Impact of female genital mutilation on sexual function and psychosocial wellbeing among Somali women: a cross-sectional study

Abstract

Background

Female Genital Mutilation (FGM) is associated with significant physical, psychological, and sexual health consequences.

This study sought to examine the impact of FGM on sexual function and psychosocial well-being among women in Somalia compared to those without FGM.

Methods

A total of 753 women were consecutively enrolled, including 707 with FGM and 46 without. Data collected included age, type of FGM (Types I–IV), decision-maker, and setting of the procedure. Participants completed the Female Sexual Function Index (FSFI) and the Brief Symptom Inventory-18 (BSI-18) to evaluate sexual function and psychosocial well-being.

Results

The prevalence of FGM was 93.9%, with Type II being the most common (47.1%), followed by Type III (28.1%), Type I (18.9%), and Type IV (5.9%). Mothers were the primary decision-makers in 60.0% of cases. Sexual dysfunction was significantly more prevalent among women with FGM (64.6%) compared to those without (34.8%) (p < 0.001). The incidence of dysfunction increased with FGM severity: Type I (52.2%), Type II (60.2%), Type III (74.9%), and Type IV (90.5%) (p < 0.001). Women with FGM demonstrated significantly decreased sexual desire, arousal, lubrication, orgasm, satisfaction, and higher pain, anxiety, depression, and somatization (p < 0.001). Regression analysis revealed a strong inverse association between FGM and all domains of sexual and psychological health, with odds ratios increasing with the FGM type (Type I: OR = 2.1; Type II: OR = 2.8; Type III: OR = 5.6; Type IV: OR = 17.8).

Conclusion

Our findings suggest that women in FGM experience significantly greater psychosexual and psychosocial impairments compared to their non-FGM counterparts.

Introduction

Female genital mutilation (FGM) is a culturally rooted practice that encompasses all forms of partial or total removal of the external female genitalia, or other injuries to the female genital organs, for non-medical reasons. The World Health Organization (WHO) formally adopted the term “female genital mutilation” in 1996 to emphasize the severity of the practice and its health and human rights implications, replacing the previously used term “female circumcision.” FGM is deeply rooted in cultural traditions, social norms, and gender roles across various communities, particularly in regions of sub-Saharan Africa, the Middle East, and parts of Asia. Its continuation is often linked to notions of femininity, sexual purity, family honour, and marital eligibility. In many practicing communities, FGM is considered as a rite of passage into womanhood and a prerequisite for social acceptance and marriage. These practices are often reinforced by patriarchal social structures and intergenerational transmission of cultural norms, creating intense social pressure to conform. FGM is internationally recognized as a violation human right and a form of gender-based violence with profound physical, psychological, and social consequences [1–3].

The WHO classifies FGM into four major types based on the extent of anatomical alteration. Type I (clitoridectomy) involves the partial or total removal of the clitoris and/or the clitoral hood; Type II (excision) includes the removal of the clitoris and the labia minora, with or without excision of the labia majora; Type III (infibulation)involves the narrowing of the vaginal opening through the cutting and repositioning of the labia; and Type IV encompasses all other non-medical harmful procedures such as pricking, piercing, incising, scraping, and cauterization. These procedures are typically performed by traditional practitioners or, increasingly in some areas, by medical professionals a phenomenon known as the medicalization of FGM [1–3].

This study sought to examine the impact of FGM on sexual function and psychosocial well-being among women in Somalia compared to those without FGM. To our knowledge, this is the first study in Somalia to comprehensively assess both psychosexual and psychosocial outcomes. In this setting, women face significant social, economic, and gender-based challenges amid prolonged civil conflict. In a relatively large sample (n = 753), psychosexual status was evaluated using the Female Sexual Function Index (FSFI) and psychosocial status was evaluated using the Brief Symptom Inventory-18 (BSI-18).

Materials and methods

Study design and participants

This cross-sectional study included data on 753 consecutive women who had presented between July and December 1, 2023, to the Department of Gynaecology of Mogadishu Somali Turkey Training and Research Hospital in Mogadishu, the capital city of Somalia. Data included maternal age, type of FGM (Type I, II, III, and IV), menarche age, age of marriage, person who makes the FGM decision, the place where FGM was performed, person who performed FGM operation, area of residency, education status, and family income.

The participants were asked to complete two questionnaires: The Female Sexual Function Index (FSFI) and the Brief Symptom Inventory-18 (BSI-18). For those who were illiterate, the questionnaires were completed by a gynaecology specialist (HBH or UE), consistent with responses given by the participants.

Inclusion criteria were being married in a monogamous marriage, and sexually active. Exclusion criteria were being married in a polygamous marriage, comorbid conditions (e.g., renal or liver failure, diabetes mellitus, hypertension, and coronary artery disease), history of a previous major pelvic trauma, psychiatric or neurological disorder, alcoholism, illicit drug use, and use of drugs that might affect sexual function. These criteria were applied to minimize potential confounding factors that could independently influence sexual function and psychological well-being. As noted above, the study population restrictions may limit generalizability.

