Exploring Beliefs and Attitudes Toward Female Genital Mutilation/Cutting Among Healthcare Providers in New York City

Abstract

Given the increase of African immigrants from countries with high female genital cutting (FGC) prevalence, this study explored U.S. healthcare providers’ beliefs and attitudes regarding FGC. A total of 31 professionals who have provided services to FGC-experienced women in New York City were interviewed; data were analyzed using grounded theory. Results indicated that, although a majority of respondents emphasized maintaining a nonjudgmental and open-minded attitude toward clients’ experiences, some only focused on the negative aspects of FGC. Also, multifaceted efforts by providers to understand the cultural meanings of FGC and resolve their own cultural dissonance were identified. The implications for practice were discussed.

Female genital mutilation/cutting (FGC) refers to “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” (WHO, 2016), and is practiced worldwide including in Africa, the Middle East, Asia, and South America (UNICEF, 2016). More recently, FGC has grown in domestic relevance in the United States due to the rapid increase of immigrants from sub-Saharan African countries (Anderson, 2017) with a high prevalence of FGC (Mather & Feldman-Jacobs, 2016). In particular, the New York City (NYC) metropolitan area is one of the top destinations for sub-Saharan African immigrants (Anderson, 2017; Echeverria-Estrada & Batalova, 2019) and therefore has a strong presence of women and girls exposed to or at risk of FGC. It is estimated that more than 500,000 women and girls in the United States, and approximately 50,000 women and girls in New York state, have undergone FGC or are at risk (Goldberg et al., 2016; Mather & Feldman-Jacobs, 2016).

Given the increased number of women and girls in the United States with FGC experience, studies have shown that U.S. medical care providers often encounter patients who have undergone FGC. However, studies indicate a “know-do gap” whereby medical service providers often treat patients with FGC, but without commensurate knowledge about FGC or training on how to treat these patients (Lane et al., 2019; Leye et al., 2008; Moaddab et al., 2017). Such discrepancy between knowledge and practice might lead service providers to provide inappropriate or inadequate care, including inadvertently exhibiting biased attitudes toward FGC when interacting with their patients or clients.

In fact, studies of immigrant women’s healthcare experiences have noted that female immigrants who experience negative sequelae of FGC fear providers’ lack of knowledge about FGC and their insensitive attitudes (Akinsulure-Smith et al., 2018; Ormrod, 2019; Vangen et al., 2004). These women report being disrespected, humiliated, stigmatized, and shamed (Evans et al., 2019b; Hess et al., 2010; Mehta et al., 2018; Pavlish et al., 2010). In countries to which these women migrate, including the United States, where the dominant discourse is that FGC is an illegal act and/or a human rights violation, positive or alternative meanings of FGC are not well known (Goldenstein, 2014). Therefore, to many women and girls who have undergone FGC, interacting with Western healthcare and social service providers may prove more distressing than helpful, and can hinder clients from receiving appropriate care (Goldenstein, 2014; Nour, 2004).

Meanwhile, studies on providers’ attitudes toward FGC have reported that many providers expressed strong emotions around FGC, including shock, disgust, and horror (Evans et al., 2019a; Ogunsiji, 2015). Providers saw FGC as an alien and negative cultural practice and described women’s bodies after FGC as abnormal or mutilated. Some providers struggled to maintain their professionalism when encountering FGC (Evans et al., 2019a). This kind of attitude could be problematic, especially when clients report any kind of positive experience regarding FGC. Chu and Akinsulure-Smith (2016) found that 23% of West African immigrant women who had undergone FGC felt that they had benefited from FGC, and 44% perceived they had not been harmed by FGC. Thus, it is important to critically examine the assumptions held by service providers regarding FGC.

Previous studies have investigated Western service providers’ knowledge, attitudes, and practices regarding FGC, including in Italy (Caroppo et al., 2014; Surico et al., 2015), Belgium (Cappon et al., 2015; Leye et al., 2008), Spain (González-Timoneda et al., 2018; Kaplan-Marcusan et al., 2009), Australia (Ogunsiji, 2015; Sureshkumar et al., 2016), the United Kingdom (Jackson, 2017; Relph et al., 2013), and Sweden (Widmark et al., 2010). However, few studies have examined U.S. service providers (Hess et al., 2010; Lane et al., 2019; Moaddab et al., 2017). Moreover, most studies have focused on physical health service providers such as gynecologists, primary healthcare professionals, nurses, and midwives, with very few studies focusing on mental health service providers (Jackson, 2017). Since women’s health care is not limited to physical care, but also includes psychological care such as counseling or psychiatric services, or provision of social services, research that is limited to medical providers may not fully capture the women’s and girls’ experiences when encountering the various forms of service provision. In addition, only a few studies explore service providers’ subjective understandings (i.e., how to make sense of FGC) or their attitudes toward FGC (Jackson, 2017; Ogunsiji, 2015; Widmark et al., 2010). The majority of current research has been limited to evaluating service providers’ factual knowledge regarding FGC (e.g., identifying countries with a high prevalence of FGC, types of FGC, and legality), their practice with FGC-experienced clients, and their level of training.

