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HELSEVEL-H-Gode og effektive helse-, omsorgs- og velferdstjenester

Physical and psychological health care for girls and women with Female Genital Mutilation/Cutting (FGM/C)

Alternative title: Helsehjelp for jenter og kvinner som har vært utsatt for kjønnslemlestelse

Awarded: NOK 11.7 mill.

This study had three objectives: 1. Identify needs for physical and mental health care for those subjected to FGM/C from the perspectives of affected minority groups as well as the health care professionals. 2. Explore how people from affected minorities seek physical and mental health care. 3. Explore how the Norwegian health system is organized to accommodate minority groups that practice FGM/C. The study was conducted among Somalis, Sundanese, Gambians and Eritreans in Oslo, Trondheim and Drammen. One hundred qualitative interviews were done with health workers, including 24 GPs. A quantitative survey was done in which 223 GPs answered the questionnaire. A study was done in Gambia with 12 year-olds who had undergone genital mutilation. Both the qualitative and quantitative study showed that GPs are reluctant to address FGM/C during consultancy. Affected women are also reluctant to address the topic. Two thirds of GPs had received training in genital mutilation, but 75% thought they needed knowledge about typology and legislation. GPs are overloaded with work, and consultation time is too short. The GPs themselves say that they are satisfied with their cultural competence. However, the qualitative studies show that women demand cultural understanding and respect. There are barriers in the system indicating that women with FGM/C and mental health problems have difficulties being referred further, e.g. to Avtalepsykologer and DPS. In the municipal services, there are hardly any SSA women (Sub Saharan African Women). Several health workers experience that immigrants are discriminated against in the health care system. However, SSA women do not say that they are discriminated against or receive unequal health services. The use of the specialist health services open clinics was done on the basis of different motivations and norms of the SSA users. Norms about virginity do not indicate a positive attitude towards using the services. Norms about active sexual participation will influence willingness to use of the services. An active and positive attitude toward equality in marriage and in sexuality can positively influence the use of the service. Most of the girls/women in the study were positive to psychosocial counselling and would use such a service if it was available. The study shows that women with FGM/C type 1 and 2 as well as 3, may suffer from chronic pain and have psychosocial problems for which they do not get help from the health service. Some are turning to religion and alternative healers to get help. The study showed that the FGM ritual can not generally be described as a traumatic event (TE). Pain is not included in the DSM-4 and DSM V definition of TE. In Somalia, it is uncertain whether female genital mutilation is TE. In Gambia, the circumcision ritual can be considered as TE. In Eritrea, the cutting is performed on small babies having very little meaning-comprehension, making it difficult to decide what the ritual feels like. The experience can be TE. The quantitative Gambian study showed that there was no difference between those who were circumcised before 4 years and those who were circumcised after 4 years when it came to depressive symptoms. Those who experienced urogenital problems and complications after the FGM procedure created a significant risk of depressive symptoms and psychological stress. Only a minimal number of girls in Gambia received medical assistance when they needed it. Experience from the project suggests that clinics at the specialist level should include psychosexual counselling and pain treatment for women with all types of FGM. The services of the clinics focus on deinfibulated women (ie WHO type 3). Women suffering from types 1 and 2 do not have a targeted service. It important to make the municipal health service more accessible to these women by disseminating information about Aktivitetshus, Rask Psykisk Helsehjelp and Frisklivssentraler. There should be more Avtalepsykologer in the areas where immigrants live, as they are located on the West side of Oslo. Health information as well as information about the services should be available so that women could better navigate in the system. The NGOs can be used for this. The project team has consisted of Mai Maghob Ziyada (Ph.D candidate), Bothild Bendiksen (post doc). Cecilie Knagenhjelm Hertzberg, Trond Heir. Ragnhild Elise Johansen has been the supervisor for the PhD student. Inger-Lise Lien was the project manager. The project collaborated with Professor Rex A Kuye and Fabikary Minteh at the University of the Gambia. The project has collaborated with several Norwegian and foreign researchers. The project has published six articles so far. Several articles are under review, and the doctoral dissertation is being finalized. The project started on 01.04. 2017 and lasted until 31.10.2021.

The study addresses the organization and utilization of health care services at the primary and secondary level due to physical and psychological health consequences of female genital mutilation. It will address the model of health care, and examine the patterns of utilization of health care services to discover if these patterns are governed by conditions due to beliefs and resistance, or conditions due to the health care system itself, i.e. as a consequence of high thresholds, low degree of availability, low accessibility or lack of symmetry in dialogue and communication. The project has three interconnected parts: identifying physical and psychological needs by comparing scores of traumatic stress between children who are cut and those who are not. It will explore health seeking believes and behavior, as well as explore how the mental and physical health care services coordinate and collaborate to satisfy the needs of minority women and children subjected to FGM/C. The project will apply mixed methods, i.e. both qualitative and quantitative. It will use Hopkins checklist and Cats trauma instruments to screen for PTSD and depression. Indicators that capture psychosocial and physical health factors will be applied. The qualitative data will be collected with in-depths interviews, focus groups discussions and participant observation. The data will be hermeneutically analyzed following a thematic approach and a process analytical model. The main part of the study will take place in Norway. Screening for PTSD scores will take place among school children in the Gambia. The project will collaborate with user groups, service providers and African and European Universities. The study will publish its findings widely, in national and international peer reviewed journals, practice oriented journals. We will spread information to policy makers, decision makers, affected communities and health service providers. One doctoral dissertation will also be produced.

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HELSEVEL-H-Gode og effektive helse-, omsorgs- og velferdstjenester