Questionnaires

The FSFI was developed by Rosen and colleagues to assess six domains of female sexual function (sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain) and has become one of the most widely used measures of sexual functioning of women. The 19-item FSFI is easy to understand and has been adapted to a number of languages. The items are scored on a five-point (1 to 5) Likert scale, with lower scores corresponding to lower levels of sexual functioning and a total score of less than 26.55 indicating sexual dysfunction. Fifteen items also include a sixth response option scored with zero indicating no sexual activity in the past four weeks. Each individual domain score is calculated by the summation of individual scores of the domain multiplied by a factor for each domain ranging from 0.3 to 0.6. Finally, the individual domain scores are added to obtain the overall score [4, 5]. In reliability analysis, interrater reliability Cronbach’s alpha coefficient of the FSFI in the Somalian language was found as 0.88 (range 0.82–0.92), with a content-related validity coefficient of 0.35 [6].

The BSI-18 is a short form of the Symptom Checklist-90-Revised. It contains the three six-item domains (somatization, depression, and anxiety), whose total score ranges from 0 to 72, with higher scores indicating increased negative feelings about the self [7, 8]. The interrater reliability Cronbach’s alpha coefficient and content-related validity coefficient of the BSI-18 in the Somalian language were 0.94 (range 0.86–0.96) and 0.32, respectively [6].

Ethics approval and consent to participate

The study was approved by the Ethics and Research Committee of Mogadishu Somali Turkey Training and Research Hospital (Permission number and date: MSTH/15144/824, 22.08.2023). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent to participate in the study was obtained from all participants prior to enrolment. For one participant younger than 16 years of age, informed consent was obtained from her parents. As a considerable proportion of the participants were illiterate, informed consent was obtained from their legal representatives. The analysis and reporting of the results were conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Data processing and analysis

Data were collected using a structured format, including relevant sociodemographic features, and were processed using the Statistical Package for Social Sciences (SPSS) version 31.0 (IBM Corp., Armonk, N.Y.; USA). Quantitative data were expressed as means, standard deviation (SD), median, minimum, and maximum, and qualitative data as frequencies and percentages. Homogeneity was checked using Levene’s test, where a p-value of > 0.05 was considered in favour of homogeneity. The Shapiro-Wilk normality test was used to check whether continuous variables were normally distributed. For pairwise comparisons, numerical variables were compared using the independent t-test if normally distributed.

Multigroup comparisons of normally distributed variables were made using the one-way ANOVA test. The Post Hoc Multiple Comparisons were used to determine between-group differences. Nominal variables were analysed with Pearson’s chi-squared test. Regression analysis was performed to determine the effect of FGM on the parameters of psychosocial and psychosexual function, both logistic and linear regression analyses were performed. Logistic regression models were used for binary outcomes (e.g., presence of sexual dysfunction), and results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Linear regression analyses were used for continuous outcomes (e.g., FSFI and BSI domain scores), and results were presented as regression coefficients (β) with 95% CIs. Multivariable regression models were constructed to adjust for potential confounders. The following covariates were included a priori based on clinical relevance: age, education level, area of residence (urban/rural), and family income. A p-value of less than 0.05 was accepted as statistically significant. All variables were expressed with 95% confidence intervals (CI).

Sample size adequacy was evaluated using G*Power (version 3.1.9.7, Heinrich Heine University, Düsseldorf, Germany). For the one-way ANOVA including five groups (total n = 753) at α = 0.05, the study had > 99% power to detect moderate-to-large effects (f ≈ 0.30). Sensitivity analysis indicated a minimum detectable effect of f = 0.13 at 80% power. For the smallest groups (control n = 46, Type 4 n = 42), the most critical comparison (No FGM vs. Type 4) showed a very large observed effect (Cohen’s d ≈ 1.55), corresponding to > 99% power, with a minimum detectable d ≈ 0.60 at 80% power. These analyses confirm that the study had sufficient statistical power despite group size imbalance.

Study design and participants

During the study period, 2810 women presented to the gynaecology outpatient clinic. Due to time constraints and physical limitations, a random sampling method was employed. Specifically, every third sexually active woman was selected after the completion of each prior questionnaire. This approach led to the random selection of 1020 women in monogamous marriages, who were invited to participate. Of these, 753 women (73.8%) consented and completed two questionnaires. Among them, 259 women (34.4%) were illiterate; their questionnaires were administered by investigators in accordance with their verbal responses. Literate women completed the questionnaires themselves, taking about 25 min on average, while it took about 35 min for illiterate participants. It should be noted that, by restricting the study population to sexually active women in monogamous marriages attending a gynaecology clinic, the findings may not be fully generalizable to the broader Somali female population. Women attending such clinics may have a higher likelihood of gynaecological, sexual, or psychological concerns, which could introduce selection bias. Of the 753 women, 707 (93.9%) were found to have undergone FGM. The remaining 46 women without FGM were included as a control group.