Therefore, this study sought to fill the gap in previous literature by investigating the beliefs and attitudes of U.S. healthcare service providers in both medical and non-medical fields practicing in NYC with clients from sub-Saharan countries with high FGC prevalence. By analyzing data from in-depth, one-on-one interviews using a grounded theory approach, this study aimed to elucidate how service providers’ beliefs and attitudes toward FGC emerge and develop in the context of these providers’ relationships with their clients and their interactions with the larger society.

Method

Preparation for the Study

All procedures and measures were reviewed and guided by a Professional Advisory Committee (PAC) comprised of seven service providers from the fields of medicine, psychology, and social work. All had extensive experience treating West African female immigrants from countries with FGC prevalence rates over 65%. The PAC reviewed the recruitment plan, the consent forms, and the questions and instructions for the interview. Members of the PAC also served as professional referral sources for the study.

To capture the knowledge and experiences of health professionals in NYC, we used tools originating from Europe which were modified to better fit U.S. contexts (Jäger et al., 2002; Kaplan-Marcusán et al., 2010; Leye et al., 2008; Tamaddon et al., 2006). This open-ended, in-depth interview guide covered the following areas: (a) providers’ sociodemographic data, including their professional settings and experiences; (b) providers’ previous contact with cases of FGC or situations where a client or patient was at risk of FGC; (c) assessment of providers’ knowledge of FGC and its impacts; (d) types of physical/psychological issues noted in clients who had undergone FGC; and (e) assessment of service providers’ attitudes, beliefs, and recommendations regarding FGC in service provision.

Recruitment and Pre-Screening

A convenience sample was used, purposively recruited from NYC. Specifically, we targeted health professionals in the New York area and agencies serving sub-Saharan African communities. Approximately 208 emails were sent to agencies and service providers across the United States, soliciting participation of service providers in NYC with experiences working with women and girls from sub-Saharan African countries. A total of 31 service providers responded to the PI via email, indicating their willingness to participate in the study. Each potential participant received a follow-up phone call a week later.

All potential participants were screened using a short demographic questionnaire to determine eligibility (i.e., that they were service providers and had worked with sub-Saharan African immigrant women who had experienced FGC). All 31 health professionals who expressed interest were found to be eligible. Then, the PI set the meeting date, time, and place convenient to each interviewee to conduct the open-ended, in-depth interviews.

Data Collection

The interviews were conducted between June 2017 and March 2018. Written informed consent was obtained from each participant upon arrival at the interview site; the PI conducted the open-ended, in-depth interviews. The duration of the interviews varied from 20 to 60 min, and the entire interview was audio-recorded. Each participant received US$50 as compensation for their time upon completion of the interview. All procedures were approved by the Institutional Review Board of the City University of New York (CUNY).

Participants

A total of 31 interviews were conducted. The majority of participants identified as female (n = 27, 87.1%) followed by male (n = 3, 9.7%), and other (n = 1, 3.2%). The mean ± SD age of the participants was 46.06 ± 14.24 years, ranging from 24 to 73. More than half of the participants were originally from North America (n = 18, 58.1%) followed by Africa (n = 9, 29.0%), Asia (n = 2, 6.5%), and Europe (n = 1, 3.2%). Nearly half of the participants had earned a master’s degree (n = 14, 45.2%), followed by 10 PhD degrees (32.3%), five MD degrees (16.1%), and two bachelor’s degrees (6.5%). The sample included eight psychologists (25.8%), eight social workers (25.8%), five case managers/other (16.1%), three psychiatrists (9.7%), three nurses/midwives (9.7%), two obstetrician/gynecologists (6.5%), and two physicians or physician assistants (6.5%). The mean ± SD work experience was 16.26 ± 12.80 years, ranging from 1 to 45 years. More than half of the participants were working at public/non-profit facilities (n = 18, 58.1%), followed by hospitals (n = 6, 19.4%), private practice (n = 6, 19.4%), and university settings (n = 1, 3.2%). The number of women and girls from sub-Saharan Africa who had received services from the participants ranged from 2 to 1,000 and ranged from 20% to 60% of the providers’ total clients. Ten participants (32%) reported having received some form of structured training regarding how to work with women who have undergone FGC.

