Perceptions of the psychological experiences surrounding female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria

Abstract

Evidence about psychological experiences surrounding female genital mutilation/cutting (FGM/C) remains weak and inconclusive. This article is the first of a series that deploys qualitative methods to ascertain the psychological experiences associated with FGM/C through the lifecycle of women. Using the free listing method, 103 girls and women, aged 12 to 68 years from rural and urban Izzi communities in Southeastern Nigeria, produced narratives to articulate their perceptions of FGM/C. Sixty-one of them had undergone FGM/C while 42 had not. Data was analysed using thematic analysis and the emerging themes were related to experiences and disabilities in the psychological, physical, and social health domains. While physical experiences were mostly negative, psychological experiences emerged as both positive and negative. Positive experiences such as happiness, hopefulness, and improved self-esteem were commonly described in response to a rise in social status following FGM/C and relief from the stigma of not having undergone FGM/C. Less commonly reported were negative psychological experiences, e.g., shame when not cut, anxiety in anticipation of the procedure, and regret, sadness, and anger when complications arose from FGM/C. Some participants listed disruption of daily activities, chronic pain, and sleep and sexual difficulties occurring in the aftermath of FGM/C. Most participants did not list FGM/C as having a significant effect on their daily living activities. In light of the association of FGM/C with both positive and negative psychological experiences in the Izzi community, more in-depth study is required to enable policy makers and those campaigning for its complete eradication to rethink strategies and improve interventions.

Keywords

circumcision female genital mutilation/cutting free listing health psychological

Introduction

Female genital mutilation/cutting (FGM/C) refers to all procedures involving partial or total removal of the female external genitalia or other injuries for non-medical reasons (World Health Organization [WHO], 2018). Global estimates indicate that between 100 and 200 million girls and women are currently living with FGM/C in various parts of the world (WHO, 2018). With a national prevalence of 25–30%, Nigeria has the highest absolute number of FGM/C cases in the world, because of a large population of 168 million and very high prevalence rates found in some parts of the country (Federal Ministry of Health [FMOH], 2013).

The FGM/C National Policy Initiative in Nigeria was introduced in 2002 as a result of concerted efforts for the elimination of FGM/C (FMOH, 2013). Interventions in the National Policy included surveys to determine the prevalence of FGM/C, provision of support for anti-FGM/C legislations in all states, education of communities on the need to eliminate FGM/C, and the provision of alternative sources of income for cutters (FMOH, 2013). After several years of interventions, reports revealed limited impact (FMOH, 2013). The difficulties with eliminating the practice are not limited to Nigeria. Interventions have had limited success all over the world (Johansen, Diop, Laverack, & Leye, 2013).

The signing of the Violence Against Persons (Prohibition) Act of 2015 into law in Nigeria, which prohibits all forms of violence against persons, was an outcome of years of persistent advocacy for the elimination of FGM/C. All four types of FGM/C identified in the literature are practised in Nigeria (FMOH, 2013; Okeke, Anyaehie, & Ezenyeaku, 2012). Type I, which is also known as clitoridectomy, is the least severe form and involves the removal of the prepuce or all or part of the clitoris. Type II involves the removal of the clitoris and partial or total removal of the labia minora, while Type III is the removal of the clitoris, labia minora, parts of the labia majora, and the narrowing of the vaginal orifice (infibulation), leaving a very small opening for urine or menstrual flow. Indeterminate forms, which include cuts, pricking, piercing, scraping, stretching of the vagina, or the introduction of corrosive substances and herbs into the vagina, are classed as Type IV.

The commonest type of FGM/C practised in Nigeria is Type I. Types II and III are less common and found in all zones of the country. Type IV is found in two regions: in Northern Nigeria, the practice is known as “Gishiri” and involves cuts made into the vaginal wall; and in the South, it involves the introduction of herbs into the vagina (FMOH, 2013; Okeke et al., 2012). The three major ethnic groups in Nigeria, the Hausa, Igbo and Yoruba, practise FGM/C (FMOH, 2013; Okeke et al., 2012).

The medical and obstetric health risks of FGM/C have been extensively studied. Reported problems include chronic pain, bleeding, infections, increased risk associated with caesarean sections, postpartum haemorrhage, extended maternal hospital stay, stillbirths or early neonatal death, low birth weight, higher risk of transmitting HIV, and death (Berg, Denison, & Fretheim, 2010, Okeke et al., 2012; WHO, 2018). Informants from the three major ethnic groups in Nigeria (Hausa, Igbo and Yoruba) cited health complications of FGM/C, such as bleeding and pain, infertility, pain during and after sexual intercourse, and prolonged labour (Anuforo, Oyedele, & Pacquiao, 2004). Okonofua, Larsen, Oronsaye, Snow, and Slanger (2002) examined premenopausal women attending clinics in Nigeria, and found that cut women were more likely than uncut women to have reproductive tract morbidity and complications of pregnancy.

Understanding the sociocultural determinants of this practice is central to identifying the factors that continue to drive it. In virtually all cultures where it is practised, FGM/C was viewed as a non-negotiable rite of passage into womanhood that leads to an improvement in the social value of a woman (Anuforo et al., 2004; Johansen, 2002).

In societies where FGM/C is practised, a great premium is placed on the marriageability of women and in the belief that FGM/C ensures purity and protection for the girl-woman before marriage (Inhorn & Buss, 1993). Mackie (2003) observed that the importance of a daughter’s marriageability far outweighed the importance of health, consent, and maintenance of body integrity. Several studies among practising cultures reported that these cultures viewed FGM/C as an attempt to make the female genitals clean and pure, enabling the girl or woman to maintain her virginity and reputation until she would be “opened up, by her husband” (Talle, 1993; Toubia, 1993).

In keeping with purity theories, Boddy (1982) described FGM/C as a practice that protects and prepares the woman for motherhood and ensures fertility. Studies carried out in Nigeria found that the reasons for keeping the practice in place were to keep girls pure as virgins, to protect the girls’ reproductive potential, to increase fertility, and to aid the childbirth process (Anuforo et al., 2004; FMOH, 2013). There are beliefs among practising communities that uncut women have higher rates of stillbirths because if the baby’s head touches an uncut clitoris, death will occur (Anuforo et al., 2004).

