Worldwide, approximately 44 million girls under age 15 years have undergone female genital cutting (FGC) (1, 2). Although many countries have passed laws banning FGC, it is still practiced by several African tribes. In the Republic of The Gambia (The Gambia), the site of the present study, the prevalence rate of FGC is around 75% (3, 4). The FGC procedure involves partial or total removal of external female genitalia or other injury to the female genitalia for cultural, religious, or other nontherapeutic reasons. The World Health Organization classification differentiates among four types of FGC (5). Type I (clitoridectomy), type II (excision), and type III (infibulation) account for approximately 66, 26, and 8% of cases in The Gambia, respectively (6).

The immediate medical complications of FGC include excessive bleeding, pain, swelling of the genital tissues, urinary retention, and problems with wound healing (7, 8). In the longer term, women who have undergone FGC are at greater risk for gynaecological, sexual, and obstetric complications (8).

In contrast to a large body of literature on the physical health effects of FGC, knowledge is limited regarding the mental health consequences. In a 2019 systematic review, Abdalla and Galea (9) identified 16 studies that examined mental health associated with FGC, six of which presented the association between FGC and mental health as the sole research question. Overall, the studies showed a higher burden of adverse mental health outcomes among women who were subjected to FGC compared with women who were not. Some studies have shown a correlation between the severity of FGC and the severity of adverse mental health outcomes. As the authors noted, the included studies had small sample sizes and did not consider confounding factors, such as traumatic life events such as being exposed to actual or threatened death, serious injury, violence or sexual assault. Thus, it cannot be ruled out that the adverse mental health outcomes are the result of other conditions that disadvantage women subjected to FGC.

Some studies have addressed various aspects of mental health among women and adolescent girls who have undergone FGC, including post-traumatic stress disorder (PTSD), depression, anxiety, somatisation, insomnia, helplessness, irritability, and low self-esteem (10–14). The premise of studies investigating PTSD, e.g., (11, 14–18) has been that the FGC procedure can represent a threat to the child’s physical integrity and be traumatic through inflicting pain and harm. None of these studies investigated whether the symptoms of PTSD could be related to other traumatic events in the lives of these girls and women, which is important because, for example, more severe PTSD could potentially relate to multiple traumatic experiences. To gain deeper insight into this issue, we investigated serious life events experienced by 12 years-old Gambian girls. Our aim was first to examine the extent to which FGC relative to other serious life events was reported as the event that currently bothered the girls the most. Our second aim was to examine the prevalence of PTSD in this population and the extent to which PTSD was attributed to FGC.

Overall, the Mandinka were the largest ethnic group, comprising more than half of the 125 participants (Table 1). Almost half of all participants (46.4%) had undergone FGC before age 4 years. At the age of 12 years, the participants had experienced a wide range of serious life events in addition to FGC (Table 2), with an average of 4.5 serious life events per individual. The events experienced by most participants, apart from FGC, were witnessing violence, experiencing violence or assault themselves, death of a close relative, and being exposed to a natural disaster or serious accident (Table 2).

There was great variation in which type of event bothered the participants the most (Table 2). Around one-sixth of the girls (16.8%) stated that FGC was the event that currently bothered them the most, whereas the rest emphasised other experiences (75.2%) or did not report events that bothered them (8.0%). For example, 28.0% stated that the death of a close relative was the event that currently bothered them the most (Table 2).

Girls who cited FGC as the event that bothered them most differed significantly in some ways from the other participants (Table 1), including having undergone FGC at an older age, having better daily functioning, and possibly having a lower prevalence of PTSD (4.8% versus 22.1%, p = 0.065). These two groups did not differ in current physical complications, including genital pain, spending a long-time urinating, or having pain when urinating.

Overall, the prevalence of probable PTSD was 19.2%. Of 24 cases of PTSD, one (4.2%) was attributed to the experience of FGC, and the remaining 23 (95.8%) were attributed to other serious life events (Table 2).

Gambian girls who had undergone FGC had generally experienced a wide range of additional potential traumatic events that, to a greater extent than FGC, they rated as the event that currently bothered them the most. One in every six of the girls considered FGC as the serious life event currently bothering them the most. Although the prevalence of probable PTSD was high (19.2%), of 24 cases identified, one was linked to FGC and the other 23 attributed to stress reactions to other serious events.

The findings demonstrate the importance of considering a wide range of potential traumatic events when examining mental health in girls who have undergone FGC, as they may have experienced other traumatising events that warrant attention and preventive efforts. High rates of mental health problems among females who have undergone FGC, which has been documented in several studies (9), must be interpreted with caution because girls who have undergone FGC also may have been severely exposed to other traumatic events.