Data Analysis

The transcripts were analyzed using a grounded theory approach (Charmaz, 2006). In preparation for the analysis, members of the research team transcribed each audio-recorded interview as instructed by the transcription manual, prepared based on conventions in Agar and MacDonald (1995). When the first draft transcription was completed, a second team member listened to the same interview and reviewed the transcription, which was checked again by a third team member. If there were any inconsistencies between the reviewers, the PI listened to the audio recording and resolved them.

To develop a list of codes, which was used for the entire analysis process, three representative transcripts were selected and read multiple times to identify potential codes by applying the open coding strategy. The three transcripts were then coded line by line by each team member, using the list of potential codes. The team then examined the overlapping codes and determined the final set of codes to be used for all transcripts.

The finalized set of codes and the transcripts were entered into the ATLAS.ti software, a coding and analysis tool. To increase inter-coder reliability, we applied a systematic procedure to code each transcript, as follows: Two research team members were assigned to each transcript and independently coded their assigned transcript. The two documents were then merged, using the “same Primary Documents same codes” merging procedure, which created a merged document showing the overlap and discrepancies in the two research members’ coded texts. The two research members then discussed each portion of coded text in order to come to a consensus. All documents for which consensus was achieved were merged into a single hermeneutic unit on which thematic analysis could be performed. Bi-weekly team meetings were held for the iterative discovery and determination of the salient themes of the transcripts.

Results

The primary goal of this study was to explore service providers’ beliefs and attitudes toward FGC. We elicited the beliefs and attitudes through analysis of the providers’ responses to topics including the service providers’ level of comfort addressing FGC in their service provision, self-evaluation of their understanding of the reasons for and impact of FGC, knowledge of positive and alternative meanings of FGC, and reactions to reports of positive FGC experiences by their clients.

The following is an overview of the providers’ responses to such topics. Regarding participants’ level of comfort addressing FGC, the majority of the service providers (n = 22, 73.3%) indicated that they felt somewhat comfortable addressing FGC with their clients. On the other hand, some providers (n = 6, 20%) implied a level of discomfort addressing FGC with their clients. These providers reported feeling “underequipped” or “unsure about what to ask.” There were also a couple of providers who expressed ambivalence. For example, one participant stated feeling “two ways”: being comfortable from a “process perspective” about asking the client to recount the client’s experience, questions, concerns, or perceived impact of FGC, but being uncomfortable addressing unfamiliar details such as the cultural aspects or “nuances about the different types” of FGC or the reasons behind FGC. On the self-evaluation of their knowledge of FGC, less than half of the service providers (n = 13, 44.8%) stated that they had sufficient knowledge about the cultural reasons for FGC. Notwithstanding this, a majority of the service providers (n = 20, 64.5%) reported they were aware of positive rationales for FGC. In addition, more than half of the service providers (n = 19, 65.5%) reported that they had sufficient knowledge regarding the impact of FGC on physical and mental health.

Through line-by-line analysis of the contents of the above-mentioned responses, we elicited nine themes which portray the service providers’ beliefs and attitudes toward FGC. These themes are organized into three categories: (1) Client: service providers’ reactions to clients’ FGC experiences; (2) Self: service providers’ own beliefs and attitudes toward FGC; and (3) Larger society: service providers’ interaction with the larger society regarding FGC. The categories are presented in Table 1. The following sections review each theme with examples from the interviews. Participants are identified by their profession and the number of years worked in that profession.

Table 1.

Categories of Themes.

Category	Themes
Client • Service providers’ reactions about clients’ FGC experiences	Emphasis on maintaining non-judgmental and open-minded attitude  Parallel processing of clien’s reported FGC experiences  Desire to educate their clients
Self • Service providers’ own beliefs and attitudes toward FGC	Reconciling cultural contexts of FGC with providers’ own personal views  Biased understandings of FGC  Efforts to make sense of FGC
Larger society • Service providers’ interaction with the larger society regarding FGC	Motivation to advocate for informed understanding of FGC

Abbreviation: FGC = female genital cutting.

Service Providers’ Reactions to Clients’ FGC Experience

In the context of interacting with clients in the clinical setting, service providers reported that their reactions to clients’ FGC experiences fell within three main themes: emphasis on maintaining a nonjudgmental and open-minded attitude; parallel processing of clients’ reported FGC experiences; and a desire to educate their clients.

Emphasis on Maintaining a Nonjudgmental and Open-Minded Attitude.