Controlling the sexuality of women and reducing their desire for sex in order to protect them were reasons for sustaining the practice in several cultures (Anuforo et al., 2004; Boddy, 1982). For married women, a reason given for the continued practice of FGM/C is that it limits the desire for sex due to pain during sexual intercourse and reduces the probability of extramarital sex (Anuforo et al., 2004). Several cultures allude to FGM/C as a process of beautification of women. The process is said to make the woman more attractive physically and socially and to make the genitalia more attractive (Anuforo et al., 2004; Boddy, 1982; Inhorn & Buss, 1993). Studies in practising cultures have also described several health benefits believed to be a result of FGM/C. For example, studies from Nigeria, Sierra Leone, and Egypt found that FGM/C was believed to ensure girls’ health, pubertal maturation, and genital cleanliness (Anuforo et al., 2004; Inhorn & Buss, 1993; Kallon & Dundes, 2010).

Some researchers have suggested an association between FGM/C and Islam, but there is no evidence in support of this. Islamic texts do not provide any reason to support the practice (Silverman, 2004), and in Nigeria and most of Africa, the practice occurs across religions and cultures (Anuforo et al., 2004). In Nigeria, prevalence rates are lowest in predominantly Muslim populations, who are based in the Northern region, and highest among Christian populations in the Southeast (Anuforo et al., 2004). FGM/C occurs on the African continent among Christians, Muslims, Jews, and practitioners of traditional African religion alike (Walley, 1997).

Other reasons offered for the sustained practice of FGM/C are appeal to social cohesion: social ceremonies that involve the participation of the entire community surround the process of FGM/C. In Southwestern Nigeria, the cutting coincides with the naming ceremony of the baby girl, while in the Southeast, a girl who has just undergone the procedure is provided with special food, is allowed to rest for a whole week, and is surrounded by girls who have had FGM/C dressed in colourful clothes (Anuforo et al., 2004). In Sierra Leone, the cutting is part of an initiation process into secret societies, in which the girls are taken into the forest for several weeks (Ahmadu, 2000, 2007; Kallon & Dundes, 2010). Leaders of the society emphasize that the essence of the process is to give the girls a sense of belonging. Ahmadu (2000, 2007) provides further insights into FGM/C, to which she refers as “circumcision” in her writing as an insider from an ethnic group where FGM/C is entrenched and as an intellectual and anthropologist who has experienced FGM/C personally. She emphasizes that the female secret society promotes peace through marriages, sexual conduct, fertility, and reproduction.

Given the links to deeply entrenched cultural beliefs, anthropologists have concluded that efforts to stop FGM/C must arise from the affected communities themselves (Gruenbaum, 1982). Studies reveal that women in affected communities respond negatively to calls for eradicating FGM/C, especially when the calls come from outside their communities and cast a judgement of condescension on their traditions.

In contrast to the rich socio-cultural literature surrounding the FGM/C process, there is a paucity of studies addressing psychological experiences surrounding the practice of FGM/C (Berg et al., 2010). The few studies that have examined the psychological issues surrounding the practice of FGM/C have used a cross-sectional approach, rather than looking at experiences before, during, and after the cutting (Berg et al., 2010). Johansen (2002) analysed the experience of pain associated with FGM/C among Somali women who had emigrated to Norway and described a complex interaction of physical, cultural, social, and psychological experiences. However, these descriptions given by the emigrant women must be viewed in light of the changes in self-perception that may occur with migration to Western cultures, where the practice of FGM/C is seen in very negative light. Most women described the cutting as the most painful experience they ever endured. Expressions like “darkness in my life”, “a sense of loss of both body and soul”, and a “heavy burden I will always carry” suggest psychological distress. The husbands of these infibulated women described not only the physical pain that they themselves had experienced, resulting from the wounds sustained during penetration in sexual intercourse, but also their emotional trauma resulting from the pain they caused their wives. Aside from these findings, there is very little information about the psychological experiences surrounding the practice of FGM/C (Berg et al., 2010).

Qualitative research methods are useful to explore the rationale behind health behaviours within their socio-cultural context, local worldviews, and meaning. This report is the first in a series of four articles from a WHO-funded study that use qualitative research methods designed to gain a deeper understanding of the psychological experiences of the practice of FGM/C understood within its sociocultural context. This research work therefore involved a community in Nigeria were FGM/C is practised in adolescence and adulthood to allow for the recollection of psychological experiences. This took the researchers to the Izzi community in Ebonyi State in the Southeast of Nigeria, which also has the highest FGM/C prevalence in Nigeria (Ibekwe, Onoh, Onyebuchi, Ezeonu, & Ibekwe, 2012). The primary aim of this first part of the larger study was to identify the key meanings surrounding FGM/C, with a particular focus on perceptions of psychological experiences among different subgroups of Izzi women. The secondary aim was to provide guidance for the development of questions and probes for more in-depth qualitative interviews with key informants.

Methods

Free listing

To collect qualitative data in this study, we used the method of free listing (Fiks, Gafen, Hughes, Hunter, & Barg, 2011). Free listing provides a broad overview of the key issues surrounding cultural domains in a local community, helps in the identification of the most pertinent issues, and can be used to compare differences in perceptions within sub-groups (Barg, Keddem, Ginsburg, & Winston, 2009; Betancourt, Speelman, Onyango, & Bolton, 2009; Sobo & Kurtin, 2003). The rationale for using the free listing method as a first stage in our research was to tease out the perceptions of psychological experiences of girls and women surrounding the FGM/C procedure. The free listing method has been useful in exploring the local community’s perception of mental health problems among war-displaced youth in northern Uganda (Betancourt et al., 2009), the local perception of the mental health effects of the genocide in Rwanda (Bolton, 2001), as well as the psychosocial effects of organized crime in Haiti (Bolton, Surkan, Gray, & Desmousseaux, 2012). The free listing, reported in this paper, was followed by key informant interviews which will be the focus of another article.

The free listing method entails asking questions designed to elicit multiple responses in the form of a list. For each identified response, the interviewee is asked to give a very brief description (Bolton et al., 2012). The relative salience or importance of a response item on the list is determined by its frequency. In this way, qualitative responses are converted into quantifiable counts, which help determine the strength of the theme (Bolton, 2001; Bolton et al., 2012). In the Izzi community, pilot testing revealed that when participants were requested to “list” all that they knew on an aspect of FGM/C, they either did not respond at all or they responded with descriptions and phrases. The questions therefore were changed from “list all you know” to “tell me all you know”. Similar methodological issues have been documented in other studies using the free list method in Africa (Betancourt et al., 2009; Bolton et al., 2012). Hence, questions were still structured, but the prompt did not include asking for a list; participants were allowed to respond freely in the form of narratives and a list of key meanings were extracted from the narrative with the help of thematic analysis.

