M A L M Ö U N I V E R S I T Y H E A LT H A N D S O C I E T Y D I S S E R TAT I O N S

Camilla Palm

Navigating Conflicting Norms
on Body and Sexuality
Exploring Swedish-Somali Women’s and Swedish Welfare
Workers’ Perceptions of Female Genital Cutting

NAVIGATING CONFLICTING NORMS ON BODY AND SEXUALITY

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Navigating Conflicting Norms
on Body and Sexuality
Exploring Swedish-Somali Women’s and Swedish Welfare
Workers’ Perceptions of Female Genital Cutting
Thesis for Doctoral Degree (Ph.D)
By Camilla Palm
The thesis will be defended in public at Malmö University, Niagara, NI:C0E11,
Nordenskiöldsgatan 1, Malmö
Friday, April 19 2024, at 10.00
Principal Supervisor
Eva Elmerstig, Associate Professor
Malmö University
Department of Social WorkCo-Supervisor(s)Charlotta Holmström, Associate Professor
Malmö University
Department of Social Work
Birgitta Essén, Professor
Uppsala University
Department of Women’s and Children’s Health, (IMHm)
Opponent
Claudia Merli, Associate Professor
Uppsala University
Department of Cultural Anthropology and Ethnology
Examination Board
Monica Christianson, Associate ProfessorUmeå University
Department of Nursing
Kristofer Hansson
Malmö University
Department of Social Work
Lisen Dellenborg, Assistant Professor
University of Gothenburg
Sahlgrenska Academy, Institute of Health and Care Sciences3Malmö University Health and Society Doctoral Dissertations
2024:6

Copyright Camilla Palm 2024

Paper 1 © Sexual and Reproductive Health Matters
Paper 2 © Sexuality & Culture
Paper 3 © Frontiers in Sociology
Paper 4 © Camilla Palm (Manuscript submitted)
Cover Designer: Rebecka Eriksson

ISBN 978-91-7877-471-5 (tryckt)
ISBN 978-91-7877-472-2 (pdf)
ISSN 1653-538 (Malmö)
DOI 10.24834/isbn.9789178774722
Print: Media-Tryck, Lund university, 2024

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CAMILLA PALM
NAVIGATING CONFLICTINGNORMS ON BODY
AND SEXUALITY
Exploring Swedish-Somali Women’sand Swedish Welfare Workers’ Perceptionsof Female Genital Cutting

Malmö University, 2024
Faculty of Health and Society
Uppsala University, 20245

This publication also available at:
mau.diva-portal.org

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TABLE OF CONTENTS
ABSTRACT ....................................................................................................... 11
LIST OF PAPERS ............................................................................................. 15
ACKNOWLEDGMENTS .................................................................................... 17
FOREWORD ..................................................................................................... 21
1. INTRODUCTION ........................................................................................... 23
Aim................................................................................................................. 24
Terminology ................................................................................................... 24
Outline of the thesis ....................................................................................... 25
2. APPROACHES AND RESPONSES TO FGC ............................................... 27
Definitions and variations of FGC .................................................................. 27
FGC as a global concern ............................................................................... 29
Global anti-FGM discourse........................................................................ 29
The FGM standard tale ............................................................................. 31
Critiques of anti-FGM discourse ................................................................ 32
FGC work in Sweden..................................................................................... 35
FGC as a form of honor-based violence ................................................... 35
Health and human rights approach ........................................................... 36
Social work and FGC ................................................................................ 37
3. RESEARCH ON FGC, GENDER, AND SEXUALITY ................................... 39
Gender and sexuality in contexts of origin .................................................... 39
Sexuality in context ................................................................................... 40
Social change ............................................................................................ 41
Sexual health research .................................................................................. 42
Limitations of Western models of sexuality ............................................... 43
Change of social meanings in migration ....................................................... 45
Body, sexuality, and identity construction ................................................. 45
Impact of migration .................................................................................... 46
Welfare encounters in migration .................................................................... 48
4. THEORETICAL FRAMEWORK .................................................................... 51