Many providers emphasized the importance of having a nonjudgmental, open-minded attitude when interacting with their clients in addressing FGC, understanding the impact of FGC, and responding to the client’s positive FGC experience. More than half of the participants (n = 16, 51.6%) expressed that they valued these principles, and some gave examples of how they incorporated them into their practice. For these providers, an open and nonjudgmental attitude was crucial to establishing rapport with their clients. Providers described their efforts to communicate their nonjudgmental attitude to their clients, being aware that their clients may be uncomfortable during physical examinations.

Once I feel I’ve established a rapport with them I ask them [about it]. I look very carefully when I am examining them, and then I very nonjudgmentally say, “I see you’ve been cut. Do you mind telling me how old you were?” I always start with that question—-how old you were when it was done.

(Midwife, 18 years of experience)

Approaching FGC with such nonjudgmental attitudes apparently had an impact on the level of comfort experienced by the service provider in addressing FGC in their service provision as stated below.

Yes, [I would be comfortable with the patient] because I would take a nonjudgmental approach to it, and take the approach of asking them what it meant to them, as opposed to assuming that [it was negative]. […] Some people who have experienced it may not feel traumatized by it.

(Psychiatrist, 35 years of experience)

This theme was especially predominant when providers were asked about their expected responses to clients’ reports of positive experiences about or desire to have FGC. Many providers were aware that it was important to refrain from showing judgment to keep their clients engaged in the professional relationship. Providers also expressed their willingness to explore the various subjective meanings of FGC to respect the clients’ own decisions in pursuing their well-being. When asked about their expected response to a client who reported a good or positive experience or the desire for FGC, providers answered:

I do my best as always to understand. I believe that every patient comes in with his or her own matrix or variables and it’s not for me to impart judgment or my own personal beliefs on them but to sit there, to work with them, in an empathic, open-minded way, to understand their needs and to help them live the life that they desire.

(Psychologist, 7 years of experience)

This theme was intertwined with service providers’ desires to understand and be attuned to their clients’ point of view. Seven providers emphasized the importance of considering individual contexts, including cultural contexts, since FGC might not be a negative experience for everyone, and the meaning of FGC might be different depending on each individual context.

I think it’s about having an open mind to a person’s experience and everybody’s experience about everything. While it’ll tend to go along certain norms and there’s average responses to everything, somebody is going to have another experience. So it’s not really—-to me—-a matter of knowing, as much as it’s a matter of having an open ear.

(Psychologist, 41 years of experience)

Parallel Processing of Clients’ Reported FGC Experiences.

On some occasions, service providers expressed surprise about their clients’ negative physical response to their cutting, and the secrecy and extreme nature of the FGC procedure. Even a service provider with decades of experience working with clients with FGC stated:

They were told that all girls went through this ritual and they were taken to somebody and cut, and it was horrific and traumatic for them as children. And one of them said she developed an infection—-that they rubbed dirt in it afterwards. It was very powerful.

(Gynecologist, 35 years of experience)

In describing their clients’ FGC experiences, many providers appeared overwhelmed by the extent of the physical pain, often using the word “trauma” to emphasize the nature of the event: “So, my memory of it is that there was no anesthesia, she was sewn up, and it was horrifically painful and very traumatic” (Psychologist, 40 years of experience).

Three providers’ responses involved a parallel processing of the clients’ story. For these providers, the extent and level of the physical and psychological trauma and betrayal described by some of their clients was distressing or overwhelming. Their responses went further than simply describing the clients’ pain, during which the providers appeared to feel the pain themselves.

I know it’s a very painful thing, but it’s also, as a female provider, painful for me just to imagine what that person went though. So, for me, that’s why the first time I remember like it’s yesterday, because even though it wasn’t me, I could feel. […] Yeah, it was trauma … it was traumatizing to me.

(Physician assistant, 20 years of experience)

Desire to Educate Their Clients.

When encountering their clients’ FGC experiences, five providers expressed their experiences or willingness to educate their clients and challenge the clients’ cultural values. They believed that they had a responsibility to raise awareness of the risks of FGC and to educate clients so that they have a better understanding of what happened to them, and how people outside and inside of their communities perceive FGC.

Educating and reeducating you as to what procedure is done, what’s being taken away from you, what potential issues you may have in terms of infection control. I do educate them, I do feel like a lot still hold on to those cultural values, and—-if I can say—-subjectively, unfortunately, but I question it. I ask questions, I attack you to do the critical thinking and push a little further, “Why is that?” “Were you brainwashed?” “What is that?”

(Nurse practitioner, 11 years of experience)

I got very good at drawing vulvas—-I can draw a vulva in 2 minutes flat, I can just draw it and point out “these are your parts,” and I invite them to go look and to examine. So, it was lot of just education about that practice and then, really trying to give them some critical analysis around “this is how it’s viewed by the world by outsiders, and this is how it’s viewed by insiders.”