Setting

This study was carried out among the Izzi community in Ebonyi State, Southeastern Nigeria. The Izzi are a subgroup of the Igbo, one of the three largest ethnic groups in Nigeria. The Southeastern region of Nigeria has the highest FGM/C prevalence among all six geopolitical regions in the country, with 49.2% of girls and women aged 15 to 49 years having undergone FGM/C (National Bureau of Statistics (NBS) 2011). Type I, II, and III are the three types of FGM/C found in Ebonyi State. In a study of 516 primigravid women attending two health institutions in Ebonyi State, 342 (66.3%) had undergone FGM/C with Type I FGM/C in 28.1%, Type II in 59.6%, and Type III in 12.3% (Lawani, Onyebuchi, Iyoke, & Okeke, 2014). As stated earlier, Izzi communities in Ebonyi State perform FGM/C in adolescence and early adulthood or just before marriage as a rite of passage (Echiegu, 1998), thus improving the chances of recall of the psychological experiences accompanying the procedure.

Sample

The study plan was to interview a convenience sample of 120 female participants divided equally between urban and rural settings, with each setting including 30 female participants who had undergone FGM/C and 30 who had not. Each group of 30 respondents was to be further stratified based on age category into three groups of 10 participants each (12–19 years, 20–40 years, and over 40 years), reflecting different parts of the lifecycle: adolescence, adulthood, and middle age. The purpose of this sampling method was to ensure a broad variety of perspectives based on age and place of abode (rural versus urban), while increasing the generalizability of the results. In Nigeria, rural areas are remote and residents have reduced access to health facilities and anti-FGM/C awareness campaigns when compared to those living in urban settings (FMOH, 2013; Nworgu & Nworgu, 2013). Rural areas suffer marked deprivation, manifest in severe poverty, as well as poor educational systems, health services, and transportation systems (International Labour Organization, 2015). Other sociodemographic information, such as level of educational attainment and occupation, were not obtained in this study, which was meant to provide a broad overview of the psychological experiences surrounding FGM/C.

Recruitment procedure

Sampling by quota, as described above, was carried out using clusters. A list of all household clusters was obtained from the National Population office in the selected study sites. Some clusters were randomly selected from the total sample frame and households in the selected clusters were approached to participate. All eligible members of the selected households who consented to be interviewed were recruited until enough numbers for each quota were attained. The selection and approach of the eligible members was conducted one day ahead of the interviews by the study leader and the community mobilizers. Approximately six months before data collection (October 2012), OO and JA met with NE (study leader) and the local research team to finalize the planning of the study, visit the study site, and negotiate community access. It was at this point that contact was made with community mobilizers, who were youth leaders, leaders of women’s groups, and political leaders who helped to facilitate access to the community. The recruitment of participants for the free listing component of the study and interviewing process occurred over a one-month period in April 2013.

Data collection

Five trained interviewers (three female and two male) collected data on the community perceptions of FGM/C using the free listing method. NE selected the interviewers in collaboration with all researchers. She explained that it was best to have a mix of male and female interviewers because in Izzi communities the cutting process is open to, and carried out by, both males and females alike. Among the Izzi, cutting is a family business and cutters pass this down to their female or male children, a finding supported by Anuforo and colleagues (2004) and by Asekun-Olarinmoye and Amusan (2008) in a study of FGM/C in the three major Nigerian ethnic groups. NE also provided the information that boys and men were actively involved in holding down the girls during the cutting and that older women feel comfortable with, and would confide in, young men, whom they see as their “sons”. Despite the explanations provided, the women may have been uncomfortable discussing their perceptions of FGM/C with the male interviewers—and this may be a limitation of this study. All interviewers had at least a Bachelor’s degree in sociology, social work, nursing, or psychology and were fluent in both the local Izzi dialect of the Igbo language and in English. In order to allow for adequate levels of privacy for each respondent, interviews were conducted under trees, in a room of the town or village hall, or at a health centre. Each interview lasted about 1 hr 30 min, and was recorded verbatim in Izzi dialect using a digital voice recorder.

During community mobilization and throughout the period of data collection, the local term for FGM/C, which is “Female Circumcision”, was used. The open-ended questions were aimed at understanding the participants’ general views about FGM/C, as well as its associations with health, psychological experiences, and daily living activities. The researchers and interviewers were trained during a 5-day workshop on the study methods. Discussions were also held based on the study objectives and literature on FGM/C. Five consensual questions to be asked during the free listing interview, together with probes, were derived from these discussions (see Appendix I in Supplemental Material Online for full free listing interview): (1) Please tell me all you know about Female Circumcision practices in your community; (2) Can you tell me all the related health and wellbeing issues surrounding Female Circumcision? (3) How does Female Circumcision affect the emotions, mind, or psychological wellbeing of a person? (4) How does Female Circumcision affect the day-to-day living of a person from the time they wake up and even when they sleep? (5) Is there any other thing that you may have remembered and would like to share about how Female Circumcision affects individuals, families and the community at large?

The Research and Ethics Committee (REC) of the Ebonyi State University Teaching Hospital and the World Health Organization’s (WHO) Ethical Committee gave approval for this study. Informed consent was obtained from all participants and in the case of minors, from both the legal guardian and minor using signatures or thumb printing, as relevant. Participants each received the equivalent of $5 (USD) for light refreshments and reimbursement of transportation costs, as some had to travel from their home to the town hall or health centre.

Data analysis

The interviews were transcribed and translated from the local language into English by the interviewers. An expert in both the Izzi dialect of Igbo and the English language crosschecked this process. The analysis was carried out in two phases. First, the transcripts were read through by the researchers (TB, OO, JA, and NE), prominent themes were identified, and the frequency of each theme was determined by a simple tally method. Where there were discrepancies, these were discussed and harmonized. The most frequently occurring themes were identified and used to guide the formulation of the questions for the next stage of the larger study (in-depth key informant interviews that will be discussed in another paper). The second phase consisted in entering the transcriptions of the free list interviews into ATLAS.ti (version 7) qualitative analysis software. TB, OO, and a research assistant (who was a doctoral student in sociology) did a coding of emergent themes. Similar codes were merged or renamed until a consensus was reached between TB and OO. Thereafter, ATLAS.ti was used to compute frequencies and compare groups of participants. The frequency of themes related to community perceptions about FGM/C, health issues, and perceptions concerning psychological experiences and effect of the practice on daily living activities were compared by age, location, and circumcision status using Chi-square tests at 5% level of significance.

Results

Of 103 participants interviewed, 37 (35.9%) participants were in the 12–19 age group, 44 (42.7%) from the 20–39 age group, and 22 (21.4%) from the 40 and above age group. (There were fewer participants aged 40 years and above because all the women in this age group had undergone the FGM/C procedure in rural and urban Izzi communities and this is why 103 participants were interviewed and not 120 as planned.) There were slightly more urban participants than rural ones (see Table 1). The age of the respondents ranged from 12 to 68 years, with a mean of 28.6 years (SD = 14.6).