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The social construction of FGC ..................................................................... 51
Social problems formulations .................................................................... 51
Governing of the body ............................................................................... 53
Classifications and subjectivities ................................................................... 55
Interactive kinds......................................................................................... 55
5. METHODS ..................................................................................................... 59
Study design .................................................................................................. 59
Interviews with welfare workers ..................................................................... 60
The empirical material ............................................................................... 60
Recruitment ............................................................................................... 60
The interviews ........................................................................................... 61
Interviews with Swedish-Somali women........................................................ 62
The empirical material ............................................................................... 62
Recruitment ............................................................................................... 62
The interviews ........................................................................................... 63
Data analysis ................................................................................................. 65
Methodological reflections ............................................................................. 66
Trustworthiness ......................................................................................... 66
Interviews as co-produced ........................................................................ 67
Strengths and limitations ........................................................................... 68
Ethical considerations .................................................................................... 69
6. RESEARCH FINDINGS ................................................................................ 71
Paper I ........................................................................................................... 71
Paper II .......................................................................................................... 73
Paper III ......................................................................................................... 74
Paper IV ......................................................................................................... 76
7. DISCUSSION ................................................................................................ 79
Framing FGC as a social problem ................................................................. 79“The mutilated woman” and “the potential upholder” ................................ 80
Welfare work, health, and biopower .............................................................. 82
Health approach, prevention, and self-regulation ..................................... 82
Help and support through medical discourse ............................................ 85
Monotrait myopia in counseling ................................................................. 87
Looping effects and identity constructions .................................................... 88
Discursive change ..................................................................................... 898

Sunna-pharaonic binary ............................................................................ 90
Positioning on axes of wrong and harm .................................................... 92
Constructions of sexual responsiveness in relation to FGC ..................... 93
Becoming self-aware of FGC .................................................................... 95
Implications for practice ................................................................................. 98
FUNDING ........................................................................................................ 101
POPULÄRVETENSKAPLIG SAMMANFATTNING ......................................... 103
REFERENCES ................................................................................................ 107

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ABSTRACT

Female genital cutting (FGC), sometimes referred to as female genital mutilation,is the subject of intense debate, exposing tensions between varying cultural values
about bodies and sexuality. In Sweden, FGC is framed as a social problem
designed to control female sexuality, and national efforts have long aimed toprevent it from being perpetuated. Welfare workers have a key role in interpretingand implementing FGC politics, making the welfare encounter a site where
sometimes divergent cultural understandings about FGC, bodies, and sexuality
converge.
In this thesis, I explore how sexuality and sexual health are constructed inrelation to FGC through welfare work and from the perspectives of different
generations of Somali women in the Swedish setting of immigration. Based on
individual interviews (16) and focus groups (3) with welfare workers (24) insocial care, healthcare, and education, I investigate how FGC, sexuality, andsexual health, is approached in counseling and information targeting young
women potentially affected by FGC. Through individual interviews (12) andfocus groups (9) with Swedish-Somali women of different generations (53), I
examine how women relate to and make sense of their own FGC experiences inlight of changing social norms and discourse of FGC post-migration to Sweden.
I discuss how concepts of FGC, body, sexuality, and sexual health are navigatedand negotiated by investigating meanings ascribed to FGC by the various actors.
I also consider the ways in which the understandings of these notions arechanging depending on a complex interchange between individual experience,social interaction, and global discourse on FGC.
The thesis consists of four papers. The first two papers explore the complexityof how to counsel and address FGC in welfare encounters while having a difficult
dual role – working to protect future generations from the practice, while
simultaneously encouraging and empowering those for whom it has already been
done, without undermining body image or sense of sexual capacity. The first
paper found that a key problem is the over-reliance on medical models of
sexuality that tend to result in a reductionist focus on the genitals for sexual11

function, perhaps under-emphasizing the role of the mind, emotions, andsociocultural factors. This approach often led welfare workers to conclude that
FGC inevitably negatively interferes with sexuality and sexual health. It was also
primarily within a biomedical discourse that solutions and strategies to promote
young women’s sexual wellbeing were sought.
The second paper investigate how welfare workers understand and respond tohealth discourse about FGC, using counseling on menstrual pain as an empiricalexample. The study found that welfare workers navigate their various sources ofknowledge, where acquired FGC-knowledge worked as a lens through whichyoung women’s situations were understood. Medical discourse, and menstrual
pain in particular, was also used as a starting point for discussing drawbacks of
FGC, in order to deter young women from forwarding the practices to future
generations.
The third paper highlights how women navigate dominating discourse of FGC
in their efforts to make sense of their experiences. The study found that imageries
and dominant framings of FGC affect how women are perceived by others, or
how they expect others to perceive them, also affecting women’s selfunderstanding. Women “talked back” to and talked through expectedcategorizations and elements of dominant discourse that put women with FGC ina stigmatized position. Doing this, they reinforced categorizations of the mostextensive form of FGC (type III, pharaonic cutting) as stigmatized and harmful,while less extensive forms of FGC (type I-II, IV, sunna cutting) weredisconnected from some of the stigma attached to FGC.
The fourth paper examines subjective experiences and perceptions of sexuality
in relation to FGC. The study found that while FGC has been seen as a means tomold a tempered female sexuality in line with cultural standards for proper
gendered behavior, both gender standards and means to achieve them havechanged under influence of migration and global FGC politics. The findings
suggest that while premarital virginity remains as an important value, the external
regulation of sexuality through FGC to protect female chastity has been replaced
by increased emphasis on inner control and self-discipline. Women disqualified
previous rationales for the practice by unsettling the connection of FGC to
reduced sexual responsiveness. Many described sexual responsiveness as
inherent and not necessarily adversely affected by FGC, although experiences
varied. While most expressed positive expectations on sexual desire and pleasure,emerging was also more mixed understandings among some older and younger
women. These were associated with notions of the clitoris as significant forsexual responsiveness, causing women to question their bodily and sexualadequacy. Such understandings shall be seen in light of previous cultural ideas
about FGC as contributing to reduced sexual responsiveness, which is reinforcedin the Swedish context which emphasizes the negative impact of FGC on
sexuality.