The overall prevalence of PTSD in our study was far higher than reported in general populations of children and adolescents in the United States and Europe (26–28). These differences may be linked to the high incidences of potentially traumatic events identified in the current study, such as the death of close relatives, exposure to violence, and experiences of natural disasters or serious accidents. The prevalence of serious life events among these girls was far higher than in population studies from the United States and Europe (26–28). FGC cannot be ruled out as contributing significantly to adverse mental health, but our findings indicate that other traumatic events or their accumulation may predominate as explanatory of high rates of PTSD among Gambian girls. Girls who have undergone FGC may also have experienced major challenges in terms of economic, social, or cultural burdens that can significantly affect mental health.

The link between age at FGC and FGC as the event that bothered girls the most may be related to changes in memory encoding, retention, and retrieval that occur during early childhood. Most people have no recollection of infancy and earliest childhood, but quantitative changes in basic memory processes can explain the fading of childhood amnesia during the third and fourth years of life (29). Although the timing of FGC may affect how the event is remembered later, the exceptionally low prevalence of PTSD related to FGC in the current work does not provide evidence in support of the hypothesis linking FGC timing and development of PTSD (18).

Girls who rated FGC as the event that bothered them the most had overall better daily functioning and a trend to a lower prevalence of PTSD compared with girls who rated other events as bothering them the most. This indicates that other events may have been a greater burden on functioning and mental health than FGC.

The finding that FGC was not the predominate trauma related to PTSD for most of these girls deserves some reflections regarding possible protective mechanisms. Psychological reactions in response to trauma depend on how an individual interprets the event, including being able to understand it in a meaningful context (30, 31). In the traditional circumcision of Gambian girls, the procedure is deeply rooted in a cultural context of ritual acts and celebration (32). The girl is being prepared to be the centre of a large family celebration where she will receive honour, gifts, and gratitude.

After the procedure, the girl undergoes formal instruction about the importance of the FGC and why it was carried out. She is repeatedly told that the procedure will turn her into a proud and honourable woman, so that she can get married, have children, and live a good and respectful life (32). The use of words and phrases such as “clean” and “being like your mother,” as well as tautological explanations such as “it’s necessary” and “that’s how we do it,” makes the learning more explicit. In line with knowledge that meaning-making processes are central to recovery and resilience (33), growing up with an integrated identity as a “cut, proud, and honourable” woman might contribute to the maintenance of mental health.

Second, traditional rituals following FGC may be effective in reducing pain and emotional stress. In their discussion of cultural protection against traumatic stress after FGC in Gambian girls, Schultz and Lien (32) argue that traditional rituals are rich in elements similar to the principles of modern empirically based crisis intervention. In keeping with five essential principles of trauma intervention described by Hobfoll and colleagues (34), the girls are provided with a sense of safety in the aftermath of the operation, and they are calmed down and encouraged through the healing period (32). Self-efficacy is empowered, as is the connectedness and feeling of belonging to the tradition, family, and female identity. A collective hope is linked to their new status, their position, and future identity (32).

Third, an ecological view of trauma recovery (35, 36) should be included. According to this view, the extensive social support provided in the procedure’s aftermath and the need to adapt to the cultural collectivist mindset may serve adaptive purposes and support mental health maintenance.

The datasets presented in this article are not readily available because Data are from the project “Physical and psychological healthcare for girls and women with Female Genital Mutilation/Cutting (FGM/C).” According to the approval from the Norwegian Regional Ethics Committee and the Gambia Government/MRC Joint Ethics Committee, the data are to be stored properly and in line with Norwegian and Gambian laws of privacy protection. Public availability would compromise privacy of the respondents. However, anonymised data are freely available to interested researchers upon request, pending ethical approval from our ethics committees: ethics@mrc.gm/post@helseforskning.etikk.no. Requests to access the datasets should be directed to TH (trond.heir@medisin.uio.no).

The studies involving humans were approved by The Norwegian Regional Ethics Committee, & The Gambia Government/MRC Joint Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

TH: analyzing data, data interpretation, and writing the draft. BB: planning study design, analyzing data, data interpretation, and writing the draft. FM and RK: planning study design, data interpretation, and actively contribute to the writing process. I-LL: organization of the research project, planning study design, data interpretation, and actively contribute to the writing process. All authors contributed to the article and approved the submitted version.