Table 1.

Sociodemographic characteristics of the study participants (n = 103).

Characteristic	n	%
Age
12–19	37	35.9
20–39	44	42.7
40 and above	22	21.4
Location
Urban	53	51.5
Rural	50	48.5
FGM/C status
Cut	61	59.2
Uncut	42	40.8

Community perception of FGM/C

The general themes that emerged from the interviews were that FGM/C is a tradition undergoing change with implications throughout the lifecycle of girls and women, a rite of passage, a practice with reproductive health and social advantages that could lead to health complications, and finally, uncut girls and women are subjected to stigma (see Table 2).

Table 2.

Themes emerging from narratives on community perception of FGM/C (N = 103).

			Location		FGM/C Status		Age
No.	Community perception	All n = 103 %	Rural n = 50 %	Urban n = 53 %	Cut n = 61 %	Uncut n = 42 %	12–19 n = 37 %	20–40 n = 44 %	<40 n = 22 %
1.	Good practice	80	100	47*	71	93*	100	90	9*
2.	Fading practice	76	64	86*	69	86	57	93	73*
3.	Tradition	71	72	70	74	67	62	68	86
4.	Bad practice	67	54	79*	54	86*	73	91	9*
5.	Government disapproves	60	60	60	72	43*	22	70	95*
6.	Carried out on female infants, adolescents and adults	47	46	47	54	36	38	61	32*
7.	Uncircumcised girls are stigmatised	41	52	30*	43	38	32	36	64*
8.	Maturity/rite of passage	37	46	28	43	29	24	25	73*
9.	Prevents promiscuity	31	18	43*	36	24	19	46	23*
10.	Facilitates childbirth	31	38	25	33	29	49	30	5*
11.	Gives a sense of belonging	28	40	17*	30	26	22	27	41
12.	Leads to complications	26	36	17*	33	17	14	25	50*
13.	Prerequisite for marriage	25	30	21	28	21	16	11	59*
14.	Confers honour/status	24	20	28	26	21	14	25	41
15.	Leads to difficult delivery	22	22	23	25	19	16	30	9
16.	Painful experience	23	14	32*	30	14	5	39	23*
17.	Requires treatment	22	4	40*	26	17	16	34	9*
18.	Secretly done now	18	22	15	10	31*	19	25	5
19.	Accompanied by ceremonial acts	12	12	11	18	2*	3	2	45*
20.	Sometimes has to be redone due to complications	10	8	11	7	14	5	18	0*
21.	Carried out by designated cutters	8	6	9	8	7	8	11	0
22.	Based on parental wish	8	8	8	8	7	3	14	5
23.	Beautifies	7	6	8	7	7	8	7	5
24.	Involves removal of the clitoris	5	4	6	5	5	5	2	9
25.	Girls held down during procedure	2	2	2	3	0	0	2	5
26.	Reduces sexual urge	1	0	2	2	0	0	2	0
27.	Improves health	1	0	2	0	2	3	0	0

p < .05.

Several participants expressed multiple thoughts about FGM/C as a “good practice” (80%), a “practice in transition” (76%), a tradition (71%), and a “bad practice” (67%). The most common general theme (80%) was that FGM/C was a good practice, as can be seen from the words of an 18-year-old urban adolescent without FGM/C:

That is our tradition and they see it as a good tradition, which everyone must undergo.

The second most frequent general theme (76%) was that it was a practice in transition, as portrayed in the words of another 17-year-old urban adolescent without FGM/C:

In this community now, it will be very difficult to see such a practice still going on. But from women 19 years old up to the aged are the people that you can see that had ‘female circumcision’ but among girls from 12 years down, you can’t see any.

Other frequent themes captured are that FGM/C is a traditional practice, a bad practice, and that the government disapproved of the practice, as can be seen from the quotes below:

Our mothers in this community used to circumcise us as a tradition. They did not do it based on anything, but it was done based on our culture. (17-year-old rural adolescent with FGM/C)

This female circumcision is not good at all, because it has sent many to early graves. (30-year-old urban woman without FGM/C)

The only reason we stopped female circumcision is because the government said we should stop it for the sake of our health. (35-year-old rural woman with FGM/C)

Differences in community perception of FGM/C across location and age

With respect to differences in perceptions across groups, all rural women (100%) referred to FGM/C as a good practice when compared to urban women (47%) (χ²= 36.28, df = 1, p < .001); see Table 2. Views about FGM/C as a fading practice (χ²= 7.27, df = 1, p = .007) and as a bad practice (χ²= 7.41, df = 1, p = .006) were more commonly reported by urban women. Uncut participants more commonly viewed FGM/C as a good practice (χ²= 7.39, df = 1, p = .007), as well as a bad practice (χ²= 10.79, df = 1, p = .001), but a lower proportion of uncut participants viewed FGM/C as a practice of which government disapproves (χ²= 8.2, df = 1, p = .004) compared to cut participants. The descriptions of FGM/C as being a practice disapproved by the government (χ²= 35.63, df = 2, p < .001), as a rite of passage (χ²= 17.56, df = 2, p < .001), and as prerequisite for marriage (χ²= 21.91, df = 2, p < .001) were significantly more frequent among older respondents. A significantly higher proportion of rural women viewed FGM/C as a practice that gives a sense of belonging (χ²= 6.74, df = 1, p = .009).

Community perceptions on health, psychological experiences, and daily living activities surrounding the experience of FGM/C

Table 3 reveals themes emerging from narratives on health-related issues, psychological experiences, and effects of FGM/C on daily living.

Table 3.

Themes emerging from narratives on health-related issues, psychological experiences and effects of FGM/C on activities of daily living (N = 103).