12In conclusion, this thesis sheds light on the complex nature of FGC in a context
of immigration, particularly highlighting FGC in relation to individual care andcounseling in welfare encounters. In Sweden, FGC is framed as a social problem,
shaping how women with FGC are perceived and understand themselves.
Welfare workers predominantly address FGC from a health perspective, often
adopting a genital reductionist approach. Medical discourse plays a dual role:empowering women through knowledge while also exerting control over theirbodies, drawing boundaries of some bodies as normal, and others as pathological.
Interviews with Somali women shed light on their interactions with FGCconstructs in the Swedish context, illustrating a complex interplay ofsociocultural, individual, and global influences.

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LIST OF PAPERS

This thesis is based on the following papers, which are referred to in the text by
their Roman numerals:
I Palm, C., Essén, B., Johnsdotter S., (2019). Sexual health counselling targeting
girls and young women with female genital cutting in Sweden: mind-body
dualism affecting social and health care professionals’ perspectives. Sexual andReproductive Health Matters, 27(1), 192-202.
II Palm, C., Johnsdotter, S., Elmerstig, E., Holmström, C., Essén, B. (2022).
Adolescent sexual and reproductive health counselling in relation to female
genital cutting: Swedish professionals’ approach to menstrual pain as anempirical example. Sexuality & Culture, 26, 1-25
III Palm, C., Elmerstig, E., Holmström, C., Essén, B. (2023). The relationshipbetween dominant Western discourse and personal narratives of female genital
cutting: exploring storytelling among Swedish-Somali girls and women.
Frontiers in Sociology, 8: 1188097
IV Palm, C., Sexuality constructions in relation to female genital cutting. A
qualitative inquiry among young and older Swedish-Somali women. Manuscript
submitted.

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ACKNOWLEDGMENTS

With perseverance and relief, I embark on the acknowledgment section of thisthesis – as a start to an end of the journey of conducting this research and writing
this thesis. In this space, I extend my heartfelt thanks to those whose paths I havecome to cross on the journey. Some of you, I would like to give extra thanks.
Eva Elmerstig and Lotta Holmström, my supervisors in Malmö: I express mydeepest gratitude for your unwavering support and invaluable guidance throughthis PhD journey. Eva, for your candid feedback, infectious enthusiasm andappreciative comments. Lotta, for your sharp vision and big heart. You bothmanaged to see beyond long and colorful drafts and sense where I was heading
which helped me keep moving forward. I had fun working with you and I could
not have done this without your support. I express my sincere thanks and gratitude
for having had the opportunity to work with you.
Birgitta Essén, my supervisor in Uppsala, for inviting me into this research andintroducing me to the joy of science. I appreciate your sharpness and ability to
see the overall picture. Your pioneering work and unceasing engagement toimprove the sexual and reproductive health of women is inspirational. I also thankSara Johnsdotter for her support during the initial part of the study.
Marcus Herz and Lisen Dellenborg, for insightful comments during my halftime seminar, I thank you. I also thank Elise Johansen and Björn Johnson for yourgenerous and valuable feedback and recommendations as pre-examiners during
my final seminar. Thanks also to Pernilla Ouis and Kristofer Hansson who, as
pre-reviewers, read and commented on the manuscript at the end. Yoursuggestions helped improve the text considerably. I extend sincere appreciation
to Ylva Hernlund at Textjouren for your quick responses, meticulous editing, andinvaluable contributions in refining the texts associated with this thesis. Your
profound understanding of the research field and your ability to discern the rightnuances and tone in the texts have added a layer of precision to this work. I also
thank Rebecka Eriksson, who made the elegant cover of the thesis.
A special thanks also to my colleagues at the Centre for Sexology and Sexuality
Studies at Malmö University. I appreciate having had a forum for17

