Female genital mutilation: a systematic review of research on its economic and social impacts across four decades

Figures & data

Fig. 1 Methodology of the research strategy and data selection

Table 1 Years of publication

Year	Number of publications	%
2002–2011	104	52.5
1992–2001	59	29.8
1982–1991	21	10.6
1972–1981	14	7.1
Total	198	100

Table 2 Study designs

Designs	n	%
Cross-sectional	64	32.3
Cohort	16	8.1
Case-control	4	2
Qualitative studies	10	5.1
Case series	14	7.1
Social analyses	40	20.2
Economic studies	3	1.5
Simple reviews	28	14.1
Systematic reviews	2	1
Other (educational recommendations, reports of conferences)	17	8.6
Total	198	100

Table 3 Categories of journals

Journals	n	%
1. Biomedical and care journals	127	64.1
Biomedicine	118	59.6
Nursing	9	4.5
2. Epidemiology and public health	31	15.7
3. Mixed journals	23	11.6
Medicine and social sciences	18	9.1
Health and human rights	4	2
Medicine and law	1	0.5
4. Journals of social sciences	15	7.6
Mixed social sciences	9	4.5
Human rights	4	2
Economics	1	0.5
Ethics	1	0.5
5. Other	2	1
Engineering	1	0.5
Environment/sustainability	1	0.5
Total	198	100

Table 4 Study settings

Study settings	n	%
Africa as a region	66	33.3
Nigeria	38	19.2
Egypt	21	10.6
Multi-site in Africa	16	8.1
Sudan	11	5.6
Somalia	8	4.1
Burkina Faso	5	2.5
Ethiopia	5	2.5
Kenya	5	2.5
Tanzania	3	1.5
Eritrea	3	1.5
Ghana	3	1.5
Chad	2	1
Gambia	2	1
Others^a	10	5.1
Total	198	100

^aOthers: Cameroon, Guinea, Ivory Coast, Mali, Niger, Senegal.

Table 5 Country affiliation of main author

Authorship countries	n	%
USA	42	21.2
Nigeria	32	16.2
UK	18	9.1
Egypt	15	7.6
International organizations	13	6.6
France	8	4.1
Sweden	7	3.5
Ethiopia	4	2
Kenya	4	2
Saudi Arabia	4	2
Sudan	4	2
Switzerland	3	1.5
Others^a	36	18.2
N/A	8	4
Total	198	100

^aOthers: Australia, Belgium, Burkina Faso, Cameroon, Canada, Cuba, Denmark, Gambia, Germany, Ghana, Israel, Italy, Kuwait, Mali, Mexico, the Netherlands, Norway, Oman, Poland, Senegal, South Africa, Spain, Pakistan.

Table 6 Research themes

Research themes	n	%
1. Medical and psychological consequences	102	51.5
2. Prevalence and ethics	68	34.4
3. Socio-economic consequences	28	14.1
Direct economic consequences	5	2.5
School attendance	2	1
Sexual and marital consequences	7	3.5
Fertility	5	2.5
Domestic violence	2	1
Discrimination	3	1.5
Marriageability	4	2
Total	198	100