No.	Health	%	Psychological	%	Daily living	%
1.	Bleeding	90	Happy & joyful	92	No effect on daily activities	42
2.	Death	64	No known benefits	32	Disrupts working activities	32
3.	Difficulties in Childbirth	55	Feeling free from shame	31	Prevents promiscuity	32
4.	No health benefit	45	Feeling honoured	26	Daily pains	28
5.	Pains	42	No negative effect	24	Sleep difficulties	22
6.	Easy childbirth	38	Depressed, sad, unhappy	17	Sex difficulties like low libido, pains, avoidance	19
7.	Keloid formation	21	Anxiety	17	Restricted movement	18
8.	Closure of vagina or cervix	21	Feeling of hope after procedure because enhances marriage prospects, fertility, and makes strong & healthy	16	Social withdrawal	18
9.	Infections	14	Painful memories	12	Eating difficulties	14
10.	I don’t know any health issues/problem	14	Feeling of regret after procedure	9	Difficulty or pains when urinating	10
11.	Complications (Non-specific)	12	Improvement in self-esteem	7	Weakness	9
12.	Improves health/strength	10	Impedes harmony in marital relationship	7	Freedom from daily abuse/shame	5
13.	No effect on Childbirth	6	Enthusiasm & happiness before the procedure	6	Not related to promiscuity	5
14.	Injury/wound	5	Feeling traumatised	6	Daily discomfort	4
15.	Regular Menses	4	Sense of fulfilment	4	Painless sexual intercourse	4
16.	Enhances fertility	3	Shame	3	Total acceptance in marriage	3
17.	Prevents diseases	2	Mixed emotions	2	Bold and confident interaction with peers	2
18.	HIV	2	–		Bad mood	2
19.	Sicknesses	4	–		Behaving maturely	2
20.	Prevents pains during sexual intercourse	1	–		Sickly life	2
21.	Weakness	1	–		Joy of exemption from house chores & work activities	1
22.	–	–	–		Not aware of difficulties in activities of daily living	1
23.	–	–	–		Sleeps well	1

Perceptions of the health-related issues of FGM/C

The health-related issues of FGM/C perceived by the study participants were mostly about physical health complications following the procedure. The most frequently recurring themes referring to potential deleterious impact on physical health include bleeding (90%), death (64%), difficulties in childbirth (55%), and pains (42%), as shown in Table 3. A few positive effects on health, such as enhanced fertility, prevention of diseases, and prevention of pain during sexual intercourse were perceived, but with much lower frequencies (see Table 3). The most frequently recurring themes are illustrated in the statements of the respondents seen below:

Yes, there will be sudden death as a result of the bleeding. (20-year-old urban woman without FGM/C)

Like the closure of the genitals due to the improper cutting of the clitoris; therefore during delivery it will be difficult for her to deliver. (28-year-old urban woman with FGM)

In my own understanding there is no health and wellbeing issue surrounding female circumcision. (28-year-old rural woman with FGM)

The adverse effect is the pain girls and women undergo during the cutting. (18-year-old rural adolescent with FGM)

There are no health and wellbeing benefits surrounding female circumcision. (36-year-old urban woman with FGM/C)

Yes, as I said before, it was very painful, and the pain would not allow me to gather myself together. It was after two weeks that I forgot the pains and became myself again. (16-year-old urban adolescent with FGM/C)

Psychological experiences surrounding the FGM/C experience

When asked specifically about the psychological experiences surrounding FGM/C, the respondents perceived positive experiences such as happiness, relief from embarrassment and shame, and feeling honoured. Neutral psychological experiences were also perceived, as well as negative experiences of sadness, regret, trauma, and shame (see Table 3).

The most frequently occurring themes were: happy and joyful feelings (92%), no known benefits (32%), freedom from stigma (31%), feeling honoured (26%), and no negative effects (24%). Less frequently mentioned themes were sadness (17%), anxiety (17%), regret (9%), feeling traumatized (6%), and mixed emotions (2%). Women with FGM/C mainly mentioned shame as an emotion they experienced when they were without FGM/C. These themes are illustrated in the words of the study participants below.

Positive psychological experience

The person who undergoes female circumcision will be very happy because she would not be humiliated again. (18-year-old urban adolescent with FGM/C)

If you undergo it, you will be respected; you will be so happy that you had circumcision and that you are now a respectable person in the community. (17-year-old rural adolescent without FGM/C)

Neutral psychological experience

There is no adverse effect because since I did mine, I have never had any problem about it. So I cannot tell that it has adverse effects. (22-year-old rural woman with FGM/C)

Ah, it does not have any effect on someone’s emotion, mind or psychological wellbeing. (64-year-old rural woman with FGM/C)

Negative psychological experience

The person whose own did not go well will be regretting and that person will not be happy but sad all the time. (23-year-old urban woman without FGM/C)

She will be having anxiety, just like someone who wants to undergo an operation will be having anxiety that something like complications might happen. (20-year-old urban woman without FGM/C)

The negative effect is anger because whenever they are teaching us may be in the class room or elsewhere, I will start crying and that will make me feel sad and angry. (15-year-old rural adolescent with FGM/C)

Someone who wants to undergo female circumcision will be having some anxiety that something may happen. (20-year-old rural woman without FGM/C)

Effects of FGM/C on activities of daily living

The most frequently recurring themes mentioned by participants in relation to daily living and activities were that FGM/C has no effect on daily activities (42%), disrupts working activities (32%), prevents promiscuity (32%), causes daily pains (28%), and difficulties in sleeping (22%). These are shown in Table 3. Less frequently mentioned themes were that FGM/C causes sexual difficulties (19%), restricted movement (18%), social withdrawal due to pain (18%), difficulties eating (14%), pain during urination (10%), weakness (9%), and daily discomfort (4%). A few lower frequency positive effects of FGM/C on daily living perceived were pain-free sexual intercourse (4%), total acceptance in marriage (3%), confidence in interaction with peers (2%), mature behaviour (2%), exemption from household chores (1%), and good sleep (1%). All of these are shown in Table 3. The most frequent themes are illustrated by the quotes of both cut and uncut women in rural and urban communities:

You cannot go to farm because of the pains. You have pains all over your body. (29-year-old urban woman without FGM/C)

I was not able to do anything the first week it happened. I was just lying down until it dried up. (23-year-old urban woman with FGM/C)

For the first week the person goes through uncontrollable pain. Then after some time elapses and the wound heals, but the pain is always there. (55-year-old rural woman with FGM/C)

Because I underwent circumcision, I do not really satisfy my husband when it comes to sex. Sometimes, my husband complains. And for me, I do not feel anything. (29-year-old urban woman with FGM/C)

“How it affects them is that bleeding may occur during or after sexual intercourse”. (40-year-old rural woman without FGM/C)

Health issues, psychological experiences, effects on daily activities across location, age, and FGM/C status

The top five themes that emerged for all questions were similar across location, age, and FGM/C status, with slight differences in the order of priority of the issues (see Table 4).

Table 4.

Five most frequent themes from health-related issues, psychological experiences, and daily living activities across location, age, and FGM/C status (n = 103).

