The FGM/C procedure, which acts as a violation of women's rights and is considered as violence against women, imposes much physical, psychosocial and social harm on women and girls, and reduces their health-related quality of life. For the first time, the current study measured the utility value of FGM/C for different socio-demographic groups. The results indicated that women/girls living with FGM/C had an average health utility of 0.971 (SE: 0.003) with median of 0.968 (IQR: 1-0.95). In other words, they lost about 3% of their Health-Related Quality of Life (HRQoL) due to FGM/C, on average.
The utility value, which subjectively represents the sum of the effects of FGM/C on women's health, was significantly lower for single (Mean: 0.950, 95% CI: 0.935–0.964) and divorced women (Mean: 0.951, 95% CI: 0.943–0.958) compared to married women. In other words, single women experienced more reduction in their HRQoL than married women. This may be due to delay in their marriage. Because the mean age of the single subjects participated in the study was significantly higher than that of the married women (38.2 vs. 33.8 years), which it may be attributed to FGM/C.
This negative effect may vary in different countries and cultures, as in countries such as Nigeria, Somalia, and Sudan, girls who have performed FGM/C have a higher chance of finding a partner and having a timely marriage.[15, 16] While in Guinea, having or not having FGM/C, did not have any effect on the chance of getting married.[17] In Iran, however, because FGM/C is performed only in certain ethnic and religious groups; therefore, it is generally considered unacceptable in society and may decease the chance of marriageability. Nonetheless, a definitive answer to this requires more in-depth studies.[18]
Another reason can be related to the perception of single women of marital restrictions of FGM/C, such as intercourse pain, less sexual pleasure and related bleeding. Since women from less developed societies may not experience these restrictions before marriage, they may over-estimate them.[15] The divorced women may also attribute their separation and failure in life to FGM/C.
Another interesting result of this study was that women in the 31–45 age group (Mean: 0.962, 95% CI: 0.956–0.969) reported a lower HRQoL than others, which appears to be due to more divorce rate of this group in comparison with other age groups. It accounts for 65% of all divorces. This group of women may attribute their divorce to FGM/C, which may be resulted from their sexual dissatisfaction or disability. This finding is in line with the results of other studies.[19–22]
Surprisingly, employed women reported less health utility than unemployed women and housewives (Mean: 0.959, Median: 0.956). This can be due to the different expectations of this group from marital life and their greater understanding of the negative effects of FGM/C on their physical and psychological health, as all 16 employed females participated in the study were university graduates. Also, employed women had a mean age above the average of the study population (Mean: 38.75, 95% CI: 37.53–39.97); therefore, they may have perceived the long-term effects of this procedure better and more than others.
In this study, only types 1 and 2 of FGM/C were considered. The findings indicated that type 1 had more severe effects on HRQoL reduction than type 2. A strong reason for this lies in the difference between the mean ages of two groups. The mean age of participants with type 1 and 2 FGM was 37.47 (95% CI: 35.86–39.9) and 27.14 (95.1% CI: 29.99–24.99), respectively. Therefore, women with type 1 FGM had experienced long-term effects of this procedure more than their counterparts. Moreover, findings showed that women who were never married or got divorced had type 1 FGM/C. There was not any divorced or single women among women with type 2 FGM/C.
Therefore, the obtained health utility value cannot be directly attributed to type of FGM itself, because women with type 2 FGM/C have not experienced its long-term effects yet. Therefore, in order to more accurately compare the effects of type of FGM/C on HRQoL of individuals, a larger sample size with the same age strata are required for all types of FGM/C.
The results of the Tobit regression model were fully consistent with the preceding findings. This shows that the effects of FGM/C become more tangible with increasing age and emergence of personal and marital dissatisfactions, which may result in divorce or in never getting married and passing the marriage age, and leads to a gradual reduction in HRQoL. The findings of the model suggest that women affected by the negative outcomes of this practice are forced to work outside the home leading to their dissatisfaction as they mainly come from households with lower income levels and larger household size than the average of the society.