Results

Female genital mutilation: settings, frequency, and types

The characteristics of women with or without FGM are summarised in Table 1. The mean age at the time of FGM was 8.0 ± 1.8 years (range 2–21). The great majority of women (54.7%) were subject to FGM aged 7–8. Of 707 women with FGM, 47.1% (n = 332) had type II FGM, followed by type III (28.1%, n = 199), type I (18.9%, n = 134), and type IV (5.9%, n = 42) forms. The family member who made the decision for FGM for the daughter was mostly the mother (60.0%), followed by the paternal grandmother (19.3%), even extending to the aunt (4.1%) and uncle (2.1%). The vast majority of FGM operations were performed at home (95.2%). Circumcision was even performed in local healthcare settings (4.8%). The operation was performed by a circumciser who was not a healthcare worker (55.5%) or by a healthcare worker other than a physician (44.5%) (Fig. 1).

Table 1.

Sociodemographic, clinical and setting characteristics of participants

Parameters	Mean ± SD	Count	Percent
Age of FGM (years)	8.0 ± 1.8	2–21
0–2 age of year		1	0.2
≥ 3 ≤ 4		7	0.9
≥ 5 ≤ 6		94	13.3
≥ 7 ≤ 8		387	54.7
≥ 9 ≤ 10		170	24.1
≥ 11		48	6.8
Current age (years)	29.2 ± 7.1	14–56
Menarche age (years)	13.4 ± 2.1
Age of marriage (years)	20.2 ± 4.1
No-FGM		46	6.1
FGM		707	93.9
Type I		134	18.9
Type II		332	47.1
Type III		199	28.1
Type IV		42	5.9
Person who makes the FGM decision
Mother		426	60.0
Paternal grandmother		136	19.3
Father		73	10.4
Grandfather		29	4.1
Aunt		29	4.1
Uncle		14	2.1
The place where FGM was performed
Local healthcare setting		34	4.8
Home		673	95.2
Person who performed FGM operation
Circumciser-not healthcare worker		392	55.5
Health care worker other than a physician		315	44.5
Area of residency
Rural		155	20.6
Urban		598	79.4
Education status
Illiterate		259	34.4
Primary school		105	13.9
Secondary and/or high school		231	30.7
University		158	21.0
Family income
Income is less than expense		258	34.2
Income is equal to expense		356	47.3
Income is more than expense		139	18.5
Sexual dysfunction **		473	62.8

**A total FSFI score of <26.55 indicates sexual dysfunction

Fig. 1.

Socio-demographic characteristics, prevalence, and decision-making dynamics of Female Genital Mutilation in Somalia

Between-group comparisons

Comparisons of the two groups with respect to the scores on FSFI and BSI are presented in Table 2. A comparison of the two groups, women with FGM and those without FGM, revealed statistically significant differences in university education level, sexual function, and psychological health. The FGM group demonstrated a significantly lower rate of university-level education (20.1%) compared to the no-FGM group (34.8%) (p = 0.047). Female sexual function index scores revealed significantly lower sexual function across all assessed domains among women in the FGM group. Compared to the no-FGM group, the FGM group had significantly lower mean scores for desire (5.0 ± 1.0 vs. 4.2 ± 1.3, p < 0.001), arousal (4.7 ± 1.1 vs. 3.6 ± 1.4, p < 0.001), lubrication (4.8 ± 1.0 vs. 3.8 ± 1.2, p < 0.001), orgasm (4.9 ± 0.9 vs. 4.0 ± 1.3, p < 0.001), and satisfaction (4.8 ± 1.4 vs. 4.0 ± 1.4, p < 0.001), and higher score pain (3.0 ± 1.0 vs. 3.5 ± 1.1, p = 0.013). The incidence of sexual dysfunction, defined as a total FSFI score of less than 26.55, was significantly higher in the FGM group (64.6%) compared to the no-FGM group (34.8%) (p < 0.001). Women with FGM showed significantly higher scores in three sub-domains of the BSI compared to women without FGM. The FGM group had higher scores in depression (2.9 ± 1.8 vs. 5.8 ± 3.6, p < 0.001), anxiety (3.2 ± 2.2 vs. 6.2 ± 3.7, p < 0.001) and somatisation (3.1 ± 1.5 vs. 5.8 ± 4.1, p < 0.001).

Table 2.

Comparison of FGM and no FGM with respect to education status, area of residency, family income, on FSFI and BSI

Parameters	No FGM (n=46), n (%)	FGM (n=707), n (%)	p*
Age (years), mean ± SD	26.8 ± 5.3	29.4 ± 7.2	0.029*
Education status n (%)			0.047**
Illiterate	10 (21.7)	249 (35.2)
Primary school	4 (8.7)	101 (14.3)
Secondary and/or high school	16 (34.8)	215 (30.4)
University	16 (34.8)	142 (20.1)
Area of residency			0.820**
Rural	11 (25.0)	144 (20.4)
Urban	35 (75.0)	563 (79.6)
Family income n (%)			0.081**
Income is less than expense	24 (52.0)	263 (37.2)
Income is equal to expense	21 (45.5)	403 (57.0)
Income is more than expense	1 (2.5)	41 (5.8)
FSFI mean ± SD
Desire	5.0 ± 1.0	4.2 ± 1.3	0.0001*
Arousal	4.7 ± 1.1	3.6 ± 1.4	0.0001*
Lubrication	4.8 ± 1.0	3.8 ± 1.2	0.0001*
Orgasm	4.9 ± 0.9	4.0 ± 1.3	0.0001*
Satisfaction	4.8 ± 1.4	4.0 ± 1.4	0.0001*
Pain	3.0 ± 1.0	3.5 ± 1.1	0.013*
Sexual dysfunction n (%)	16 (34.8)	457 (64.6)	0.0001*
BSI mean ± SD
Depression	2.9 ± 1.8	5.8 ± 3.6	0.0001*
Anxiety	3.2 ± 2.2	6.2 ± 3.7	0.0001*
Somatization	3.1 ± 1.5	5.8 ± 4.1	0.0001*

