DOI: 10.1111/1471-0528.

12004
Psychosexual health
www.bjog.org

Sexual quality of life in women who have

undergone female genital mutilation: a
case–control study
SHA Andersson,a J Rymer,b DW Joyce,c C Momoh,d CM Gaylee
a
Department of Anaesthesia, Trafford Hospitals, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
b
King’s College School of Medicine, London, UK c Maudsley Hospital, London, UK d Women’s Services, Guy’s and
St Thomas’ NHS Foundation Trust, London, UK e The Graduate School, Imperial College London, London, UK
Correspondence: Dr SHA Andersson, Department of Anaesthesia, Trafford Hospitals, Central Manchester University Hospitals NHS Foundation
Trust, Moorside Road, Davyhulme, Manchester, M41 5SL, UK. Email: stefan.andersson@nhs.net

Accepted 1 August 2012. Published online 10 October 2012.

Objective To investigate the sexual quality of life of women
who have undergone female genital mutilation (FGM) and
compare them with a similar group who has not undergone
FGM.
Design Case–control study.
Setting A large central London teaching hospital.
Population A total of 73 women who had undergone FGM and
37 control women, who had not undergone FGM but were from a
similar cultural background where FGM is practiced.
Methods The women completed a questionnaire containing the
Sexual Quality of Life-Female (SQOL-F) questionnaire.
Main outcome measures SQOL-F score.
Results Women who have undergone FGM of any type have a
significantly lower (P < 0.001) overall SQOL-F score than control
women (mean = 62.44, SD = 27.93 versus mean = 88.84,
SD = 13.73). Women who were sexually active and had undergone
FGM type III differed the most from sexually active controls
(P < 0.05) in their SQOL-F score. Women who were sexually
inactive but who had undergone FGM reported significantly lower
overall SQOL-F scores (P = 0.015) than sexually inactive controls,
but were not differentiated by type of FGM.
Conclusion FGM significantly reduces women’s sexual quality of
life, based on the results of the SQOL-F questionnaire.
Keywords Female genital mutilation, sexual quality of life, Sexual
Quality of Life-Female questionnaire.

Please cite this paper as: Andersson S, Rymer J, Joyce D, Momoh C, Gayle C. Sexual quality of life in women who have undergone female genital mutilation:
a case–control study. BJOG 2012;119:1606–1611.

• Type III: Narrowing of the vaginal orifice with creation

Introduction
With such a significant expansion of the migrant popula-
tion in the UK, female genital mutilation (FGM) is becom-
ing an important issue within the practices of many health
professionals, particularly, general practitioners, obstetri-
cians and gynaecologists.
Female genital mutilation is defined as any procedure
‘involving partial or total removal of the external female
genitalia without medical reasons.’1 It has been classified by
the World Health Organization (WHO) as follows:
• Type I: Partial or total removal of the clitoris and/or the
prepuce (clitoridectomy)
• Type II: Partial or total removal of the clitoris and the
labia minora, with or without excision of the labia majora
(excision)
of a covering seal by cutting and appositioning the labia
minora and/or the labia majora, with or without excision
of the clitoris (infibulation)
• Type IV: All other harmful procedures to the female gen-
italia for non-medical purposes, for example, pricking,
piercing, incising, scraping and cauterization.2
As many as 140 million women and girls worldwide have
had the control of their sexuality and the full enjoyment of
their rights and liberties taken away from them.3,4 Another
3 million girls are at risk of experiencing the same fate.5
These women and girls are, or will be, the victims of FGM.
Female genital mutilation is always traumatic and has no
known health benefits,2,3 and the complications range
from bleeding and infection to death. Although the physical
complications have previously been reported, the effects on