Table 7 Socio-economic findings related to FGM

Direct quantified economic consequences	1. Victims of type 3 FGM have a shortened life expectancy. Annual costs of FGM-related obstetric complications in six African countries represent $3.7 million or 0.1-1% of government spending on health for women aged 15–45 years. Global loss of life years of FGM is estimated to up of 2.8 million life years (17).
	2. In a Nigerian University Hospital study the duration of necessary clinical follow-up due to medical complications was 13 months (18).
	3. At a Nigerian Medical Center the average management cost of medical complications of FGM per victim was $120 (19).
	4. At a Maternity Hospital in Somalia the mean number of hospitalization days per victim due to FGM complications was 16.5 days (20).
	5. Obstetric and gynecological operations to treat direct complications of female circumcision in a Sudanese Teaching Hospital represented 7% of the total number of operations (21).
School attendance	1. Immediate marriage with no return to school after the FGM procedure has been reported from Kenya (22).
	2. Female circumcision contributes to high school dropout (23).
Sexual and marital	1. In Guinea FGM did not affect the likelihood of premarital sex nor marriage (24).
consequences	2. In Egypt marital/sexual problems (dyspareunia, loss of libido, failure of orgasm and husband's dissatisfaction) was higher among circumcised women (25).
	3. In Egypt men perceived FGM as possibly having negative effects on women's sexual response (26).
	4. In a study implemented in 5 medical centers in Egypt 68.9% of circumcised women reported having sexual problems, 31.5% suffered from dyspareunia, 49.6% had decreased sexual desire, 36% had difficulties with arousal and 16.9% had anorgasmia (27).
	5. At 3 Nigerian hospitals, FGM was shown as not attenuating the sexual arousal of women (28).
	6. In a Nigerian study being circumcised did not lead to early sexual experiences (29).
	7. In Egypt a study among 250 circumcised women, the women reported: vaginal dryness during intercourse(48.5%), lack of sexual desire (45%), less frequency of sexual desire per week (28%), less initiative during sex (11%), less pleasure from sex (49%), less orgasms (39%), less frequency of orgasm (25%), difficulty reaching orgasm (60.5%) (30).
Fertility	1. FGM is associated with and may contribute to increase the number and ratio of births of male boys (Odds Ratio = 1.019; 95% C.I.=1.007, 1.032) as shown in a study on 413,384 births from 22 African countries (31).
	2. Infertility rate in infibulated women can be as high as 30% (32).
	3. In Egypt FGM type III has been associated with infertility in representative samples of women (33).
	4. In Sudan circumcision did not lead to impaired fertility in married women, except for higher prevalence of primary infertility among those who had undergone Pharaonic (Type 3) or intermediate (Type 2) circumcision (34).
	5. Female circumcision was not associated with increased infertility nor with reduced fertility in studies from the Central African Republic, the Ivory Coast and Tanzania (35).
Domestic violence	1. In a study from Egypt holding positive beliefs of FGM practice was associated with maternal physical violence (69.8% had hit their children during the year prior to the survey) (36).
	2. In a study from Egypt circumcised women were 7.5 times more likely to accept that husbands have the right to beat their wives (37).
Discrimination	1. The major deterrent to marriage between men from circumcising families and uncircumcised women is the hostility and discrimination an uncircumcised woman faces among circumcised women (38).
	2. In a study outpatients of a Nigerian hospital, stigmatizing attitudes toward the uncircumcised women were reported: 74% said they are promiscuous, 49% said they are shameful, 14% cursed/outcast, 66% would not recommend them for marriage (39).
	3. In Nigeria uncircumcised women were less eligible as wives and they were ostracized by women themselves (40).
Marriageability	1. From the Southern African Development Community region it is reported that women who have not undergone the practice may find it difficult to get husbands (41).
	2. The expectation that FGM leads to better marital outcomes is enough to perpetuate the practice as a social norm, even though the value of it within the marriage might be very low (42).
	3. Informants from Egypt characterized FGM as a prerequisite for marriage, enabling girls to acquire a social identity, economic security, and some measure of familial authority in a patrilineal society. A bride who proves her virginity receives material benefits, social approval and preserves the honor of her family (43).
	4. Only for a gabar gudban (closed woman) as opposed to the term buriya gab (woman with clitoris) does the father receive a good bride price (yarad), which contributes to the economic prosperity of the village (44).

Annex 1. Details of search strategy (in French and English)