interdisciplinary discussions on sexuality issues and I am grateful for ourcollegiality. I also thank the Nordic FOKO network, which provided a space forscientific discussions and addressing intricate inquiries in this specific field of
research. To my international colleagues from the semester at University of
Amsterdam – we met in 2018 and still stay in contact and I am truly grateful forall our discussions and delving into the world of sexuality.
Zahra Abdi Mohamed, I am truly grateful for your research assistance, and ourcollaboration and friendship, for sharing joy and sorrow, and working with thejoint aim to improve the situation for young women. We have worked together
for ten years now. I hope for many more.
H* and A*, F* and M*, so as to safeguard the integrity of women you havehelped put me in contact with, I refrain from writing your names, but you know
who you are. Wax badan baan kaa bartay – mahadsanid! Thank you for all thegood laughs, heartfelt discussions, and for putting up with my repeated inquires.
A shout-out also to J*, who helped twist and turn on the FGC-issue among
Somalis in Sweden, also providing a father’s perspective on the research. I am
grateful for our collaboration.
The greatest of all thanks to all you women who participated in this study andgenerously shared your views. I hope I did you justice. Thanks also to the welfare
workers who participated in this research, sharing your thoughts and struggles tomake life better for young women. To the organizations, school nurses, andwomen who facilitated recruitment and helped with organizing the interviews
with girls and women – I express my greatest thanks.
To the past and present staff and doctoral students at Malmö University and
IMCH, Uppsala University: our joint discussions, laughter, inquisition, andsharing of everyday life events have played pivotal role in making this journey
not only endurable but also a fine one. Thank you!
Anna A, and Jonna A, my Malmö/Copenhagen-based Uppsala-team. I am
forever grateful of our discussions and for having conducted this journey withyou by my side. Anna A, for your guidance and calm support, within and outsideof academia – what would I have done without you?; Jonna A, for your warm
heart and sharp insights, thank you. Anna W, for your friendship and ourscientific discussions; Maria A, for your presence and support.
Dawan R and Jakob T, we started our PhD journeys at Malmö University
together and I am forever thankful for your support and our discussions. Dawan,
I am grateful for having shared an office with you, for your friendship, frankness,and for our stimulating discussions. Jakob, for warm laughs, for friendship andhelping me manage academic life; Ylva G, what would Bill have done without
her Bull?; Ida H, for your kind heart and your friendship.
Till mina vänner utanför akademin som upplevt avhandlingen på nära håll, somstått ut med tider av ghostande och som erbjudit rum för återhämtning. Lina K
och Josefine N med familjer, tack för er vänskap, för utflykter och rekreation.

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Daniel S och Phille L, för vår långa vänskap, höga skratt och diskussioner. Daniel
för ditt stöd och ditt lugna sätt, Phille för din uppriktighet och energi. Maria M,
för stimulerande och skrattiga diskussioner – ”hur fel kan det gå?”. Tack också
till kompisfamiljen Erik och Sofie, och till min äldsta vän Sara B som alltid stått
där när det stormat. Jag är glad att ha er i mitt liv!
Älskade mamma, den här avhandlingen är till dig. Det finns ingen ände på mintacksamhet för allt du gjort och allt du är – för mig, för mina barn. Tack för all
barnpassning, allt ditt stöd, all din omsorg och dina lugnande råd. Till mina
bröder, tack för all kärlek, våra pratstunder, skratt och nörderier. Tack svärmor
och svärfar för att ert hem fått vara en tillflyktsort och plats för återhämtning, för
barnpassning och lek. Fredrik, min klippa och min trygga hamn. Du är min
främsta källa till stöd, lugn, och kärlek. Tack för att du är du, you’re a keeper!
Mina barn, Vidar och Lo, ni är min största glädje och mening.