1606 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

sexual function and satisfaction have been poorly
reported.6,7 The British Medical Association states in their
leaflet on FGM: ‘Little is documented about the psychosex-
ual and psychological sequelae of female genital mutilation.’8
We hypothesise that women who have undergone FGM
will have a low sexual quality of life; the aim of this study
was therefore to explore the impact of FGM on sexual qual-
ity of life in women who have undergone this procedure.
Methods
An African Well Women’s Clinic was established at Guy’s
Hospital in 1997 to serve women who had previously
undergone FGM. Initially the clinic mainly attracted
women who were pregnant but has expanded to receive
women who have had FGM requesting reversal and women
who have had FGM and have gynaecological problems.
One hundred and twenty-eight women were recruited
between March 2006 and September 2010 from a central
London Teaching Hospital women’s services directorate
that has a special interest in FGM and serves an ethnically
diverse area of London. The controls were recruited from
the general gynaecology clinic, which has a very diverse
ethnic population and also the antenatal, postnatal and
gynaecology wards.
Inclusion criteria were: aged 16 years or older; to have
undergone FGM, or to be from a cultural background
where FGM is frequently practiced but had not undergone
FGM. The women had to be able to understand English or
be accompanied by an approved interpreter. The women
were only asked to participate when a researcher was pres-
ent in the clinic. A study like this is prone to selection bias
as the practice of FGM is deeply rooted in cultural tradi-
tions. We tried to address this bias by recruiting controls
from cultural backgrounds where FGM is practised.
The women were asked to complete a questionnaire that
was divided into two parts: part one asking demographic
questions and a second part containing the Sexual Quality
of Life-Female (SQOL-F) questionnaire (previously vali-
dated for measuring sexual quality of life in women with
female sexual dysfunction aged over 18 years).9 Use of the
Sexual Quality of Life Assessment Tool was made under
licence from Pfizer Ltd, Sandwich, UK.
Written informed consent was obtained from all women
and all questionnaires were anonymous.
Demographics measured included, age, country of birth,
civil status, number of children, smoking status, alcohol con-
sumption, self-reported history of depression and type of
FGM. Women choose their type from a table describing the
different types. In some cases, the researcher specified this.
The FGM classification was based on the WHO 1995 typol-
ogy2 of FGM with the alteration of type IV, which was further
subdivided into Angurya (scraping of tissue around the
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
SQOL-F in FGM
vaginal orifice) or Gishiri cuts (cutting of the vagina), and
introduction of corrosive substances or herbs into the vagina.
This was a case–control study with a two to one ratio.
Statistical analyses were conducted in MATLAB 2006b
(MathWorks Inc., Cambridge, UK), with exploratory analy-
sis (analysis of variance) with independent variables being
group (control versus FGM), age, country of origin, marital
status, children, sexually active, smoking, alcohol and self-
reported depression and the dependent variable being
SQOL-F. Further post-hoc multiple comparison analysis,
with Bonferroni correction, explored the effect of FGM
type on SQOL-F.
Ethics approval was gained from Bromley Local Research
Ethics Committee, REC reference number 06/Q0705/3.
Results
A total of 128 women were recruited, of whom two with-
drew (one case and one control), 12 did not complete the
SQOL-F questionnaire appropriately for a score to be cal-
culated, one control from Zimbabwe and one from Angola
were excluded as there are no reports in WHO data2 of
FGM being practiced in these countries. Two further con-
trols from the Democratic Republic of the Congo were also
excluded because there are only anecdotal reports of FGM
being practiced there,2 resulting in 73 women with FGM
and 37 control women being included in the analysis. One
participant was found to have completed two question-
naires over the years so the second one was voided.
Only women who had a good command of English or
who were accompanied by a suitable interpreter were
invited to participate when the researcher was present,
hence the prolongation of the recruitment period.
Within the FGM group the mean age was 29.16 (n = 70)
with a range of 19–39 years and in the control group the
average age was 34.03 (n = 35) with a range of 20–59 years.
Of the women who had had FGM, the type of FGM was
distributed as follows: FGM type I 27.4% (n = 20), FGM
type II 12.33% (n = 9), FGM type III 35.62% (n = 26),
Angurya/Gishiri cuts 1.37% (n = 1), Corrosive substances
1.37% (n = 1), unspecified (unknown or not specified)
21.92% (n = 16). (Table 1).
Sixty-three (86.3%) of the 73 women who had under-
gone FGM were from Somalia, Sierra Leone, Nigeria or
Eritrea, whereas of the 37 controls, 32 (86.49%) were from
Nigeria and Ghana (Table 2). All women were immigrants
to the UK.
Exploratory analysis (analysis of variance) examining group
(control versus FGM), age, country of origin, marital status,
children, sexually active, smoking, alcohol, self-reported
depression on the dependent variable SQOL-F showed a main
effect of group (F1,71 = 11.74, P = 0.001), and being sexually
active, (F1,71 = 17.21, P = 0.0001) with control women
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 Andersson et al.