(Social service provider, 20 years of experience)

However, one provider also believed that if an adult client still desires to proceed with FGC even when made aware of the risks, then the provider should respect their client’s opinion and decision.

I will do a lot of psychoeducation with my client, depend[ing] on your age. If you are an adult, let’s say you are between 25 and 30, you come in to me and you say you’re going to have FGM, I will assess the risk and educate the individual about the risk. But if you chose to go for it, you will have all the information you needed to make that informed decision.

(Social worker, 17 years of experience)

Service Providers’ Own Beliefs and Attitudes Toward FGC.

In working with this population, a number of these providers were forced to grapple with their own beliefs and attitudes regarding FGC. Three themes emerged describing such processes in developing their own attitudes, beliefs, and understandings: reconciling cultural contexts of FGC with providers’ own personal views; biased understandings of FGC; and efforts to make sense of FGC.

Reconciling Cultural Contexts of FGC with Providers’ Own Personal Views.

Throughout the interview, six providers reflected on their own identities and cultural backgrounds when demonstrating their understanding of FGC. They were aware of the fact that their understanding of FGC might be affected by the dominant culture to which they belong and how their gender, ethnic, or cultural background (real or perceived) might prevent clients from talking about their FGC experiences, especially if they see them as positive.

For example, one provider emphasized the importance of managing their own cultural context, recognizing that clients’ willingness to discuss FGC could be negatively affected by the dominant social discourse in America, which views FGC as a human rights violation.

I think it’s really important to manage my own cultural context, because I think that as an American, the mentality about it is that obviously it’s a violation against human rights and so forth. So, I think it’s easy to see it as this evil thing that’s being done, without considering how that might affect how people talk about it to you or whether they even report it-—even if it wasn’t a negative experience for them, that they might be embarrassed to talk about it if they feel like you have negative opinions about it.

(Psychologist, 4 years of experience)

Other providers were similarly conscious of the impacts of their own racial, cultural, and gender identities: “I’m very conscious about the fact that I’m a white provider and living within the United States and that comes with its own worldview” (Social worker, 7 years of experience).

Perhaps based on these efforts to reflect on their own identities and backgrounds, these providers were able to separate their own views from those of the cultures their clients were from. This could represent a way of dealing with cultural dissonance, which refers to the discrepancy between the providers’ own cultural understanding of FGC and the clients’ cultural understanding. Providers attempted to recognize the clients’ cultural perspectives even if they were different from their personal views, which sometimes involved relativizing their own views.

One provider personally found FGC “horrible” (Psychologist, 4 years of experience), and a violation of human rights, but also acknowledged that there was a cultural context that gives meaning to FGC. Another provider held their own beliefs about the harmful nature of FGC, but also cautioned against imposing Western-centric hierarchies which could disempower the diverse African and female voices on this subject. According to this provider, when there was a conflict between the provider’s and the client’s cultural views, the provider would challenge their own view by learning from the client.

I would like to think that I practice in a way that, if someone comes to me with a different understanding or an understanding that challenges my own, if not actually contradicting my own [views], that I’ll be in a position to sit with them, try to explore that with them, and learn from that experience.

(Psychologist, 22 years of experience)

In a similar context, when asked about how they reconciled the client’s positive attitudes or outcomes with conflicting hospital or national policies, providers emphasized that it was important to recognize the client’s context.

We have to recognize the context in which this occurs, right? Because nothing is decontextualized; everything has an impact and effect, on all the different levels. And because service provisions [are] happening in the United States, we are obligated to make our clients aware of the legal standings or policy standings that are there; you don’t have to go into detail but just kind of say, “Hey, so this is the lay of the land here and this is how this is viewed,” while keeping in mind that we have to support our clients by respecting the fact that they may have positive attitudes about this or beliefs, whether they have been circumcised or not, and that is okay.

(Social worker, 23 years of experience)

Biased Understandings of FGC.

Meanwhile, six providers’ view was limited to negative aspects, even though there was a range of attitudes in which these biases were communicated, from straightforward assertions to measured evaluations. For example, providers described FGC (or certain aspects of FGC that were involuntary) as “brutal” and “inhumane” (Social worker, 5 years of experience).

These providers assumed that all client responses to FGC would be negative, based on their clinical experience. Even if the client reported positive aspects of FGC, these providers believed that such reports were due to avoidance or were a way of coping with the negative consequences, or a self-justification of the violence.

My personal opinion, I don’t think there is a positive experience, because from the patients I’ve seen in the long [run], that had children, there was a shameness to when they had to have a physical [examination] and people would see this. Because the first thing [is], they would be shocked, and you can see there was shameness to it.