SD standard deviation, FSFI Female Sexual Function Index, BSI Brief Symptom Inventory

Table 3 presents the comparative outcomes of the FSFI and the BSI across women with varying types of FGM and those without FGM. The data reveal statistically significant differences across multiple dimensions of sexual function and psychological wellbeing. Women with FGM, regardless of the types, had significantly lower scores across several FSFI subdomains, including desire, arousal, lubrication, orgasm, and satisfaction, when compared to women without FGM (p < 0.05). With respect to pain, women with FGM Types II, III, and IV had significantly higher levels of pain compared to women with no history of FGM (p < 0.05). However, there was no significant difference in pain level between FGM type I and no-FGM (p > 0.05). In addition, among women with FGM, the overall incidence of sexual dysfunction was 64.6% (n = 457), with the highest incidence observed in type IV FGM (90.5%) and the lowest in type I (48.5%). The incidence of sexual dysfunction significantly increased with the severity of FGM type (p < 0.05). Across all types of FGM, women also scored significantly higher on subdomains of the BSI, including anxiety, depression, and somatisation, compared to women without FGM (p < 0.05). However, there were no significant differences between the FGM and no-FGM groups regarding family income or area of residence (p > 0.05).

Table 3.

Between-group comparisons of no-FGM and types of FGM with respect to scores on FSFI and BSI

Parameters	No-FGM (n = 46) Mean ± SD	FGM type 1(n = 134) Mean ± SD	FGM type 2 (n = 332) Mean ± SD	FGM type 3 (n = 199) Mean ± SD	FGM type 4 (n = 42) Mean ± SD	P*
FSFI
Desire	5.0 ± 1.0	4.4 ± 1.2	4.3 ± 1.2	3.9 ± 1.3	3.2 ± 1.3	P1:0.036,P2:0.010,P3:0.0001,P4:0.0001
Arousal	4.7 ± 1.1	4.0 ± 1.3	3.6 ± 1.4	3.5 ± 1.4	2.8 ± 1.2	P1:0.031, P2: 0.0001,P3: 0.0001,P4: 0.0001
Lubrication	4.8 ± 1.0	4.2 ± 1.3	3.9 ± 1.1	3.6 ± 1.1	3.2 ± 1.0	P1:0.014,P2: 0.0001,P3: 0.0001,P4: 0.0001
Orgasm	4.9 ± 0.9	4.3 ± 1.4	4.1 ± 1.2	3.8 ± 1.3	3.2 ± 1.2	P1:0.029,P2: 0.0001,P3: 0.0001,P4: 0.0001
Satisfaction	4.8 ± 1.4	4.1 ± 1.4	4.1 ± 1.3	3.8 ± 1.4	3.3 ± 1.3	P1:0.027,P2:0.012,P3: 0.0001,P4: 0.0001
Pain	3.0 ± 1.0	3.3 ± 1.0	3.3 ± 1.0	3.7 ± 1.3	4.4 ± 1.0	P1:1.00,P2:1.00,P3:0.006,P4:0.0001
Sexual dysfunction, n (%)	16 (34.8)	70 (52.2)	200 (60.2)	149 (74.9)	38 (90.5)	P:0.0001
BSI
Anxiety	3.2 ± 2.2	5.5 ± 3.0	5.5 ± 4.2	7.5 ± 2.9	8.5 ± 3.7	P1:0.001,P2:0.001,P3:0.0001,P4:0.0001
Depression	2.9 ± 1.8	5.2 ± 3.0	5.3 ± 3.8	6.3 ± 3.5	8.6 ± 3.3	P1:0.001,P2: 0.0001,P3: 0.0001,P4: 0.0001
Somatization	3.1 ± 1.5	5.1 ± 3.8	5.3 ± 4.4	6.6 ± 3.7	8.1 ± 4.2	P1:0.024,P2:0.004,P3: 0.0001,P4: 0.0001

ANOVA was used to compare means across FGM types. Bonferroni correction was applied for multiple post hoc comparisons, Levene’s test was performed to assess the homogeneity of variance, Post hoc p-values reported are adjusted using the Bonferroni method

NS  Not significant, FGM  Female Genital Mutilation, SD  standard deviation, FSFI  Female Sexual Function Index, BSI  Brief Symptom Inventory

* P1:no FGM -Type 1,P2:no FGM -Type 2,P3:no FGM - Type 3, P4:no FGM - Type 4

Regression analysis

The results of the regression analysis are summarised in Tables 4 and 5. Illiteracy was significantly associated with FGM. Female genital mutilation showed significant inverse associations with FSFI subdomains, including desire, arousal, orgasm, satisfaction, and pain, as well as with overall sexual dysfunction. Additionally, FGM was significantly associated with the BSI subdomains of anxiety, depression, and somatisation (p < 0.05) The relationships between FGM and non-FGM participants with the assessed variables were first explored through univariate analyses. Multivariable models were then developed to control for potential confounding factors. Following adjustment, both the strength and direction of the associations were generally consistent with the univariate results (Table 4).