		Health Related Issues of FGM/C
		Location		Age			FGM/C Status
No	5 most frequent themes	Rural n = 50	Urban n = 53	12–19 n = 37	20–39 n = 44	>40 n = 22	Cut n = 61	Uncut n = 42
		%	%	%	%	%	%	%
1.	Bleeding	100	60*	57	100	59*	80	100*
2.	Death	92	38*	46	80	50*	69	57
3.	Difficulties in childbirth	70	42*	24	80	55*	61	48
4.	No health benefit	40	49	19	61	50*	46	43
5.	Pains	30	53*	38	55	23*	48	33
		Psychological experiences of FGM/C
		Location		Age			FGM/C status
No	5 most frequent themes	Rural n = 50	Urban n = 53	12–19 n = 37	20–39 n = 44	>40 n = 22	Cut n = 61	Uncut n = 42
		%	%	%	%	%	%	%
1.	Happy or joyful	100	66*	65	82	100*	100	71*
2.	No benefits	40	25	22	39	36	34	29
3.	Free from shame	42	21*	30	32	77*	30	33
4.	Honour & respect	34	19	14	23	59*	34	14*
5.	No negative effects	36	13*	14	27	36	25	24
		Effects of FGM/C on activities of daily living
		Location		Age			FGM/C status
No	5 most frequent themes	Rural n = 50	Urban n = 53	12–19 n = 37	20–39 n = 44	>40 n = 22	Cut n = 61	Uncut n = 42
		%	%	%	%	%	%	%
1.	No effect	40	43	30	36	73*	52	29*
2.	Disrupts work	46	19*	38	32	23	25	43
3.	Prevents promiscuity	18	43*	19	45	23*	36	24
4.	Daily pains	30	26	35	32	9	23	36
5.	Sleep difficulties	20	25	30	18	18	18	29

p < .05.

Differences in health themes relating to FGM/C

A significantly higher proportion of rural women compared to urban ones mentioned bleeding (χ²= 24.89, df = 1, p < .001), death (χ²= 32.91, df = 1, p < .001), and difficulties in childbirth (χ²= 8.45, df = 1, p = .004) as health-related issues of FGM/C (see Table 4). Urban participants, on the other hand, more commonly mentioned pains (χ²= 5.51, df = 1, p = .019). A much higher proportion of women in the 20–40 age group mentioned bleeding (χ²= 24.66, df = 2, p = .019), death (χ²= 11.02, df = 2, p = .019), difficulties in childbirth (χ²= 24.70, df = 2, p = .019), no health benefits (χ²= 15.17, df = 2, p = .019), and pains (χ²= 14.34, df = 2, p = .019) as health-related issues of FGM/C compared to the other two groups. Bleeding was more commonly mentioned among uncut women (χ²= 10.06, df = 1, p = .002). The 12- to 19-year-old respondents were the only ones who mentioned improvement in health and strength as a consequence of FGM/C and some of them expressed the view that FGM/C prevents pain during sexual intercourse.

Differences in psychological experiences

Higher percentages of rural women mentioned happiness (χ²= 20.58, df = 1, p < .001), freedom from shame (χ²= 5.42, df = 1, p = .02), and no negative effects (χ²= 7.27, df = 1, p = .007) as psychological experiences associated with FGM/C (see Table 4). Older respondents significantly reported happiness (χ²= 10.36, df = 2, p = .006), freedom from shame (χ²= 15.47, df = 2, p < .001), and honour and respect (χ²= 15.25, df = 2, p < .001) as psychological experiences of FGM/C.

Cut women were significantly more likely to indicate happiness (χ²= 10.36, df = 1, p < .001) and feeling honoured and respected (χ²= 15.25, df = 1, p = .022) as psychological experiences. None of the older women mentioned painful memories or feeling traumatized as a psychological experience of FGM/C.

Differences in daily living activities

Disruption of daily activities due to FGM/C appeared to be more important to the rural women, as 46% of them mentioned this, compared to only 19% from the urban areas (χ²= 8.7, df = 1, p = .003). Urban women, on the other hand, more commonly mentioned that FGM/C prevents promiscuity (χ²= 7.75, df = 1, p = .005). There were significant differences in reports about the effect of FGM/C on their daily activities (χ²= 11.4, df = 2, p = .003) according to age (see Table 4). A significantly higher proportion of cut women mentioned that FGM/C had no effect on their daily activities (χ²= 5.8, df = 1, p = .016).

Discussion

This purpose of this study was to explore the perception of FGM/C in a community in Southeastern Nigeria, in order to ascertain key issues surrounding the practice and the psychological experiences of both cut and uncut women across the lifecycle. The plan was to obtain a sample of both cut and uncut women representing adolescence, early adulthood, and middle age from Izzi communities. While cut and uncut girls and women were recruited in adolescence and early adulthood, no uncut women were identified above 40 years in this community. This is an indication of the importance attached to FGM/C among the Izzi in the past, where some of the highest rates are recorded in Nigeria (Ibekwe et al., 2012; Lawani et al., 2014). Echiegu (1998), an Izzi anthropologist, had stated that before 1960, in Izzi communities, FGM/C was an initiation rite intertwined with the Izzi marriage rite and that, as such, it was compulsory for all women and men, but that this was gradually changing.

The results also substantiate the idea that FGM/C is a changing practice, as this was a commonly recurring theme in the community’s perception of FGM/C. Phrases used by the study participants such as “good practice”, “fading practice”, “tradition”, as well as “bad practice”, and “government disapproves” suggest that this is a practice in transition. This finding is not surprising given the widespread campaigns and legislation against the practice (FMOH, 2013). The government of Nigeria has carried out sustained interventions towards the eradication of FGM/C since the enactment of the first National Policy in 2002 (Federal Ministry of Health [FMOH], 2002). Some activities at the grassroots level involved the training of traditional birth attendants and village health workers, who are used as agents of change. The contradictions in the minds of the women about FGM/C were also revealed in their descriptions of the practice as being simultaneously a good and bad one, as can be seen by responses from over two-thirds of the women. Ambivalent and conflicting perceptions about FGM/C that are evident in the Izzi community are also observed in other communities (Berggren et al., 2006; Ezenyeaku, Okeke, Chigbu, & Ikeako, 2011).

In a recent study carried out in Southeastern Nigeria, only 14.3% of cut women expressed a desire to “circumcise” their daughters despite having been “circumcised” themselves, while also affirming that FGM/C was a good practice (Ezenyeaku et al., 2011). In a qualitative study on circumcised Sudanese women, Berggren et al. (2006) reported a sense of ambivalence among women who had experienced FGM/C, as many of them were caught between the fulfilment of tradition and questions about the benefits of the practice.