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FOREWORD

I came into this project about female genital cutting (FGC)1, not from the vantage
point of identifying best practices of care nor to discuss efforts to end FGC (asare common grounds for research in this field), but from an interest inintercultural sexual health encounters and the serious contemplations evoked bysuch interactions. As a social worker, I had worked primarily with non-European
immigrants. Having a Master’s degree in Sexology, I had also for several years
been engaged in sexual health classes with groups of immigrant girls, boys, andwomen. The experiences of having faced challenges in cross-cultural exchanges
regarding sexuality and sexual health intrigued me.
Teaching about sexuality, a field of knowledge engraved in controversies,
normativity, and moral opinions, poses a variety of challenges, many of which I
had experienced in my own work practice. On the one hand, with a perspectivethat acknowledges cultural differences, there is a risk of falling into
overgeneralization and culturalization, or risk cultural relativism, disconnection,and distance. On the other hand, an approach that presupposes cross-culturalsameness can fail to account for how interests, desires, values, and experiences
may differ owing to sociocultural specifics and can ultimately risk become
ethnocentric. From my work as a sex educator, I eventually came to think I had
been all too ignorant of my own bias, and of how the information to be taught
was intricately interwoven in a particularly, sexual liberal historical context. I
grappled with the questions: what knowledge and norms are produced andreproduced as desirable (and undesirable) in sexual health encounters? How candivergent opinions and knowledges be approached – with the ultimate goal beingof promoting social justice and well-being?
Within a larger project about FGC in Sweden, I was later invited to form a
PhD-research proposal focused on cultural norms and sexuality among young cut
1In the text, I use the term female genital cutting (FGC) in recognition of the potential stigmatizing

effect “mutilation” terminology may have, while also being cognizant of the politicized
implications of any and all terms used. The use of terminology will be further discussed in the next
chapter.

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women in Sweden2. I realized that issues around conflicting norms on sexuality
were highly relevant also in terms of sexual health interventions involving female
genital cutting – a practice usually deemed meaningful, at least along somedimensions, among women in practicing contexts, yet forcefully condemned inmost non-practicing contexts. The questions that had arisen from my work withsexual health encounters in their various forms eventually came to transfer to how
sexuality in relation to female genital cutting is understood and approached – inwelfare work in Sweden and among young and older women themselves, as well
as how discordant beliefs and contradictory messages about FGC are handledamong various actors in the context of sexual health.
Ultimately, this thesis engages with how young and older women from an FGC
high-prevalence context, as well as welfare workers in Sweden, navigate andreconcile complex and divergent culture-specific understandings of sexuality andsexual health along with universalizing claims of rights and concepts of bodily
harm. The results highlight the complex interplay between individual experience,social interactions, and societal norms.

2 This research was conducted within the broader project Changing attitudes toward female genital
cutting among Somalis in Sweden, headed by Birgitta Essén, professor of International Maternaland Reproductive Health, Uppsala University, and Sara Johnsdotter, professor of Medical
Anthropology, Malmö University (see Wahlberg, 2017). Questions were developed around theirprevious work discussing the impact of anti-FGC campaigns and public discourses on cut girls’ andwomen’s sexuality (see Johnsdotter, 2008; Johnsdotter & Essén, 2004).

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1. INTRODUCTION

Female genital mutilation (FGM), also known as female circumcision or female
genital cutting (FGC), refers to non-Western cutting procedures performed on
girls in absence of medical reasons. Among practicing communities, FGC is
traditionally perceived as a meaningful intervention and identity marker
associated with cultural and/or religious identity, sexual morals, enhanced
femininity, adherence to aesthetic ideals, and improved status as a woman(Abathun et al., 2016; Abusharaf, 2001; Ahmadu, 2000; Jirovsky, 2014; Njambi,
2004; Njambi, 2007; Powell et al., 2020). In contrast, in western countries thepractice is condemned and primarily understood as a form of gender-based
violence, harmful to girls and women’s health and sexuality (WHO & UN, 2008).
Immigration to such a context and subsequent encounters with discordant ideas
about FGC can call into question a bodily practice that was once normalized andassociated with positive values (Einstein et al., 2019; O’Neill & Pallitto, 2021).
At a global level, there is a broad consensus that FGC constitutes a violationof human rights, with ongoing international efforts to end it (e.g., UN, 2015;
WHO & UN, 2008). On a national level, Swedish welfare professionals, such aspractitioners in schools and health and social services, are identified as having a
key role in the government’s FGC work. They are required to provide care andsupport and to safeguard and actively promote negative attitudes towards FGC in
order to prevent future occurrences of the practice (Skr. 2016/17:10; Swedish
Ministry of Health and Social Affairs, 2018). Welfare professionals are thus
tasked with the dual role of working with both prevention and support in relation
to girls and women with FGC (Swedish Ministry of Health and Social Affairs,2018), with policies guiding their work. They are also influenced by culturespecific notions about health, bodies, and sexuality. As such, the welfare
encounter becomes the site of a social context bringing together sometimes
divergent (cultural) understandings about FGC and, ultimately, what constitutes“normal” and “abnormal,” “right” and “wrong,” “good” and “bad,” “healthy” and“unhealthy,” as regards gender, body, and sexuality.

