mothers and grandmothers, with the few means available to them at home. The fact of not having antiseptics, antibiotics, or even running water in their homes accentuates the development of potential complications. This differs from that mentioned by Kaplan et al. (2013) in the Gambia, where traditional knives appear to be being replaced by individual razor blades as a result of HIV transmission prevention campaigns, as well as traditional herbs and charms that are used for the cure and prevention of bleeding being replaced by modern drugs.

All the women and men interviewed knew about the practice of FGM and its existence in their regions of origin. In addition, although sometimes the practice was not carried out in its place of origin, they knew the origin of the practice and neighboring communities where it was carried out. However, regarding the type of FGM, more than half of the participants could not identify which one of them had been practiced, finding differences between groups depending on the country of origin. Thus, we see how women from Somalia have been subjected to more aggressive genital mutilation for the most part, except for one of the participants who, having been mutilated in Italy, suffered FGM type I. Statistics reflect that although it is only estimated that 15%-20% of women who have been mutilated have suffered type III (WHO, 2008), in some countries such as Somalia figures of 93% were reached in 2006 and 86% in 2011 (UNICEF, 2013).

The reasons for practicing FGM mentioned by the study participants were different, although they all coincide with those described in the reviewed literature (Berg & Denison, 2013). Most of the reasons lie in gender considerations and, therefore, in social constructions that attribute certain behaviors and functions to women (premarital virginity, fidelity, beauty, etc.) and that are truly discriminatory. Mainly, it is observed that FGM continues to be practiced mainly due to conformity and social pressure, a statement widely described in the literature (Gallego & López, 2010; Grose et al., 2019; Lucas, 2008; Sakeah et al., 2019; WHO, 2008).

Evidence states that fathers, mothers, and grandmothers are the main decision-makers (Alradie-Mohamed et al., 2020). However, FGM is found to be more prevalent among daughters whose mothers want FGM to continue and fathers are opposed or undecided than those whose fathers are the sole parent supporting its continuation (Cappa et al., 2020). Our findings also suggest that parental opinions may not be always a determinant, since some girls have parents who oppose the practice, and the personal attitudes, family and social norms are the ones that play an important role in determining whether the girls will undergo FGM.

Practically, all the interviewees reported being against the conduct of FGM, and only one of them told us about the experience of a close person who advocated for FGM. The reasons for abandoning the practice were mainly the consequences for the health of girls and women and the criminal consequences if FGM is carried out, since most of the participants knew the current legislation in the United Kingdom and Spain, as well as that of their countries of origin. This fact coincides with the national statistics of the different countries where, for the most part, there is a positive trend toward the abandonment of the practice. These investigations also indicate that the daughters of more educated mothers and those from urban areas are less likely to be subjected to FGM, with the trend that a higher level of instruction results in greater conviction toward abandonment (DHS, 2018; EDS, 2004, 2010).

Strengths and Weaknesses

Researchers closely engage with the research process, and participants and are therefore unable to completely avoid personal bias. The subjective nature of qualitative research may make it difficult for the researcher to be detached completely from the data. For this reason, the results were triangulated with one of the participants and with other data collection methods.

Moreover, because of the sensitive nature of the topic, some of the interviewees may not have been able to express their feelings and experiences with complete spontaneity and freedom. It was also considered that the participants did not fully tell the truth in some of the aspects discussed, since, among other things, FGM is a penalized and harmful practice both in the United Kingdom and Spain.

When using the “snowball” sample, one of the possible biases could be over representation or over sampling of a network of peers. Although they were not a homogeneous group in themselves, they may have shared characteristics because some of them were known to each other. In order to minimize this, different snowball chain starts were used. Some may have been willing to participate in our study because of their outgoing personalities.

The use of a focus group with a homogeneous group of women facilitated a richer interactive discourse that helped us explore various aspects of FGM in a context of highly vulnerable women. Furthermore, and in line with Toner (2009), small groups are beneficial as they highlight emotions and give participants more space to express themselves.

Conclusions

This study provides insights into women’s experiences after being subjected to FGM. The knowledge displayed may provide a basis for improving awareness and healthcare in such collectives, aiming toward the eradication of this harmful, traditional practice. The study presented here identifies a lack of information, memory, and knowledge about the practice of FGM and typology among women with FGM. The justification of the practice seems to be based on a multifactorial model, where sociocultural and economic factors, sexual factors, hygienic-esthetic factors, and religious-spiritual factors take on a greater role in the analysis of the interviews carried out. The participants practically unanimously agree to advocate the abandonment and eradication of this harmful and traditional practice.

In order to guarantee a multidisciplinary, cross-cultural, and respectful approach to FGM in our community, it is necessary to make the problem of FGM known to the general population and to front-line professionals, increasing their knowledge of this practice. Further research is needed to better understand the roots and motives for practicing FGM and to examine the role of different preventive measures in reducing the prevalence of FGM.

Footnotes

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.

Declaration of Conflicting Interests

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Alba González-Timoneda

Author Biographies

Alba González-Timoneda, CNM, PhD, is an associate professor in the Department of Nursing at the University of Valencia, Spain. She also works as a midwife at the University and Polytechnic Hospital la Fe of Valencia. Her research interest involves women’s health, interpersonal violence, gender violence, and woman-centeredcare.

Antonio Cano Sánchez, MD, PhD, is a professor of Obstetrics and Gynaecology at the University of Valencia and the head of the department of this specialty at the Clinic University Hospital of Valencia, Spain. His main interest is gynecological endocrinology.

Marta González-Timoneda, MD, PhD student, is a fourth-year resident doctor in Gynaecology and Obstetrics at the Clinic University Hospital of Valencia, Spain.

Vicente Ruiz Ros, RN, PhD, is a professor of Nursing at the University of Valencia, Spain. He also works as a nurse researcher at the Cardiology Service of the Clinic University Hospital of Valencia.

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