58 participants of the study (46.4%) were not willing to lose any time to regain their usual genital condition, and they reported a full health utility. These are referred to as non-traders. All of them were married and more than 81% of them were housewives. These people, on average, had a larger household size with a monthly household expenditure below the average. Therefore, it can be concluded that non-traders were less influenced by the effects of FGM/C, and were able to live their lives in accordance with the community conditions and their expectations, so they did not complain about it. The mean health utility for traders was 0.946 (95% CI: 0.943–0.950). In other words, women, who have been hurt in their personal and family life due to FGM/C, lose 5.4% of their HRQoL.
The effect of FGM/C on HRQoL in individuals can be compared with diseases such as non-severe hypoglycemic, mild primary dysmenorrhea, skin neoplasm, myopia, and otitis media associated with pain. On average, these all result in a 3% loss of HRQoL in individuals. Subgroups such as single or middle-aged women with FGM/C, who are affected by this procedure more than others, have disutility almost equal to mild gastroenteritis. Of course, since the FGM/C procedure is mainly performed during the childbirth or childhood, it has life-time effects and imposes more disease burden than the above-mentioned diseases (Table 3). If we assume that a girl performs FGM/C in her first year of life, with a discount rate of 3% and a life expectancy of 75 years, its burden of disease is equal to 0.87 year.
Table 3 Comparison of FGM’s utility value with other diseases |
Diseases | Mean of utility value | Reference |
Hypoglycemic- Non-severe daytime event | 0.972 | [23] |
Hypoglycemic- Non-severe nocturnal event | 0.977 | [23] |
Stable schizophrenia | 0.919 | [24] |
Mild Primary Dysmenorrhea | 0.970 | [25] |
Skin neoplasm of uncertain behavior | 0.970 | [26] |
Epilepsy | 0.920 | [27] |
Myopia | 0.970 | [28] |
Otitis media with pain | 0.970 | [29] |
Moderate gastroenteritis | 0.940 | [29] |
The burden of FGM/C is totally unnecessary and avoidable, provided that governments take indigenous and effective initiatives and measures to prevent from the FGM/C procedure. In order to develop domestic protocols, the main reasons for performing FGM/C should be extracted in each community, and should be considered as a basis for identifying prevention strategies. The main reasons for performing this procedure include controlling the sexual desire and behavior of girls and women; preserving a cultural and traditional practice; parents' low level of education, especially mothers and girls themselves; the pressure of families and relatives; lack of awareness of the psychical and psychological consequences of FGM/C in the long run; and linking FGM/C to religious beliefs and commands.[12, 30–32]
Of course, all prevention programs require intersectoral collaboration and should include activities such as health education to parents, passing national laws, standing against some meaningless social norms and traditional beliefs, encouragement of mothers and girls to educate, and getting help from religious missionaries.[33, 34] Nowadays, one of the new barriers to eliminate FGM/C in some countries, especially African countries, is medicalization. Doctors, nurses and some other health workers claim that they can perform this procedure in sanitary conditions, so they give FGM/C legitimacy. It not only does not help to the prevention of FGM/C, but it also encourages people to do it. Therefore, announcing that performing FGM/C is against the law can also be an effective step to reduce the incidence of this procedure.[35, 36]
The strength of the current study was to examine FGM/C victims by trained midwives in order to determine the degree of FGM/C. However, the results of the present study should be interpreted in light of its limitations. First, we did not include types 3 and 4 of FGM/C; therefore, our results can only be generalized to women with types 1 and 2. Given the fact that the more severe types of this disorder impose more long-term negative effects on the individuals and create more family and personal problems for them, it may also create greater health disutility. Therefore, it is highly recommended that the disutility of types 3 and 4 of FGM/C should be extracted in other studies. Second, the amount of health disutility of FGM/C seems to be very much influenced by the culture of the community, so if the restrictions imposed by FGM/C prevent women from meeting their personal and social expectations, it can raise women's dissatisfaction and create more disutility. Therefore, the results of this study are not necessarily the same in different societies and communities.