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A core assumption in this thesis is that perceptions of body and sexuality are
inseparable from their social context (Foucault, 1976; Grosz, 1994; Hacking,2004). Accordingly, meanings ascribed to genital cutting procedures are not fixed
but are continuously reconstructed through a lens of social context. In welfare
encounters in western settings of immigration, prevailing contestations over FGC
may be accentuated. Against this background, a central question is how various
actors comprehend and navigate sometimes different conceptualizations of FGC.
What ideas, expectations, and experiences do girls and women carry regarding
sexuality in relation to FGC? And what knowledge and understandings do
welfare workers bring into welfare encounters regarding FGC? This thesis
highlights how sexuality and sexual health in relation to FGC is sociallyconstructed in the Swedish context from the perspectives of various actors. As
such, it provides an empirical exploration of how various social constructions of
FGC take shape in the context of Swedish FGC initiatives, and how these
influence individual perceptions and experiences of sexuality and sexual health.

Aim
The overall aim of this thesis is to explore how sexuality and sexual health areconstructed in relation to FGC through welfare work and from the perspectivesof different generations of Somali women in the Swedish setting of immigration.
Research questions:• How is FGC approached in counseling and information with young
women?
• How do Somali women relate to FGC and make sense of their own FGC
experiences, post-migration to Sweden?
• What meanings do Swedish-Somali girls and women and welfare
workers respectively, ascribe to FGC in relation to body and sexuality?

Terminology
To recognize the politicized nature of the language used in this field, a note on
terminology is in place. In this work, female genital cutting (FGC) is used.
Academic scholarship generally holds FGC to be the most descriptive and nonjudgmental term, although cognizant of the politicized nature of any term used.
The mutilation terminology is here avoided, in recognition of its potential harmful
effects for people not conceiving themselves as mutilated. However, when I referto the political discourse, I will use FGM for “female genital mutilation” as thisis the official term used.

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The same applies to the interviews. In interviews with women, non-normative
terms were used (e.g., female circumcision or Somali terms such as sunna,pharaonic, gudnin), if not otherwise suggested by the interviewees. As the terms
may have varied meanings among individuals (Johansen, 2022), terms were
specified to clarify what they meant, or descriptive terms were used. Among
welfare workers, I learned that avoiding mutilation-terminology risked raisingsuspicions about the research not taking seriously the possible damage women
may suffer from FGC, which is why I used the combined “female genital
cutting/mutilation” as a catch-all term. This bears witness to the politicized andemotionally charged nature of the subject in the diaspora as described by scholars
in Sweden and the US (Johnsdotter, 2012; Leonard, 2000; Njambi, 2004). Hereadoption of more non-normative language or perspectives may lead to having
morals questioned and being positioned as not-(sufficiently)-against FGC(Johnsdotter, 2012; Leonard, 2000; Njambi, 2004).

Outline of the thesis
This first chapter has introduced the aim of the research and the researchquestions. In Chapter 2, a brief introduction to FGC is provided and thereafter the
Swedish context is introduced. It discusses Swedish approaches and responses to
FGC set in relation to global FGC politics that have influenced Swedish FGC
perspectives. It also discusses how FGC has been handled as an issue for social
work. Chapter 3 discusses previous research on FGC in relation to sexuality andwelfare encounters. In Chapter 4, the theoretical approaches that have guided theanalysis are introduced, including theories on social problems formulations,
categorizations, and subjectivity constructions. Chapter 5 presents and discusses
the research methods used and methodological choices made. In Chapter 6, asummary of the findings from the four papers are presented. In the final chapter,
Chapter 7, an overall analysis and discussion of the research findings is provided,
including its implications for social work and for welfare encounters more
broadly.

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2. APPROACHES AND RESPONSES TO
FGCThis chapter begins with introducing some of the basics of female genital cutting.
I address common notions about FGC being a well-defined, unified practice andoutline some elementary differences in procedures and associated meanings.
These differences are important to recognize in order to situate the broader issues
addressed by the thesis. Thereafter, I provide an outline of the dominant global
approaches to FGC as a human rights violation, which have informed Swedish
approaches and responses to FGC. Then follows a description of the Swedish
context, how FGC work is organized, and some of the presumptions informing
the Swedish agenda on FGC. I also discuss how sexuality has been targeted inlegal reforms, prevention efforts and public health campaigns on FGC in Sweden.

Definitions and variations of FGC
Female genital cutting (FGC), to many known as female genital mutilation(FGM), is an overarching term for a range of genital cutting procedures
performed on girls in the absence of medical reasons. Operations are practiced bydifferent groups, for diverse reasons, in different ways and under varied
circumstances (UNICEF, 2013). Mainly occurring in parts of Sub-Saharan andNortheast Africa, the Middle East, and Southeast Asia, migration has made FGC
a global concern (UNICEF, 2013). The practices pre-date the Abrahamic
religions and no known origin of the practices have been found (Hosken,
1979/1993; Johnsdotter, 2012).
The World Health Organization (WHO) has developed a categorization of
FGC into four major types. This definition is widely used in policy, law, andresearch (WHO, 2023). The four types, without sub-types, are:
Type I. Partial or total removal of the clitoral glans and/or the prepuce/clitoral hood(clitoridectomy).