(Physician assistant, 20 years of experience)

I can say more than 99% of my clients have been talking about the negative impact of FGM. I could say [about] maybe the 1% [who don’t talk about any negative aspects]. If they don’t, I see it interacting as an avoidance, and it is the only way they have to cope with what happened. If we think about gender violence in general, people always find a justification for their behavior. These justifications are there. I’m willing to listen to the people who still think that these are justifications. But my role is, really, to challenge them about those justifications. Because to me, there is no justification to take someone else’s life. Yeah, there are many people who are dying from FGM, so if you can justify a reason why you kill someone, to me, that’s extreme. That’s why I don’t trust any justification.

(Social worker, 17 years of experience)

In some cases, even if providers knew of cultural discourses around FGC, they did not accept such cultural reasons and only focused on the fact that it was illegal in the United States and a violation of human rights: “Because it’s illegal in the US, so when I have a cultural orientation, I explain to people that it’s totally illegal in the US; you cannot do that here. And if you do it, you would be imprisoned” (Case manager, 1 year of experience).

Efforts to Make Sense of FGC.

Service providers’ attitudes toward FGC were not fixed, but rather showed evolution and change through efforts to learn and to adapt familiar concepts to better understand certain aspects of FGC. Five providers described that they actively read about or researched the anthropological contexts and possible consequences of FGC to develop a comprehensive understanding of FGC.

[…] as I mentioned through my own research study that we have conducted. I’ve met with other collaborators or other providers who’ve taken care of these patients. So, that also increased my knowledge of some other medical issues, legal issues, and psychological issues that can come up; some are cultural factors.

(OB/GYN, 16 years of experience)

Two providers mentioned how they came to understand the alternative or ritual meanings of FGC by referring to the Jewish tradition of Bar and Bat Mitzvah. One of them mentioned:

I took it upon myself to read more about the history and anthropology, I wanna say it was a Wikipedia article with links, and I finally kind of made some peace with it when I understood it to be like a late medieval or early renaissance symbolic gesture of cleansing. In the same way, there is in Judaism the ritual bath or the Mikvah, in many cultures it’s the bar Mitzvah.

(Psychiatrist, 17 years of experience)

Providers learned not only from reading and research, but also by interacting with people around them. One provider described a change in her preconceived notions of FGC as a result of exposure through her daughter’s direct experience in an African country with high FGC prevalence.

She asked me what I knew and about female genital cutting and, in what she would probably describe as a very sanctimonious way, I said, well it is mutilation and we should call it by what it is, and she said something to me like, “So Mom, do you want to stay on your high horse or do you want to try and do something about it by relating to the people who experienced this and do it?” And that led to a whole discussion and I decided she was right, and that I [would] rather be helpful than rigid.

(Gynecologist, 35 years of experience)

Sometimes, existing schemas or more familiar concepts were used as analogies to understand FGC. One provider made an analogy to domestic violence, which informed her attitude about FGC.

Like domestic violence, which to me is a parallel: If a person was telling me about the suffering they had endured or problems they had from it, I would-—as I would with someone who had had other kind of violence done—-probably not be completely neutral by the time I had heard all that and understood it.

(Psychologist, 20 years of experience)

Another provider analogized FGC with torture in terms of whether it was appropriate to discuss certain aspects about FGC in their clinical work: “I don’t necessarily address the procedure itself because that’s already like torture; I was not there to experience that or to witness that. So, it’s only whatever their perception of that; [their] perceptions of reality” (Psychiatrist, 40 years of experience).

One provider, when giving a lecture to medical students about women who had the procedure when they were very young and had no recollection, cited the example of children who are born without arms.

It’s as if we’ve all seen these amazing videotapes of children that are born without arms. Let’s say a child born without arms has learned to use his feet to brush his teeth, to do everything, to write with his feet because his brain has rewired itself. So, for these women, especially the ones [who] were cut as infants and have no conscious memory of it anyway, this is normal for them, that is their normal genitalia, it’s not as if someone took them.

(Midwife, 18 years of experience)

Service Providers’ Interaction With the Larger Society Regarding FGC

Service providers’ understanding of FGC had a meaning beyond their professional setting of service provision. This interaction with the larger society regarding FGC is described in the following theme: motivation to advocate for informed understanding of FGC.

Motivation to Advocate for Informed Understanding of FGC.

In some cases, the providers’ own views about FGC impacted the way in which they interacted with their professional communities or the public at large. There were two cases where providers critiqued their own professional communities’ lack of understanding or tried to advocate for greater awareness of FGC in their professional setting.