Table 4.

Univariable and multivariable regression analysis of factors associated with FGM

Variables	OR (95% CI)	p	AOR (95% CI)	P
Education level
Illiterate	2.8 (1.2–6.4)	0.013	1.62 (0.61–4.28)	0.334
Primary school	2.9 (0.9–8.8)	0.069	2.38 (0.65–8.75)	0.193
Secondary–high school	1.5 (0.7–3.1)	0.262	1.32 (0.53–3.29)	0.551
Place of residence
Rural vs. urban	0.8 (0.1–7.5)	0.820	–	–
Sexual dysfunction	3.4 (1.8–6.4)	< 0.001	3.2 (1.6–6.0)	< 0.001

	β (95% CI)		Adjusted β (95% CI)
Age	0.06 (0.01–0.11)	0.017	0.05 (-0.01–0.11)	0.111
FSFI domains
Desire	-0.8 (-1.2–-0.5)	< 0.001	-0.7 (-1.0–0.4)	< 0.001
Arousal	-1.1 (-1.5–-0.7)	< 0.001	-0.9 (-1.3–-0.8)	0.005
Lubrication	-1.0 (-1.3–-0.6)	< 0.001	-0.90 (-1.37–-0.43)	< 0.001
Orgasm	-0.9 (-1.3–-0.5)	< 0.001	-0.7 (-0.9–0.3)	< 0.001
Satisfaction	-0.8 (-1.2–-0.4)	< 0.001	-0.6 (-1.1–0.5)	0.003
Pain	0.4 (0.1–0.8)	0.013	0.6 (0.2–1.0)	0.004
BSI domains
Anxiety	3.0 (1.9–4.1)	< 0.001	2.8 (1.7–4.0)	< 0.001
Depression	2.9 (1.8–4.0)	< 0.001	2.6 (1.5–3.7)	< 0.001
Somatization	2.7 (1.5–3.9)	< 0.001	2.6 (1.4–3.8)	< 0.001

All multivariable models were adjusted for age, education level, and area of residence

Reference categories: No-FGM for sexual function, university education for education level, FSFI Female Sexual Function Index, BSI Brief Symptom Inventory, OR Odds ratio, SE: AOR Adjusted odds ratio, Standard error, CI Confidence interval

OR: Odds ratio derived from logistic regression models

β: Regression coefficient derived from linear regression models

Table 5.

Univariate and multivariate analyses of factors associated with FGM types, sexual dysfunction, and psychological symptoms