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Type II. Partial or total removal of the clitoral glans and the labia minora, with orwithout removal of the labia majora (excision).
Type III. Narrowing of the vaginal opening through the creation of a covering seal
by repositioning the labia minora and/or majora, with or without clitoridectomy(infibulation).
Type IV. All other harmful procedures to the female genitalia for non-medical
purposes, for example pricking, piercing, incising, scraping and cauterization.

Surveys gathering global data on prevalence demonstrate that infibulation is theleast common type of FGC (UNICEF, 2013). However, global migration
patterns have contributed to infibulation being the most common form among
immigrated women with FGC in Sweden (Swedish National Board of Healthand Welfare, 2023).
Context around the cutting procedures vary widely between different groups.
Practices have gradually become medicalized, for example being performed athealthcare facilities and/or by healthcare staff with pain-relieving medications,although it is also performed under less sterile conditions (UNICEF, 2013).
Often, parents or elders decide for their children to undergo FGC as part ofpromotion of the girl’s development according to context-specific standards as
regards gender/ethnic/religious/cultural/national identity. Sometimes, promptedby peer pressure or a desire to be part of a social group, FGC is expedited or
initiated by young women themselves (Jacobson et al., 2018; Leonard, 2000;
Njambi, 2004).
Rationales for performing FGC, as well as meanings attributed to the practices,vary between different groups: a preparation for adulthood and marriage,
perceived cleanliness and protection of sexual morals, marking of
ethnic/religious/cultural identity, seen as a marker of modernization, or all
motives combined (Ahmadu, 2000; Jirovsky, 2019; Leonard, 2021; Powell et al.,2020). How an individual relates to FGC may vary depending on a range offactors, including at what age the cutting was performed, the preparations before
and the care after, whether it was a medicalized form of cutting, and the presenceor absence of long-term health complications or other conditions (Abdulcadir,2019; Esho & Kumar, 2023; Powell et al., 2020; Schultz & Lien, 2013).
While many women in practicing contexts consider their genital cutting as
normal, there are also women who contest its alleged benefits. Many, activists
and others, have also long been devoted to its abandonment (Abusharaf, 2000;
Gruenbaum, 2020; Hodžić, 2017; Nyarango, 2016). And if the above examples
present rationales for FGC that are associated with positive meanings, individual
experiences of the procedures may still be complex and vary greatly. Drawing on

28

her research and practice at a specialized care unit for FGC-affected women, theItalian physician and FGC scholar Jasmine Abdulcadir concludes that:
The feelings, experiences and memories referred to by women during and after thisrite of passage vary from bravery, honour, social and family acceptance, social
positive feedback and success, to suffering, fear, betrayal, incomprehension andpowerlessness. (Abdulcadir, 2019, p. 24)

The great cross-cultural variations and social meanings attributed to the practices,
as well as the wide range of procedures and contexts in which FGC is performed,
make the outcomes hard to establish. These factors, among others, have made
FGC a contested issue among scholars. Still under considerable debate arequestions regarding how to interpret and understand potential physical,
emotional, or social consequences related to each type of procedure, which
terminology to use, and how to best approach procedures as varied as they are(see for example Earp & Johnsdotter, 2021).

FGC as a global concern
Although there is currently a broad international consensus that FGC in all its
forms should be abolished (UN, 2015; WHO & UN, 2008), there have been, andremain, considerable contestations over the approaches used and the terms of thecondemnation (Earp & Johnsdotter, 2021; Wade, 2012). Female genital cutting
gained international public attention in the 1970s, when the Western3 women’s
movement started rallying support for its abandonment. (Hosken, 1979/1993;
Thiam, 1983). Through radical feminist activist and scholarly engagement on theissue, an international uniform articulation of opposition against FGC emerged,
forming what has been called “the anti-FGM discourse” (Njambi, 2000; Shweder,
2005). The Western feminist perspective has greatly impacted the way FGC has
been perceived and approached since – in a global perspective, and in Sweden.

Global anti-FGM discourse
The starting point for the political congregation against FGC is often attributed
the WHO Khartoum conference in 1979. It was the first to address women’sissues and women’s subjugation on an international level (Gruenbaum, 2020;
Thiam, 1986). Particularly important to the enforcement of a national eradication
agenda against FGC, was the North American radical feminist Fran Hosken,
3 “Western” is here used to connote, not the country of origin of the actors, but the ideologies having

its roots in dominant Western, primarily Euro-American morals, norms, and values, and liberal
notions of freedom, democracy, and individualism.