Table 1. Type of FGM (based on WHO classification)

women with FGM. Analysis of variance showed that there
was no significant effect of FGM type on reported SQOL-F
Cases, n (%) (F5,15 = 1.56, P = 0.26). However, a two-tailed t-test showed
that for sexually inactive women, the mean SQOL-F for the
Type I 20 (27.4) controls was significantly higher (n = 6; mean = 69.43,
Type II 9 (12.33) SD = 28.52) than for women with FGM of any type
Type III 26 (35.62) (n = 12; mean = 35.70, SD = 18.48); t16 = 2.78; P = 0.015.
Angurya/Gischiri cuts 1 (1.37)
The effect of type of FGM undergone on SQOL-F score
Corrosive substances 1 (1.37)
Unspecified (unknown or not specified) 16 (21.92)
was compared and the data are shown in Figure 1.

Discussion
Table 2. Country of origin of women participating in the study This study demonstrates that there is a statistically signifi-
cant difference in sexual quality of life scores between
Cases, n (%) Controls, n (%) women who have undergone FGM and those who have not
with the FGM women scoring lower than control women.
Cote d’Ivoire 1 (1.37) 1 (2.7) In sexually active women this study has established that
Eritrea 7 (9.59) 0 FGM type III is associated with the lowest sexual quality of
Ethiopia 1 (1.37) 0
life scores compared with controls. Further, in sexually
Gambia 2 (2.74) 0
Ghana 0 10 (27.03)
inactive women, FGM still lowers sexual quality of life, but
Guinea 1 (1.37) 0 participant numbers limited the extent to which we could
Kenya 1 (1.37) 1 (2.7) determine the effect of each type.
Liberia 2 (2.74) 0 There is a limited amount of data available that explores
Nigeria 9 (12.33) 22 (59.46) this issue, which has such a dramatic effect on the lives of
Sierra Leone 13 (17.81) 2 (5.41) women.
Somalia 34 (46.58) 0
Previous studies have shown that FGM adversely affects
Sudan 2 (2.74) 0
Uganda 0 1 (2.7)
sexual function. Alsibiani and Rouzi6 demonstrated in their
study of 260 women, half of whom had undergone FGM,
and half of whom were controls; a statistically significant
reduction in the overall Female Sexual Function Index
reporting higher SQOL-F ratings (mean = 88.84, SD = score for the former group as well as some individual
13.73) than the FGM group (mean = 62.44, SD = 27.93). domains.
Being sexually active was a potential confounder in
reported SQOL-F, where those women who were sexually
Control
active had a higher mean SQOL-F (n = 92, mean = 76.26,
SD = 24.19) than women who were sexually inactive (n = Type=1
16, mean = 44.13, SD = 25.31). Therefore, further analysis
Type=2
was conducted on two groups separated into those women
who were sexually active and those who were not. Type=3

Angrya / Gishiri cuts

Sexually active group
A multiple comparisons procedure (with Bonferroni cor- Corrosive substance

rection) within the group of sexually active women,

Unspecified
explored the effect of FGM type on SQOL-F. This revealed
that controls (no FGM; n = 34; mean = 91.20, SE = 3.76) –40 −20 0 20 40 60 80 100 120
had significantly higher SQOL-F scores (at the significance Mean SQOL−F score

level P < 0.05) than type 3 (n = 20; mean = 63.28,
SE = 4.83) and unspecified FGM (n = 12; mean = 68.70,
SE = 6.24).
Sexually inactive group
Within the group of women who were not sexually active
there were six controls (women with no FGM) and 12
Figure 1. Mean SQOL-F scores in control and FGM categories. Black
filled circle and vertical dotted line: mean SQOL-F in control group with
95% confidence interval; black filled circles and horizontal lines: mean
SQOL-F scores for FGM type and controls that differ significantly at the
P < 0.05 level, with line length indicating 95% confidence interval on
the means. Clear circles: FGM categories for which SQOL-F mean scores
were not significantly different from control at the 95% confidence
level.