Variable		OR (95% CI)	P	Adjusted OR / Estimate (95% CI)	P
	Education level
FGM Type 1	Illiterate	0.9 (0.4–2.3)	0.847	0.8 (0.3–2.0)	0.71
	Primary school	1.6 (0.5–5.5)	0.429	1.4 (0.4–4.7)	0.55
	Secondary / High school	0.8 (0.3–1.7)	0.499	0.7 (0.3–1.5)	0.41
	Reference (University)	1		1
FGM Type 2	Illiterate	2.5 (1.1–5.9)	0.035	2.2 (0.9–5.2)	0.061
	Primary school	3.6 (1.1–11.3)	0.032	3.0 (1.0–9.2)	0.048
	Secondary / High school	1.9 (0.9–4.1)	0.096	1.7 (0.8–3.6)	0.122
	Reference (University)	1		1
FGM Type 3	Illiterate	5.9 (2.4–14.4)	< 0.001	5.1 (2.0–12.8)	< 0.001
	Primary school	3.1 (0.9–10.7)	0.072	2.7 (0.8–9.0)	0.094
	Secondary / High school	1.9 (0.8–4.4)	0.124	1.6 (0.7–3.8)	0.17
	Reference (University)	1		1
FGM Type 4	Illiterate	10.0 (2.6–37.3)	< 0.001	8.7 (2.1–34.1)	< 0.001
	Primary school	5.0 (0.9–27.7)	0.065	4.2 (0.8–21.9)	0.083
	Secondary / High school	2.0 (0.5–8.0)	0.300	1.8 (0.4–7.1)	0.34
	Reference (University)	1		1
Area of residency	FGM Type 1	0.2 (0.1–2.3)	0.194	0.3 (0.1–2.5)	0.24
	FGM Type 2	0.6 (0.1–5.7)	0.631	0.7 (0.1–6.1)	0.69
	FGM Type 3	1.4 (0.1–13.7)	0.786	1.3 (0.1–12.5)	0.81
	FGM Type 4	1.6 (0.2–16.7)	0.711	1.5 (0.2–15.3)	0.74
	Reference (Urban)	1		1	-
Sexual dysfunction	FGM Type 1	2.1 (1.0–4.1)	0.043	1.9 (0.9–3.8)	0.061
	FGM Type 2	2.8 (1.5–5.4)	0.002	2.5 (1.3–4.9)	0.004
	FGM Type 3	5.6 (2.8–11.1)	< 0.001	5.0 (2.4–10.2)	< 0.001
	FGM Type 4	17.8 (5.4–58.9)	< 0.001	15.2 (4.3–52.7)	< 0.001
	Reference (No FGM)	1		1
	FGM	β (95% CI)	P	Adjusted β (95% CI)	P
FSFI – Desire	Type 1	-0.6 (-1.0–-0.2)	0.004	-0.5 (-0.9–-0.1)	0.011
	Type 2	-0.7 (-1.0–-0.3)	0.001	-0.6 (-0.9–-0.2)	0.003
	Type 3	-1.1 (-1.5–-0.7)	< 0.001	-1.0 (-1.4–-0.6)	< 0.001
	Type 4	-1.7 (-2.3–-1.2)	< 0.001	-1.5 (-2.0–-1.0)	< 0.001
Arousal	Type 1	-0.7 (-1.2–-0.2)	0.003	-0.6 (-1.0–-0.1)	0.009
	Type 2	-1.1 (-1.5–-0.6)	< 0.001	-1.0 (-1.4–-0.5)	< 0.001
	Type 3	-1.2 (-1.7–-0.8)	< 0.001	-1.1 (-1.6–-0.7)	< 0.001
	Type 4	-1.9 (-2.5–-1.4)	< 0.001	-1.7 (-2.3–-1.2)	< 0.001
Lubrication	Type 1	-0.6 (-1.0–-0.2)	0.001	-0.5 (-0.9–-0.1)	0.006
	Type 2	-0.9 (-1.2–-0.5)	< 0.001	-0.8 (-1.1–-0.4)	< 0.001
	Type 3	-1.3 (-1.6–-0.9)	< 0.001	-1.2 (-1.5–-0.8)	< 0.001
	Type 4	-1.7 (-2.2–-1.2)	< 0.001	-1.5 (-2.0–-1.0)	< 0.001
Orgasm	Type 1	-0.6 (-1.0–-0.2)	0.003	-0.5 (-0.9–-0.1)	0.010
	Type 2	-0.8 (-1.2–-0.4)	< 0.001	-0.7 (-1.1–-0.3)	< 0.001
	Type 3	-1.2 (-1.5–-0.8)	< 0.001	-1.1 (-1.4–-0.7)	< 0.001
	Type 4	-1.7 (-2.2–-1.2)	< 0.001	-1.5 (-2.0–-1.0)	< 0.001
Satisfaction	Type 1	-0.7 (-1.2–-0.2)	0.003	-0.6 (-1.0–-0.1)	0.012
	Type 2	-0.7 (-1.1–-0.3)	0.001	-0.6 (-1.0–-0.2)	0.004
	Type 3	-1.0 (-1.4–-0.6)	< 0.001	-0.9 (-1.3–-0.5)	< 0.001
	Type 4	-1.5 (-2.1–-1.0)	< 0.001	-1.3 (-1.8–-0.8)	< 0.001
Pain	Type 1	0.3 (-0.1–0.6)	0.186	0.2 (-0.1–0.5)	0.24
	Type 2	0.3 (-0.1–0.6)	0.118	0.3 (-0.1–0.5)	0.14
	Type 3	0.6 (0.3–1.0)	< 0.001	0.5 (0.2–0.9)	< 0.001
	Type 4	1.4 (0.9–1.8)	< 0.001	1.2 (0.8–1.6)	< 0.001
BSI Anxiety	Type 1	2.3 (1.1–3.5)	< 0.001	2.0 (1.0–3.2)	0.001
	Type 2	2.2 (1.2–3.3)	< 0.001	2.0 (1.1–3.0)	< 0.001
	Type 3	4.2 (3.1–5.4)	< 0.001	3.9 (2.8–5.0)	< 0.001
	Type 4	5.3 (3.8–6.7)	< 0.001	4.8 (3.5–6.2)	< 0.001
BSI Depression	Type 1	2.3 (1.2–3.5)	< 0.001	2.1 (1.1–3.2)	< 0.001
	Type 2	2.4 (1.4–3.5)	< 0.001	2.2 (1.2–3.3)	< 0.001
	Type 3	3.5 (2.3–4.6)	< 0.001	3.2 (2.1–4.3)	< 0.001
	Type 4	5.7 (4.2–7.1)	< 0.001	5.2 (3.8–6.7)	< 0.001
BSI Somatization	Type 1	2.1 (0.7–3.4)	0.002	1.9 (0.6–3.1)	0.005
	Type 2	2.2 (1.0–3.4)	< 0.001	2.0 (0.9–3.1)	0.001
	Type 3	3.6 (2.3–4.8)	< 0.001	3.3 (2.1–4.5)	< 0.001
	Type 4	5.1 (3.4–6.7)	< 0.001	4.7 (3.1–6.2)	< 0.001

All multivariable models were adjusted for age, education level, and area of residence