I was giving a general lecture on human rights and I showed the diagram and the entire room went silent and didn’t really recover till the end of the lecture, if at all. And so, I was sort of struck by my comfort and everyone else’s discomfort, and how even though these were young residents and just out of medical school that they really seemed unable to discuss it, or ask questions, or even show interest; that they were just horrified and shut down, and I thought that was really awful.

(Psychiatrist, 17 years of experience)

One provider expressed shock at encountering an African male taxi driver who maintained that he had no problem with FGC.

My driver was from West Africa, and there were a whole bunch of protestors all in white with big red spots over their genitals protesting male circumcision. And I said something like, “this is ridiculous, […] there are women who have experienced female genital cutting,” so I guess I knew more than I remembered. And he said, “Oh, in my country, we think that is a good idea.” And I just shut up at that point. I was not going to argue with the guy driving the car.

(Psychiatrist, 35 years of experience)

Another provider criticized their father’s denial that FGC happened in his country.

I would also encounter a lot of ignorance from girls who [were] like, “This is not weird,” like my dad, “That was not my Africans, they don’t do …”; treat that like forced marriages like, “We don’t do that, that’s disgusting, torturing a child …” I know we do, actually, very much.

(Social service provider, 20 years of experience)

Two providers expressed concern or discomfort regarding how some public discourses against FGC were reinforcing Western-centric ideology. One of them mentioned:

I’m an avid reader of New York Times, Wall Street Journal, and any time that there are topics [regarding] cutting in the news, I would also seek that out as a way of learning more, but again that’s still a “West is best” conceptualization.

(Psychologist, 7 years of experience)

Discussion

As a result of exploring the providers’ beliefs and attitudes toward FGC with regards to their clients’ experience, themselves, and the larger society, the findings from this analysis highlight the providers’ understandings of FGC; their approaches in working with clients who went through FGC and the challenges they encountered in this process; and their efforts to make sense of the practice, which often occurred in cultural contexts different from their own backgrounds.

Many providers emphasized maintaining a nonjudgmental and open-minded attitude, in the interest of building trust and rapport with their clients (Goldenstein, 2014). This approach valuing the relationship with their clients is consistent with the empathetic and supportive attitudes toward FGC-experienced women identified in previous literature (Evans et al., 2019a; Ogunsiji, 2015). On the other hand, it was apparent that some providers were holding onto their own negative impressions toward FGC. These providers assumed, for example, that all FGC experiences will be negative. They assumed that any explanation that is not negative is a “justification” of FGC and therefore must be rejected, and focused only on FGC as illegal and a violation of human rights. This is not surprising given the results from the previous literature, which described providers’ strong emotional reactions, such as disgust, shock, horror, and anger, and their perceptions of FGC as a backward and unnecessary cultural practice (Evans et al., 2019a; Ogunsiji, 2015). These findings merit attention, since assuming that all FGC experiences are negative can discourage women from talking about their own experiences and seeking help. Even subtle judgments and implicit prejudice of service providers can affect the clinical relationship.

Another finding worth noting is the indication of providers’ parallel processing of clients’ FGC experiences. Some providers felt overwhelmed by listening to their clients’ stories because of how the practice is suddenly imposed, physically painful, and psychologically violent. As the providers were exposed to their clients’ “traumatic” FGC experiences, some may have internalized clients’ emotional disruptions and even may have had a parallel experience of the clients’ pain, which is known as Secondary Traumatic Stress (Figley, 1995). This finding echoes previous literature reporting midwives in Western countries being “challenged” by the sight of female genitalia that were physiologically different from the “norm,” and expressing shock at encountering circumcised women (Hess et al., 2010).

The results of this study also illuminated service providers’ multifaceted efforts to understand the cultural meanings of FGC and resolve their cultural dissonance by relativizing their own perspectives. Service providers often reflected on their own cultural backgrounds, which implied that they were aware of how their own identities (e.g., ethnic, gender, and cultural background) could affect their understanding of FGC. The providers also attempted to recognize and accept the cultural values of FGC to their clients, even if different from the providers’ own beliefs toward FGC. In doing so, providers sought to reconcile the cultural context of FGC with their own personal views. This finding adds to previous literature recounting service providers’ efforts to “cross the cultural divide” (Evans et al., 2019a), to provide culturally sensitive and culturally respectful care. The results underline the importance of understanding FGC within the clients’ individual contexts, which includes the larger context of culture (Jackson, 2017).