This cultural change in the practice of FGM/C was further supported by the urban–rural comparisons, which showed that FGM/C appeared to be more of a “bad” practice than a “good” one for urban participants, and more “good” than “bad” for the rural participants. This may be because urban residents are more likely to be educated (National Bureau of Statistics, 2010), more exposed to the media, and therefore more aware of the harmful effects of FGM/C. In Ebonyi State, where this study was carried out, rural children lagged behind their urban peers in all key areas of academic achievement (Nworgu & Nworgu, 2013). In age group comparisons, the younger women all expressed ambivalent views about FGM/C, naming it as a good practice as well as a bad one, while the older women (40 years and above) did not appear to consider this as important, as very few indicated it was either a good or bad practice. Rather, they viewed FGM/C more as a traditional practice, which was gradually fading because the government disapproved of it. Thus, it appears that at least among the younger population, the perception of the usefulness of this practice may be changing. In a study on the knowledge and practice of FGM/C in women who attended a hospital in Ebonyi State, a third of the women did not know the reason for FGM/C, while culture and tradition were the reasons given by a fifth of them (Ibekwe et al., 2012). Evidence of a change in practice was found in the cross-national comparative study of countries in West Africa where rates of “circumcision” in daughters were lower than in their mothers (Sipsma et al., 2012).

The health-related issues expressed by the participants in this study are similar to those described in other studies of the effects of FGM/C (Inhorn & Buss, 1993; Johansen, 2002; Kallon & Dundes, 2010; Koukoui, Hassan, & Guzder, 2017; Okonofua et al., 2002). Up to 90% of the participants listed bleeding, and more than half listed death and perinatal difficulties as complications, an indication that the community was well aware of the physical health consequences. According to Shell-Duncan (2008), health campaigns have failed because people in communities were well aware of the health consequences of FGM/C but were willing to take risks because of the social and cultural importance of the practice. Shell-Duncan therefore advocated a shift from a health focus to a human rights focus in eradication campaigns.

One in 10 of the participants expressed positive health benefits of FGM/C, such as its ability to improve the health and strength of women, while a few believed that it enhanced fertility and prevented disease. Although the origins of the view that FGM/C enhances health are unknown, beliefs that FGM/C ensured pubertal maturation, cleanliness of the genitalia, enhanced fertility, and increased child survival were found in several communities (Anuforo et al., 2004; Inhorn & Bass, 1993; Johansen, 2002).

The greater preponderance of reports of bleeding, death, and difficulties in childbirth by rural participants may be due to the fact that health facilities in the rural areas are less likely to be equipped to handle health complications than urban ones. It may also be that the practice is less prevalent in urban settings, thus reducing the likelihood of encountering deleterious health problems. Pain was also expressed as a health concern and the descriptions given by the girls and women revealed both a physical and psychological component to the pain, similar to what Johansen (2002) found among Somali women who had undergone infibulation and who were now living in Norway.

Contradictory perceptions and emotions surrounding FGM/C were also apparent in the psychological experiences listed by the Izzi girls and women. Both positive and negative psychological experiences were associated with FGM/C in this study. Positive effects were related to freedom from shame and insults due to not being cut, and the sense of belonging, peer acceptance, and immediate rise in social status in the community after the procedure. Thus, the positive psychological experiences associated with the practice of FGM/C were linked to the social significance of having FGM/C, and the corresponding recognition that came with it—and not to the act of cutting itself. This observed positive psychological experience is very meaningful in the prevalent context of most African societies, where identity is not individualist as in many Western countries, but is based on belonging to a larger group—what has been called “collectivist identity” (Brewer & Gardner, 1996; Kirmayer, Adeponle, & Dzokoto, 2018; Kpanake, 2018). In cultures where FGM/C is practised, those who undergo the procedure are initiated into adulthood immediately; they develop a sense of self-confidence and pride and are awarded considerable public respect (Walley, 1997). In Sierra Leone, FGM/C occurs in synergy with the initiation into a secret society, seen as a cultural and social necessity (Kallon & Dundes, 2010). Those who do not undergo FGM/C are not respected as adults in society and are excluded from leadership positions, treated as unclean, unmarriageable, and promiscuous. In this context, adherence to the norms of the group, and the corresponding inclusion into the group, are paramount to wellbeing and to a sense of self, while determining one’s reputation and social standing. It is therefore expected that a person would be happy and relieved when the stigma of being uncut ceases and is replaced by pride, respect, and recognition as a result of fulfilling society’s traditional expectations. To be ostracized in a collectivist society is likely to have highly negative psychological impacts, which would account for the feeling of relief experienced after the cutting. A number of studies have reported similar findings, citing the reasons for circumcision as being respect gained from the community, a sense of belonging, and a feeling of pride among cut women based on the belief that they had become better persons through circumcision (Chalmers & Hashi, 2000; Mwangi-Powell, 1999; Whitehorn, Ayonrinde, & Maingay, 2002). Somali women living in Canada also reported a sense of pride and happiness after being cut, despite fear and severe pain at the time of the cutting (Chalmers & Hashi, 2000; Fried, Mahmoud Warsame, Berggren, Isman, & Johansson, 2013). The interpretation of the apparent psychosocial gains occurring as a result of FGM/C needs to be explored with more depth by further qualitative research. Overall, negative emotions were not mentioned as frequently as the positive ones in this study. Fewer negative emotions may not translate to lesser emotional problems expressed. This may also be explained by the fact that in African cultures, negative emotions are more likely to manifest in other ways, such as somatization (Kirmayer, 1984; Patel, Abas, Broadhead, Todd, & Reeler, 2001). Girls aged 14–19 years with FGM/C in Egypt were found to have significantly higher somatization than girls without FGM/C (Ahmed et al., 2017). Furthermore, the questions put to the participants in this study were general questions and not personalized.

Sadness and anxiety were the most commonly mentioned negative emotions and were linked to experiencing complications of the procedure, as well as to uncertainty about the outcome of the complications on their physical wellbeing. Other negative emotions, such as regret and feeling traumatized, were also mentioned as being linked to complications during child delivery. While we know that a number of studies on FGM/C report affective disorders such as depression, anxiety, and a posttraumatic stress disorder (PTSD) (Behrendt & Moritz, 2005; Knipscheer, Vloeberghs, van der Kwaak, & van den Muijsenbergh, 2015), the methodological limitations of our study do not allow us to report if this was the case or not with some of our participants. Furthermore, these studies have been heavily criticized.