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In a study by Catania et al.,10 57 women with type III
FGM reported higher scores than controls in several
domains of the Female Sexual Function Index, but this
study was confounded by the control group consisting
mostly of western women (54 of 57). In our case–control
study, we tried to eliminate this confounder by recruiting
women from similar cultural backgrounds.
Almrot et al.11 previously demonstrated the negative
impact that FGM has on fertility, specifically the correla-
tion between anatomical extent of the FGM and fertility.
This study demonstrates that in addition to these negative
physical effects, FGM has a negative psychological (holistic)
impact, as demonstrated in the reduced SQOL-F score
thereby adding further to the evidence of the harmful
effects of FGM.
The four commonest countries of origin of the partici-
pants in this study were Somalia, Sierra Leone, Nigeria and
Eritrea. Within the last 10 years, data collected on FGM in
these countries shows a prevalence of 97.9%, 94%, 19% and
88.7%, respectively [2]. One point worth noting about the
data collection in this study was the difficulty in recruiting
controls. As can be seen from the statistics outlined above,
the prevalence of FGM is so high, that suitable case controls
are rarely available. For example, we were unable to recruit
controls of Somalian descent, although the greatest numbers
of participants in the FGM group were from this nation,
because the reported FGM prevalence is 97.9%.2 This is a
potential source of bias. Ideally, the control group should
better reflect the nation of origin of the majority of cases,
however this is impossible to achieve. Some countries prac-
tice particular types of FGM and different cultural factors
play a significant role in sexuality and these different factors
cannot be elucidated in a study such as this.
Limitations of the study
Studies of human sexuality are prone to bias and have con-
founding factors because of the wider cultural context as
well as psychosocial factors that define this aspect of human
behaviour. The choice of questionnaire could be criticised
because we did not have evidence that all women had
female sexual dysfunction. However, we felt that this ques-
tionnaire was the most relevant for our study because it did
address sexual quality of life and we felt that it was the best
available at the time that had been validated. We were also
assuming that women would have some degree of sexual
dysfunction having had their genitalia mutilated. Another
specific source of bias arising from the use of this question-
naire is that it has been validated in women from the UK
and USA9 and therefore could be criticised as it has not
been validated within different cultural groups. However,
quantitative studies aiming to show between-group differ-
ences require a validated instrument. Additionally, our ini-
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
SQOL-F in FGM
tial analysis of variance showed no effect of country of
origin on the SQOL-F score regardless of FGM status.
In terms of recruitment bias, the group of women who
have undergone FGM were mainly recruited from the Afri-
can Well Women’s Clinic where they would have presented
for reversal of FGM or a gynaecological complaint. How-
ever, given the focus of our study on FGM, recruiting
appropriate women for this type of study from a different
setting would not have been possible.
This study recruited women from a variety of countries,
and subsequently has a control group consisting predomi-
nately of women of Nigerian origin, whereas the FGM
group consists mainly of women of Somali origin. Our data
may therefore be confounded by cultural attitudes to sexual
activity and satisfaction, rather than being solely attributable
to FGM-specific differences. We have not been able to find
good published data relating to attitudes to female sexuality
in Somalia versus Nigeria so we are unable to comment as
to how this may have influenced our results.
There was a high risk of both response and recall bias in
this study, as this study was investigating aspects that many
women would consider to be of a very private nature. This
meant that women may not have taken part at all or, may
have given a falsely high or low score.
Designing and implementing a study like this has been
difficult, particularly as the populations being examined are
immigrants.
Conclusion
As a result of high rates of migration of women from
nations where this practice is considered commonplace, to
areas where it is not, it is important to all multidisciplinary
practitioners to have an understanding of the impact of
this practice on the women for whom we provide care. The
effect of a reduced or poor sexual quality of life is likely to
have an effect on the general wellbeing of women.
With increasing numbers of women who have under-
gone FGM integrating into western societies, the sexual
function (and its impact on psychological health) of these
women is going to become an increasingly important issue.
It is important to raise the profile of the damage that is
caused with regards to sexual function in the hope that this
may go some way to eradicating the procedure for future
generations.
This study was conducted mainly on an immigrant pop-
ulation in London. This has enabled us to give a wider pic-
ture of the sexual quality of life of immigrant women
affected by this practice in the UK.
Disclosure of interest
All authors believe FGM to be harmful and believe its prac-
tice should be eradicated.
1609
 Andersson et al.

