Female genital mutilation or circumcision (FGM/C) is defined as ‘all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’ (Haut Commissariat des Nations Unis des Droits de l’Homme et al. 2008). Worldwide, 200 million women have undergone FGM/C and the number of potential victims is estimated at 3 million each year (World Health Organization 2020). There are four type of FGM/C depending on the level of damage to the female external genitalia (HCDH et al. 2008): (1) removal of the clitoris (partial or total); (2) removal of the clitoris and labia minora (partial or total); (3) narrowing the vaginal opening (infibulation) or (4) any non-medical harmful practice for example, burning or pricking. The customs of the communities where FGM/C is practised encourage the perpetuation of these acts of violence against women for cultural or symbolic reasons (Andro & Lesclingand 2016). Some of these customs include beliefs that FGM/C can increase childbirth ability, ensure chastity, prevent promiscuity of women and girls and/or meet religious requirements (Berg, Denison & Fretheim 2010; Terry & Harris 2013). Additionally, women who were not mutilated face ostracisation and socio-economic hardship (Berg et al. 2010) as well as stigmatisation (Terry & Harris 2013). In addition to the acute and chronic genitourinary complications, FGM/C has a significant psychological impact on its survivors. Previous quantitative findings have indicated a correlation between FGM/C and mental disorders such as post-traumatic stress disorder (PTSD), depression, anxiety and sleep disorders (Behrendt & Moritz 2005; Chalmers & Hashi 2000; HCDH et al. 2008; Mulongo, Mcandrew & Martin 2014). Other mental disorders like somatisation and phobia are mentioned (Elnashar & Abdelhady 2007). However, some authors criticise the simplistic quantitative analysis made, disregarding the impact of contextual factors such as the type of FGM/C or the migrant status of mutilated women (Pastor-Bravo, Almansa-Martínez & Jiménez-Ruiz 2018). The inclusion of qualitative data would provide a broader overview of the factors influencing the development of these psychological disorders and would lead to clear recommendations to establishing multidisciplinary treatment guidelines.

To bridge this gap, we conducted a mixed-method systematic review to map out existing literature on FGM/C’s psychological impact, based on both quantitative and qualitative data. The review sought to address the following research questions: (1) What are the main psychological disorders induced by FGM/C? and (2) How are these disorders explained by women who have undergone FGM/C?

Our mixed method systematic review followed the ‘Convergent Segregated’ methodological framework proposed by the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

According to the JBI guidelines, the results of the quantitative, qualitative and mixed method studies were integrated into a ‘configurational’ analysis. While the quantitative studies found a significant relationship between FGM/C severity and four major psychological disorders (PTSD, depression, anxiety and somatisation), qualitative studies found contextual effects through victims’ accounts (immigrant’s status and socio-cultural background). There is consistent evidence, from several studies (Ahmed, Shabu & Shabila 2019; Jacobson et al. 2018; Parikh et al. 2020; Vloeberghs et al. 2012) of FGM/C impact on PTSD severity. Conversely, other elements were not considered in these studies such as mother/daughter relationship or discussing about FGM/C prior to its practice.

Even if the majority of quantitative studies establish a relationship between FGM/C severity and psychological disorders (PTSD, anxiety, depression, somatisation), some results are discordant. For example, although some studies used the same questionnaire, heterogeneity of the study populations should lead us to compare the results cautiously. For instance, Daneshkhah et al. (2017) did not detect the effect of FGM/C on depression or somatisation, most likely because of differences in demographic characteristics between the groups. Furthermore, in the Köbach et al. (2018) study, women with Type I FGM/C had depression scores similar to non-mutilated women. We hypothesised, with configurative analysis, that non-mutilated women in this study, who were of Somalian origin, may have experienced other traumas (stigmatisation, harassment, social isolation), which led to a high level of psychological distress in this group. The same phenomenon (high level of anxiety in the non-mutilated group) could explain the lack of difference between mutilated and non-mutilated women in the Piroozi et al. (2020) study.

The influence of cultural or ethnic origins was also illustrated by Knipscheer et al. (2015). They reported that being of Somalian origin (where Type III FGM/C is often practised) paradoxically attenuated PTSD severity, depression and anxiety disorders. Again, qualitative studies describing the social pressure and stigmatisation experienced by non-mutilated women (Ahmed et al. 2019; Jacobson et al. 2018; Omigbodun et al. 2020) in their community may shed light on this result. In this context, FGM/C may be experienced as a ‘rite of passage’ and confer positive psychological effects linked to social integration and benefits that arise from it.

Similarly, immigration generated a changing perception of FGM/C and higher levels of awareness among mutilated women through media, FGM/C abolition campaigns and the access to education which is available in host countries (Jacobson et al. 2018; Vloeberghs et al. 2012). This awareness triggered a feeling of ‘abnormal sense’ among these women, previously unheard of in their home countries where being mutilated was considered as ‘natural’ and ‘the order of things’ (Jacobson et al. 2018).

It is important to note that this ‘being abnormal’ feeling was sometimes awakened by an experience with health care (Jacobson et al. 2018): Vloeberghs et al. (2012) reported negative feelings (shame, embarrassment, guilt) caused by health professionals inappropriate behaviours creating a reluctance in some women to seek gynaecological care for example. Moreover, having to undress and show their genital area during clinical examination can trigger the memory of mutilation leading to PTSD symptoms similar to sexually abused or tortured women (Parikh et al. 2020; Vloeberghs et al. 2012). Considering the ‘silence’, mentioned by Jacobson et al. (2018) as a coping or emotional management mechanism, the need for a multidisciplinary approach for these women, based on a bio-psycho-social model as advocated by WHO (World Health Organization 2016) is obvious.

In conclusion, results of this mixed method systematic review reinforce the association of FGM/C (and its degree of severity) with psychological disorders such as PTSD, depression, anxiety and somatisation. It also illustrates contextual factors, including socio-cultural factors that may influence the intensity of these psychological disorders. This reinforces the need for multidisciplinary, culturally sensitive, specific and caring care for FGM/C victims.

Future research should develop adapted and standardised questionnaires to precisely study mutilated women’s psychological disorders. Studies should select comparable groups to the baseline to avoid confounding bias. Finally, research would benefit from mixed studies, as the combination of both quantitative and qualitative data would provide rich information close to clinical reality.