In a commentary on the study by Knipscheer et al. (2015), Mustafa (2016) noted that the finding that a third of women had affective or anxiety disorders and that 17% had PTSD may be invalid for several reasons. The Western view of what is a traumatic event may not apply to FGM/C because the affected girls or women may accept this as a being normal practice in their communities. In addition, the construct of PTSD is still being questioned. Even if it were a valid construct, the symptoms of PTSD might be due to several other traumatic events, such as sexual abuse or intimate partner violence; and the anxiety symptoms might be due to other stressors, for example, uncertainty about being granted asylum. Also of note, screening tools were used and there was no control group. Mustafa (2016) concluded by emphasizing that qualitative studies in which women who have undergone FGM/C tell their own experiences may provide more valid data.

Furthermore, a greater percentage of urban compared to rural participants mentioned negative emotions associated with the practice of FGM/C. Urban participants are more likely to mix with people from other cultures and other ethnic groups, who may look down on and frown upon the practice and its complications, thus possibly increasing the vulnerability of cut urban women to the negative psychological effects of FGM/C. Considering the contradictions in these emotions, further studies are required to better understand the complexity of the psychological lived experience of FGM/C in social and cultural contexts. The expression of distress in rural and older populations through somatic symptoms also needs more study. In addition, the negative effects of FGM/C on daily living were related to work, pain, and disruption of activities, such as sleep and sex—both of which have biological, social, and psychological components (Johansen, 2002) and which other researchers have reported (Jinnah & Lowe, 2015).

This study also revealed the existence of a number of pervasive myths surrounding the advantages of the practice of FGM/C that need to be challenged and corrected by media messages; namely, that FGM/C facilitates childbirth, improves health, makes menstrual periods regular, enhances fertility, prevents disease, and makes the sexual act painless. These perceived advantages were mostly mentioned by the younger girls and may be an indication that they had internalized the beliefs for retaining FGM/C in their communities in a way that can contribute to motivating them to undergo the procedure.

Limitations

The methodology did not allow for in-depth exploration of the multiple layers of meanings and psychological experiences of women and girls who underwent the different types of FGM/C and their relationship with socio-demographic factors. As such, no definite conclusions can be drawn at this stage. Besides this, a convenience sample, which included only girls and women, was used for the study and this limits the generalizability of the results.

Conclusion

Participants in this study, who were both cut and uncut girls and women in rural and urban Izzi communities, described positive, negative, and neutral psychological experiences surrounding the FGM/C procedure. Positive feelings, such as happiness and relief, were most often described in relation to the rise in social status following the cutting and the freedom from stigma and shame in association with being uncut. Positive emotions were more likely to be expressed by rural dwellers and older women. Negative emotions, though mentioned by fewer participants, were shame from being uncut, anxiety before the procedure, and depression and regret after the procedure, usually when there were complications. There is a clear need for a more in-depth and contextualized understanding of the complex and contradictory emotions included in the psychological experiences of FGM/C.

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Footnotes

Acknowledgements

Special thanks go to the research assistants and Dr. Motunrayo Ayobola, who participated in the ATLAS.ti coding. We are grateful to Prof. Odidika Umeora and Dr. Monday Nwite Igwe for facilitating our entry into the Izzi community at the onset of data collection. We thank Dr. Paul Bolton for his involvement in the protocol development for this study. Finally, we acknowledge the contribution of Dr. Elise Ragnhild Johansen in the conceptualization and design of the study and her involvement in the early community mobilization activities among the Izzi community.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was partially funded by the World Health Organization (WHO). WHO had no role in the study design, data collection, data analysis, and interpretation.

ORCID iD

Olayinka Omigbodun

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Olayinka Omigbodun, MBBS, MPH, FMCPsych, FWACP (Psych), is Professor and Head of Psychiatry and Director, Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Nigeria. She is a consultant in child and adolescent psychiatry at the University College Hospital, Ibadan. Professor Omigbodun is currently principal investigator of various multinational projects designed to build up child and adolescent mental health capacity in Africa, to improve child mental health service utilization in Nigeria, and to roll back the HIV epidemic in Nigerian adolescents. Her published work covers different aspects of child and adolescent mental health as well as women’s mental health, with an emphasis on public health, school health, vulnerable youth, service development, and psychological interventions.

Tolulope Bella-Awusah, MBBS, MSc. CAMH, FWACP (Psych), is a senior lecturer at the Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria, and Head of Child and Adolescent Psychiatry at the University College Hospital, Ibadan, Nigeria. Dr. Bella-Awusah’s research focuses on mental health services for vulnerable youth and other ethnic populations. Her research interests include adolescent health, school mental health, mood disorders, and mental health promotion.

Danielle Groleau, PhD, is Associate Professor and Associate Director of Graduate Studies in the Department of Psychiatry at McGill University, Canada. Dr. Groleau researches social and cultural determinants of reproductive health behaviour as well as illness meaning and experience in mental and physical health. She is currently the Principal Investigator of a study on Expressive Writing in school-based settings to promote well-being in adolescents and supervises a research project on FGM/C in Guinée. Her published works focus on mental health services research, methodological issues in qualitative research, and social and cultural determinants of reproductive health behaviour.

Jibril Abdulmalik, MBBS, MSc, is a psychiatrist and senior lecturer with the Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria. Dr. Abdulmalik’s published works focus on mental health services research, improving access to care via integration into primary care, stigma reduction, as well as vulnerable populations such as children and adolescents and incarcerated offenders.

Nkechi Emma-Echiegu, PhD (Medical Social Work), is a senior lecturer with the Department of Psychology and Sociological Studies in the Ebonyi State University, Abakaliki, Nigeria. Dr. Emma-Echiegu’s research interests include the psychological experiences and consequences of female genital cutting and vesicovaginal fistula, orphans and vulnerable children, and quality of post-abortion care. She is the Nigerian Principal Investigator of a multi-country study on the Quality of Post Abortion Care in Nigeria.

Babatunde Adedokun, MBBS, PhD, is an epidemiologist at the College of Medicine, University of Ibadan, Nigeria. He is currently a postdoctoral scholar at the University of Chicago, USA. He has participated in the design, conduct, implementation, and report writing of studies in diverse areas, such as child and adolescent mental health, cancer epidemiology, HIV/AIDS, and reproductive health. Dr. Adedokun’s current research is in cancer epidemiology, with a focus on the genetic and non-genetic risk factors for breast cancer among women of African ancestry.

Akinyinka O. Omigbodun, MBBS, FWACS, is a professor of Obstetrics & Gynaecology at the College of Medicine, University of Ibadan, Ibadan, Nigeria. Professor A. O. Omigbodun conducts research on various aspects of reproductive health, including the sexual health of youth and maternal mental health. He is the Nigerian Principal Investigator of a multinational study assessing how inhabitants of dense urban settlements access health services, especially reproductive health services. His published work covers different aspects of female reproductive/sexual health and rights, and female genital malignancies.

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