Reference categories: No-FGM for all parameters, university education for education level, FSFI Female Sexual Function Index, BSI Brief Symptom Inventory, OR Odds ratio, AOR Adjusted odds ratio, Standard error, CI Confidence interval 

OR: Odds ratio derived from logistic regression models

β: Regression coefficient derived from linear regression models

The analysis revealed that all types of FGM were significantly and inversely associated with the FSFI subdomain scores for sexual desire, arousal, orgasm, satisfaction, and overall sexual function. However, no significant association was found between Types I and II FGM and the FSFI pain subdomain. In contrast, Types III and IV FGM were significantly associated with higher pain scores during sexual activity. Furthermore, all types of FGM showed significant associations with the BSI subdomains of anxiety, depression, and somatisation (p < 0.05). There was a statistically significant association between the severity of FGM and the likelihood of sexual dysfunction. Women who had undergone Type I FGM demonstrated a twofold increase in the odds of sexual dysfunction (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.0–4.1; p = 0.043), Type II FGM was associated with an OR of 2.8 (95% CI: 1.5–5.4; p = 0.002), Type III with an OR of 5.6 (95% CI: 2.8–11.1; p < 0.001), and Type IV with an OR of 17.8 (95% CI: 5.4–58.9; p < 0.001) compared to those without FGM. Notably, the wide confidence interval observed for Type IV reflects the relatively small sample size in this subgroup (n = 42), indicating reduced precision of the estimate. The associations between FGM types and the evaluated variables were first examined using univariate analyses. Subsequently, multivariable models were constructed to adjust for potential confounding factors. After adjustment, the magnitude and direction of the associations remained largely consistent with the univariate findings (see Table 5).

Discussion

We evaluated the impact of FGM on psychosexual and psychosocial outcomes using FSFI and BSI scores.in Somali women. To our knowledge, To our knowledge, this is one of the largest studies examining both the psychosexual and psychosocial impacts of FGM in Africa. The prevalence of FGM in our cohort was 93.9%,among the highest reported in sub-Saharan African, second only to Guinea (94.5%) [9]. Our study found that FGM was most performed at ages 7–8 years (54.7%). In many countries, FGM/C has typically performed at early ages, most commonly between 0 and 5 years. However, in countries such as Kenya, Egypt, Sierra Leone, Liberia, and Tanzania, the practice has more commonly performed at ages 9 to 14 years or older. In contrast, in Somalia and Guinea, it has most common performed between the ages of 5 and 9 years [9]. Our study indicated that FGM was predominantly performed by traditional circumcisers (55.5%), followed by healthcare workers other than physicians (44.5%), with no procedures performed by physicians. This pattern is consistent with global data; However, in some settings, particularly in Egypt, a high proportion of FGM procedures (81.9%) are performed by medical professionals [9].

In this study, the most prevalent type of FGM was Type II (47.1%), followed by Type III (28.1%), Type I (18.9%), and Type IV (5.9%). A systematic review and meta-analysis that included 163 studies and 30 regions assessed FGM prevalence and types, which suggested that the most common type of FGM among women was “flesh removed” (corresponding to Type I or II) in 19 countries. Among girls, the most prevalent types were, referred to as not sewn closed, (Types I, II, or IV) and “flesh removed” (Type I or II), each being the most common in 8 countries. Type III (sewn closed) was most frequently reported among women in Sudan (77.0%) and the Central African Republic (49.6%). In Somalia, the most common type was a combination of Type III and IV (64.2%), often referred to as Pharaonic [9].

In this study, Women with FGM had significantly lower FSFI scores across all domains and higher BSI scores, indicating impaired sexual function and poorer psychological well-being. These impairments increased with FGM severity, and regression analyses confirmed independent associations. Furthermore, our study provides compelling evidence that FGM was significantly associated with a heightened risk of sexual dysfunction (OR:3.4). The incidence of sexual dysfunction among women with FGM was 64.6%, compared to 34.8% in those without FGM. A dose–response relationship was observed, with type IV demonstrating the highest incidence (90.5%) and type I the lowest (48.5%). These findings indicate a clear association between FGM severity and adverse psychosexual outcomes. These findings contribute to the limited literature addressing both psychosexual and psychosocial impacts of FGM, particularly in the Somali context. Previous systematic reviews and meta-analyses have also demonstrated significant associations between FGM and adverse mental health outcomes, including increased risks of depression, anxiety, post-traumatic stress disorder, and somatoform disorders, as well as higher rates of dyspareunia and sexual dysfunction [10].

Female genital mutilation, especially in its more extensive forms, results in irreversible damage to external genital structures critical for sexual function. The destruction or modification of these tissues compromises neurovascular integrity, thereby impairing sexual arousal and orgasmic capacity. In addition, chronic pain and psychological trauma may further contribute to reduced sexual function. The dose-response relationship observed in this study supports the cumulative physiological and psychosexual harm associated with increasing severity of FGM.

Elevated somatisation scores among women with FGM may reflect the somatic expression of psychological distress, particularly in cultural contexts where emotional expression may be limited. These findings highlight the complex interaction between psychological and physical health outcomes in this population and underscore the importance of culturally sensitive approaches to care.