Contribution to authorship
SA and JR took part in the conception and development of
the study; SA took part in acquisition and analysis of data,
and in drafting and editing the paper, JR took part in
acquisition of data and revising the paper and acted as
supervisor. DJ analysed data, drafted the results section and
revised the paper. CM took part in acquisition of data and
editing/revising the paper and CG in acquisition of data
and drafting the paper.
Details of ethics approval
Ethics approval was obtained from Bromley Local Research
Ethics Committee, REC reference number 06/Q0705/3.
Funding
No funding sought or obtained.
References
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3 UNICEF. Female Genital Mutilation/Cutting: A Statistical Exploration.
New York: UNICEF, 2005.
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cal and mental harm. J Psychosom Obstet Gynaecol 2008;29:225–9.
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sexual quality of life in women. J Sex Marital Ther 2005;3:385–97.
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dir D. Pleasure and orgasm in women with female genital mutila-
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11 Almroth L, Elmusharaf S, El Hadi N, Obeid A, El Sheikh MA, Elfadil
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Commentary on ‘Studying the psychosexual impact of female genital

mutilation’

Female genital mutilation (FGM) is still widely practised in many parts of the world despite legislative attempts to
eliminate it. FGM describes a range of procedures that involve cutting, excising or otherwise deliberately injuring the
external genitalia of female babies, girls and young women. It is firmly rooted in the tradition of those cultures that
practise it, where it is believed to protect women from disgrace and promiscuity, or is used as an initiation ritual that
celebrates a girl’s rite of passage into womanhood. But tradition cannot justify damaging women’s long-term health
and sexuality. Female genital mutilation is condemned by the international medical community as a morally offensive
and unacceptable act that causes harm and violates human rights. The physical effects of FGM are well characterised
and include both immediate threats (haemorrhage, infection) and long-term consequences (problems with childbirth,
pelvic pain, sexual dysfunction). By contrast, comparatively little is known about its psychological sequelae, in particu-
lar, the effects of FGM on sexual quality of life.
Immigrants seeking refuge from war, civil unrest and drought in FGM-practising countries such as Somalia and
Eritrea are increasingly settling in Western Europe and North America, where, as a result, FGM has become an
important public health issue. The psychological impact of FGM on sexual health is poorly understood but is likely to
be particularly complex for immigrant women experiencing new attitudes to FGM and different cultural norms of
sexual expectation compared with those with which they grew up. An improved understanding of these psychosexual
issues will greatly enhance our ability to provide appropriate, specialised care for women who need it. In this study,
Andersson et al. explored the impact of FGM on sexual quality of life in women originating from African countries
where the practice is endemic. Studies like these are vitally important but challenging to design and conduct. Their
design is hampered by the lack of a validated tool for the population of interest; the Sexual Quality of Life-Female
(SQOL-F) questionnaire was validated on women from Europe, the USA and Australia (Symonds et al., Journal of Sex
and Marital Therapy 2005;31:385–97), all countries with very different expectations of female sexuality. There are also

1610 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
 SQOL- in FGM

challenges in recruitment to this type of study. Andersson et al. recruited women from a specialised African Well
Woman Clinic designed to address obstetric concerns, gynaecological problems and reversal of FGM. In such a
cohort, women experiencing sexual difficulties are likely to be over-represented. Participants originated mostly from
Somalia, Eritrea and Sierra Leone, where FGM is widely practised, whereas women in the control group originated
mainly from Ghana and Nigeria, where it is less common, adding a serious potential source of bias. On top of these
difficulties, recruitment was slow, partly because of language barriers but perhaps also because studies like this ask dif-
ficult questions about topics that evoke shame or fear of reprisal in prospective participants. In combination, these
confounding factors limit interpretation of the data and our ability to draw robust conclusions from them. Even so,
studies like these are a brave attempt to explore tough issues in the real world, where bias cannot always be controlled
for. Future work is required to substantiate these findings.

Disclosure of interests
I declare no conflicts of interest.

E Crosbie
University of Manchester, St Mary’s Hospital, Manchester, UK

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 1611