Implications for Practice

The current study demonstrates a need for more education and/or training opportunities in the providers’ specific fields. The findings of this study indicate that not only factual knowledge regarding FGC (e.g., types of FGC, countries with high rates of FGC, Kaplan-Marcusan et al., 2009), but also the cultural meanings/reasons for FGC should be included in such professional training, as well as how FGC is viewed in the clients’ cultural contexts. Such training will help providers broaden their perspectives, which might currently be limited to the negative aspects, and resolve any implicit prejudices they may have had (Jackson, 2017). It is important to recognize that relatively few women who have undergone FGC see themselves as “mutilated” or “genitally distorted” (Balk, 2000; Chu & Akinsulure-Smith, 2016). In this vein, understanding that FGC is “a valued and accepted societal norm in many African and Middle Eastern cultures” (Goldenstein, 2014, p. 98) can equip providers with the sensitivity to build a trusting provider-client relationship and help improve the provider’s confidence in talking about FGC (Evans et al., 2019b). Even if a provider retains a personal negative perception toward FGC, being aware of their own positionality as a Western professional and endeavoring to reconcile the cultural context of FGC with their own personal view through training and education will help them maintain their professionalism.

Another aspect that calls for attention is a need to intervene in or prevent the providers’ possible parallel processing of a client’s reported FGC experiences. As Akinsulure-Smith and Sicalides (2016) recommended to mental health service providers, we should “monitor counter-transferential responses closely so that any personal and/or judgmental responses regarding the practice of FGC do not cloud service provision” (p. 359). To this point, this study suggests a need for self-care and countertransference education. This risk may also be mitigated by the provision of general FGC-related training. If the service provider is unfamiliar with FGC or views it as an alien practice, the chances of the provider being traumatized will be higher, but if the provider has enough relevant knowledge and experience, it is less likely that they will be distressed.

Limitation and Strengths

A few limitations to the study design should be acknowledged. Our sampling, purposive and self-selected in nature, was not representative of any particular group and thus limits the ability to generalize our findings to the larger population of U.S. service providers. To increase generalizability, future research efforts should prioritize a nationally representative sample, including other top immigration destination cities in the United States, as well as involve quantitative research. Relatedly, the present study’s sample is largely female; future studies need to include more male providers as well. Our study also did not include pediatric providers, an important segment in the prevention and identification of vacation cutting cases (Lane et al., 2019). Lastly, reliance on providers’ self-reports involves the risk of social desirability bias, even though we attempted to mitigate the role of such bias by emphasizing confidentiality throughout the interview process.

Despite these limitations, this study benefited from a number of strengths. This study’s inclusion of mental health professionals and social service providers broadened prior literature’s focus on medical providers, and thus achieved a multifaceted examination of the landscape of service provision that FGC-affected individuals may encounter. In addition, this study expands the research concerning U.S. service providers specifically. Importantly, this study contributed to an emerging field of only a handful of studies that examine providers’ beliefs and attitudes toward FGC. The nuanced understanding of this topic that this qualitative study provides could be a valuable resource for education, training, and intervention efforts targeting service providers who work with FGC-affected individuals.

Conclusion

In light of the growing number of African immigrants in the United States, it is imperative that all health professionals understand their clients’ cultural contexts and reflect on any bias or assumptions they may hold toward FGC to provide appropriate care to FGC-affected women. Even subtle judgments and implicit prejudice of service providers can affect the clinical relationship and discourage FGC-affected individuals from discussing their experiences and seeking help. This study has demonstrated the attitudes and beliefs the service providers currently hold with regard to their clients’ experiences, themselves, and the larger society. The themes that emerged from this study demonstrated the providers’ approaches in working with clients who experienced FGC, and challenges they encountered in this process, as well as their efforts to make sense of the practice, which often occurred in cultural contexts different from their own backgrounds. Finally, this study signals a need for further education and/or training opportunities in each discipline, so that service providers can provide culturally sensitive care to the target population, and to prevent providers from experiencing parallel-processing responses that might hinder the provision of unbiased services.

Biographies

Moonkyung Min received her MA in Counseling Psychology from Ewha Woman’s University and was previously a visiting researcher at the City College of New York. She is currently a PhD student in Counselling Psychology at the University of Calgary. Her areas of professional interest include trauma and resilience, refugees’ and immigrants’ mental health, and how immigrant families approach and handle conflicts around various cultural identities.

Adeyinka M. Akinsulure-Smith received her PhD in Counseling Psychology from Teachers College, Columbia University. She is currently a tenured professor in the Department of Psychology at the City College of New York and at the Graduate Center of the City University of New York. She is a senior supervising psychologist at the Bellevue Program for Survivors of Torture in New York City. Her areas of professional interest include immigrant mental health, trauma and resilience, self-care among mental health service providers, and the application of group interventions.

Tracy Wong received her PhD at the City University of New York. She is currently an associate professor at Brooklyn College, City University of New York. Her areas of interest include health disparities, infant mortality, immigrant and minority communities, and trauma and loss.