The elevated somatisation scores among FGM survivors may reflect a somatic manifestation of psychological distress, particularly in cultural contexts where direct expression of emotional suffering is constrained. Such somatic symptoms are well-documented in trauma-affected populations and underscore the complex interaction between psychological and physical health outcomes in this group. The variability in psychological responses, as evidenced by the standard deviations, likely reflects individual differences shaped by socio-cultural factors, coping mechanisms, and access to support. This highlights the necessity for personalised, culturally sensitive interventions when addressing the mental health needs of women who have undergone FGM.

Apart from the psychosexual and psychosocial detrimental effects of FGM on women, our findings indicate three noteworthy features and underlying rationales for the practice. First, the decision to perform FGM was usually made by the mother, highlighting the urgent need to educate women, particularly mothers and expectant mothers, as a preventive measure against continuing the practice. Second, almost all (95.2%) of the FGMs were performed at home, with none undergoing in hospitals. This indicates that the practice is largely carried out in informal, non-medical settings, which may increase the risk of complications and reduce opportunities for medical oversight or intervention. Third, the individuals performing FGM were mostly not trained medical professionals. Notably, 55.5% of the procedures were performed by traditional circumcisers who were not healthcare workers, while the remaining 44.5% were performed by healthcare workers other than physicians. This highlights the involvement of non-physician health personnel in perpetuating the practice, raising concerns about both medical ethics and the need for stricter regulation and awareness within the healthcare sector.

Strengths and limitations

This study has several notable strengths. First, the relatively large sample size (n = 753), including 707 women with FGM, enhances the statistical power and reliability of the findings. Second, the study employed validated instruments, the Female Sexual Function Index (FSFI) and the Brief Symptom Inventory-18 (BSI-18) to assess sexual functioning and psychological well-being, respectively. These standardized tools support the validity and comparability of the results with other studies in the field. Additionally, the study provides a detailed stratification of outcomes by FGM type (I–IV), allowing for a more granular understanding of the relationship between FGM severity and its health consequences. The use of regression analysis further strengthens the study by identifying independent associations between FGM type and adverse psychosexual outcomes, while accounting for potential confounding factors. Lastly, by focusing on a population in Somalia a country with one of the highest global prevalence rates of FGM the study offers valuable, context-specific insights into a critical public health issue. Despite these strengths, the study has several limitations. First, there was a marked imbalance between the control group (n = 46) and the FGM group (n = 707), which may have affected the statistical precision of comparisons and increased the risk of unstable estimates, particularly in subgroup analyses.Although post-hoc power analysis indicated that the overall sample size was sufficient to detect moderate-to-large effect sizes, the relatively small control group limited the ability to detect smaller effects and reduced the sensitivity of the analyses. In addition, smaller subgroups such as Type IV FGM (n = 42) yielded less precise estimates, as reflected by the wide confidence interval (OR = 17.8; 95% CI: 5.4–58.9). Therefore, these findings should be interpreted with caution. Nevertheless, the consistency in the direction and magnitude of associations across FGM types and between univariate and multivariable models suggests that the overall findings are robust despite the group size imbalance.

Second, the study population was derived from women attending a gynaecology outpatient clinic, which may not be representative of the general population. Women seeking gynaecological care may have a higher likelihood of experiencing sexual or psychological symptoms, potentially leading to selection bias. Third, the inclusion criteria were restricted to sexually active women in monogamous marriages. This may limit the generalizability of the findings to the broader population of Somali women, including those who are unmarried, not sexually active, or in different social contexts.Therefore, the findings of this study should be interpreted with caution, and future studies with more balanced group sizes and population-based sampling are needed to confirm these results.

Conclusion

Our findings suggest that women in FGM experience considerably higher psychosexual and psychosocial adverse effects as compared with their non-FGM counterparts. FGM is highly prevalent in Somalia and is strongly associated with impaired sexual function and increased psychological distress. The severity of FGM associated with the magnitude of adverse outcomes, underscoring the urgent need for public health interventions, awareness campaigns, and legal reforms.

Abbreviations

FGM

Female genital mutilation

WHO

The World Health Organization

FSFI

Female sexual function index

BSI-18

Brief symptom inventory-18

OR

Odds ratio

CI

Confidence interval

SPSS

Statistical package for social science

STROBE

Strengthening the reporting of observational studies in epidemiology

Authors’ contributions

HBH and UE made substantial contributions to the proposal design and data collection. AB made analysis, report, writing and drafting the manuscript. AB, BS, GG, GK, CE, and ZO made revised. Finally, all authors reviewed, revised and approved the manuscript for publication.

Funding

This study has not received any funding.

Data availability

All data generated or analysed during this study are included in this article. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. The corresponding author (drumuterkok@gmail.com) can be contacted for the data with a reasonable request **.**.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics and Research Committee of Mogadishu Somali Turkey Training and Research Hospital (Permission number and date: MSTH/15144/824, 22.08.2023). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent to participate in the study was obtained from all participants prior to enrolment. For one participant younger than 16 years of age, informed consent was obtained from her parents. As a considerable proportion of the participants were illiterate, informed consent was obtained from their legal representatives. The analysis and reporting of the results were conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.