Database	Search equation
1. PubMed	(“Circumcision, Female”[Mesh] OR “Female Circumcisions”[tiab] OR “Female Circumcision”[tiab] OR “Infibulation”[tiab] OR “Infibulations”[tiab] OR “Clitoridectomy”[tiab] OR “Clitoridectomies”[tiab] OR “Clitorectomy”[tiab] OR “Clitorectomies”[tiab] OR “Female Genital Cutting”[tiab] OR “Female Genital Mutilation”[tiab] OR “Female Genital Mutilations”[tiab]) AND (“Africa”[Mesh] OR "Africa*"[tiab] OR “Algeria”[tiab] OR “Egypt”[tiab] OR “Libya”[tiab] OR “Morocco”[tiab] OR “Tunisia”[tiab] OR “Cameroon”[tiab] OR “Central African Republic”[tiab] OR “Chad”[tiab] OR “Congo”[tiab] OR “Democratic Republic of the Congo”[tiab] OR “Equatorial Guinea”[tiab] OR “Gabon”[tiab] OR “Burundi”[tiab] OR “Djibouti”[tiab] OR “Eritrea”[tiab] OR “Ethiopia”[tiab] OR “Kenya”[tiab] OR “Rwanda”[tiab] OR “Somalia”[tiab] OR “Sudan”[tiab] OR “Tanzania”[tiab] OR “Uganda”[tiab] OR “Angola”[tiab] OR “Botswana”[tiab] OR “Lesotho”[tiab] OR “Malawi”[tiab] OR “Mozambique”[tiab] OR “Namibia”[tiab] OR “South Africa”[tiab] OR “Swaziland”[tiab] OR “Zambia”[tiab] OR “Zimbabwe”[tiab] OR “Benin”[tiab] OR “Burkina Faso”[tiab] OR “Cape Verde”[tiab] OR “Cote d'Ivoire”[tiab] OR “Gambia”[tiab] OR “Ghana”[tiab] OR “Guinea”[tiab] OR “Guinea-Bissau”[tiab] OR “Liberia”[tiab] OR “Mali”[tiab] OR “Mauritania”[tiab] OR “Niger”[tiab] OR “Nigeria”[tiab] OR “Senegal”[tiab] OR “Sierra Leone”[tiab] OR “Togo”[tiab])
2. Embase	(‘female circumcision’/exp OR "Female Circumcisions":ti:ab OR "Female Circumcision":ti:ab OR "Infibulation":ti:ab OR "Infibulations":ti:ab OR "Clitoridectomy":ti:ab OR "Clitoridectomies":ti:ab OR “Clitorectomy”:ti:ab OR “Clitorectomies”:ti:ab OR “Female Genital Cutting”:ti:ab OR “Female Genital Mutilation”:ti:ab OR “Female Genital Mutilations”:ti:ab) AND (“Africa”/exp OR Africa*:ti:ab OR “Algeria”:ti:ab OR “Egypt”:ti:ab OR “Libya”:ti:ab OR “Morocco”:ti:ab OR “Tunisia”:ti:ab OR “Cameroon”:ti:ab OR “Central African Republic”:ti:ab OR “Chad”:ti:ab OR “Congo”:ti:ab OR “Democratic Republic of the Congo”:ti:ab OR “Equatorial Guinea”:ti:ab OR “Gabon”:ti:ab OR “Burundi”:ti:ab OR “Djibouti”:ti:ab OR “Eritrea”:ti:ab OR “Ethiopia”:ti:ab OR “Kenya”:ti:ab OR “Rwanda”:ti:ab OR “Somalia”:ti:ab OR “Sudan”:ti:ab OR “Tanzania”:ti:ab OR “Uganda”:ti:ab OR “Angola”:ti:ab OR “Botswana”:ti:ab OR “Lesotho”:ti:ab OR “Malawi”:ti:ab OR “Mozambique”:ti:ab OR “Namibia”:ti:ab OR “South Africa”:ti:ab OR “Swaziland”:ti:ab OR “Zambia”:ti:ab OR “Zimbabwe”:ti:ab OR “Benin”:ti:ab OR “Burkina Faso”:ti:ab OR “Cape Verde”:ti:ab OR “Cote d Ivoire”:ti:ab OR “Gambia”:ti:ab OR “Ghana”:ti:ab OR “Guinea”:ti:ab OR “Guinea-Bissau”:ti:ab OR “Liberia”:ti:ab OR “Mali”:ti:ab OR “Mauritania”:ti:ab OR “Niger”:ti:ab OR “Nigeria”:ti:ab OR “Senegal”:ti:ab OR “Sierra Leone”:ti:ab OR “Togo”:ti:ab)
3. CINAHL	((MH “Circumcision, Female”) OR TI (“Female Circumcisions” OR “Female Circumcision” OR “Infibulation” OR “Infibulations” OR “Clitoridectomy” OR “Clitoridectomies” OR “Clitorectomy” OR “Clitorectomies” OR “Female Genital Cutting” OR “Female Genital Mutilation” OR “Female Genital Mutilations”) OR AB (“Female Circumcisions” OR “Female Circumcision” OR “Infibulation” OR “Infibulations” OR “Clitoridectomy” OR “Clitoridectomies” OR “Clitorectomy” OR “Clitorectomies” OR “Female Genital Cutting” OR “Female Genital Mutilation” OR “Female Genital Mutilations”)) AND (MH "Africa+") OR TI ( Africa* OR Algeria OR Egypt OR Libya OR Morocco OR Tunisia OR Cameroon OR “Central African Republic” OR Chad OR Congo OR “Democratic Republic of the Congo” OR “Equatorial Guinea” OR Gabon OR Burundi OR Djibouti OR Eritrea OR Ethiopia OR Kenya OR Rwanda OR Somalia OR Sudan OR Tanzania OR Uganda OR Angola OR Botswana OR Lesotho OR Malawi OR Mozambique OR Namibia OR “South Africa” OR Swaziland OR Zambia OR Zimbabwe OR Benin OR “Burkina Faso” OR “Cape Verde” OR “Cote d'Ivoire” OR Gambia OR Ghana OR Guinea OR “Guinea-Bissau” OR Liberia OR Mali OR Mauritania OR Niger OR Nigeria OR Senegal OR “Sierra Leone” OR Togo) OR AB ( Africa* Algeria OR Egypt OR Libya OR Morocco OR Tunisia OR Cameroon OR “Central African Republic” OR Chad OR Congo OR “Democratic Republic of the Congo” OR “Equatorial Guinea” OR Gabon OR Burundi OR Djibouti OR Eritrea OR Ethiopia OR Kenya OR Rwanda OR Somalia OR Sudan OR Tanzania OR Uganda OR Angola OR Botswana OR Lesotho OR Malawi OR Mozambique OR Namibia OR “South Africa” OR Swaziland OR Zambia OR Zimbabwe OR Benin OR “Burkina Faso” OR “Cape Verde” OR “Cote d'Ivoire” OR Gambia OR Ghana OR Guinea OR “Guinea-Bissau” OR Liberia OR Mali OR Mauritania OR Niger OR Nigeria OR Senegal OR “Sierra Leone” OR Togo)
4. BDSP	(“Mutilation sexuelle” OU Excision OU Infibulation OU “Ablation clitoris” OU “Circoncision féminine” OU Clitorectomie OU Excision OU “Mutilation génitale féminine” OU MGF) ET (Afrique OU africain OU africaine OU africains OU africaines OU Angola OU Bénin OU Botswana OU Burkina Faso OU Burundi OU Cameroun OU Canaries OU Cap Vert OU Centrafrique OU Comores OU Congo OU “Côte d'Ivoire” OU Djibouti OU Egypte OU Erythrée OU Ethiopie OU Gabon OU Gambie OU Ghana OU Guinée OU Ile Maurice OU Kenya OU Lesotho OU Libéria OU Madagascar OU Maghreb OU Malawi OU Mali OU Maurice OU Mozambique OU Namibie OU Niger OU Nigeria OU “Océan Indien” OU Ouganda OU Rwanda OU “Sahara espagnol” OU Sénégal OU Seychelles OU Sierra Leone OU Somalie OU Soudan OU Swaziland OU Tanzanie OU Tchad OU Togo OU Zaïre OU Zambie OU Zimbabwe)
5. Web of Science, PsycINFO, FRANCIS, Sociological abstracts	(“Female Circumcisions” OR “Female Circumcision” OR “Infibulation” OR “Infibulations” OR “Clitoridectomy” OR “Clitoridectomies” OR “Clitorectomy” OR “Clitorectomies” OR “Female Genital Cutting” OR “Female Genital Mutilation” OR “Female Genital Mutilations”) AND (Africa* OR Algeria OR Egypt OR Libya OR Morocco OR Tunisia OR Cameroon OR “Central African Republic” OR Chad OR Congo OR “Democratic Republic of the Congo” OR “Equatorial Guinea” OR Gabon OR Burundi OR Djibouti OR Eritrea OR Ethiopia OR Kenya OR Rwanda OR Somalia OR Sudan OR Tanzania OR Uganda OR Angola OR Botswana OR Lesotho OR Malawi OR Mozambique OR Namibia OR “South Africa” OR Swaziland OR Zambia OR Zimbabwe OR Benin OR “Burkina Faso” OR “Cape Verde” OR “Cote d'Ivoire” OR Gambia OR Ghana OR Guinea OR “Guinea-Bissau” OR Liberia OR Mali OR Mauritania OR Niger OR Nigeria OR Senegal OR “Sierra Leone” OR Togo)
6. WHOLIS, RERO, SAPHIR	Circumcision, female, Africa, African, Mutilation sexuelle, Afrique

[MeSH]=MeSH Term

[tiab]=Search in title (ti) and abstract (abstract)

/exp = Emtree term

:ti:ab=Search in title (ti) and abstract (abstract)

MH=Subject heading

TI, AB=Search in title, abstract

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