29

whose publications on FGC became widely cited (Hosken, 1979/1993; Thiam,1983). With The Hosken Report: Genital and sexual mutilation of females,
Hosken popularized the term “female genital mutilation” (Hosken, 1979/1993;
Thiam, 1983).
Sexuality was particularly targeted. Hosken and her contemporaries drew on
first-hand accounts of FGC among women in Africa, with interviews conductedby themselves or others. Grounded in patriarchal theory, FGC accounts wereanalyzed as “the most eloquent expression of the control exercised by thephallocratic system over female sexuality” (Thiam, 1986, p. 60). Being a bodymodification that in many practicing contexts often is performed to induce
chastity and ensure pre-marital virginity in women, FGC is through thisperspective primarily seen as a physical and symbolic violence on female
sexuality, creating and maintaining female sexual subjugation (Daly, 1979; El
Sadaawi, 1980; Hosken, 1979/1993). In this perspective FGC is seen to lead to acompletely erased sexual capacity. Among the early literary advocacy
contributions, empirical data that complicated conclusions of sexual harm, forexample refusal among cut women to accept notions of destroyed ability to sexual
satisfaction, were disregarded as inauthentic (Hosken, 1979/1993; Thiam, 1986).
The “sexual mutilation approach” has primarily been proposed by anti-FGM
activists and the early radical feminism-oriented researchers (Johansen, 2007).
This is likely also connected to the fact that FGC became a topic of global
attention during a time when the Western women’s movement developed politics
around sexuality (see for example the "sex wars" debate in Duggan & Hunter,
2014; Rubin, 1984). Johansen (2007) notes that “a key factor here is theconsideration of the clitoris as the main location of sexual pleasure” (p. 235). The
Hite Report had recently been published, demonstrating the role of the clitoris forsexual pleasure among US women (Hite, 1976/2004). Previously, Freudian ideas
about clitoral sexuality as immature had dominated (Bell, 2005). In the 1970s,
however, a feminist’s intent on women’s sexual liberation and autonomy centered
the clitoris (Bell, 2005; Parker, 1995). Here, feminists focused on the clitoris’s
autoerotic function as a shield against compulsory heterosexuality (Hite,
1976/2004; Rich, 1980). Hence, it is not surprising that excision of the clitoris isequated with repression of female sexuality (Bell, 2005).
Within the radical feminist frame of understanding, FGC practices are seen as
inherently abusive and too abject for women to truly consent to. Women’s
involvement in the continuation of the practices is, within this framework,
understood in terms of false consciousness (Daly, 1979, p. 164) or viewing
female proponents as “locked in their culture” (Thiam, 1986). This perspectiveemphasizes a universality of experience, and early advocates stressed the needfor global sisterhood to fight against a world-wide patriarchal oppression (Daly,
1979; Hosken, 1979/1993). The targeting of FGC, accordingly, often took shape
as a missionary commission with the role of the West being to raise awareness30

among affected communities (Gruenbaum, 2020, p. 25). Efforts to promoteabandonment of the practices have within this framework focused on the potential
negative emotional, physical, and sexual consequences from FGC (El Sadaawi,
1980; Hosken, 1979/1993; Thiam, 1986).
The formation of a global uniform language and thinking employed tounderstand, describe, and approach FGC as a human rights violation have among
FGC scholars been called “the anti-FGM discourse” (Njambi, 2000). Other “antiFGM” terms have also variously been used to describe knowledge, discourse,
social movement/s, law, and/or advocacy aimed at ending FGC (Jacobson et al.,2022). An important actor in the dissemination of scientific knowledge,
definitions, policy, and guidelines regarding FGC is the WHO. The anti-FGM
discourse can be understood as global, in the sense that many countries havegathered around the WHO’s anti-FGM policy. The approach to FGC in the
Swedish context, including its relation to the global anti-FGM discourse, will beelaborated on below.

The FGM standard tale
One essential aspect of the anti-FGM discourse is the so-called “standard tale” of
FGM (Leonard, 2000, 2021). Scholars have identified how FGC, despite the greatcross-cultural variations in practices, reasons, and meanings associated with thepractices, has come to be portrayed in a now familiar way, commonplace in antiFGM work, policy papers, media reporting, and introductory sections in research(Gruenbaum, 2005; Njambi, 2007; PPAN, 2012; Rogers, 2009; Wade, 2011). The
sociologist Lori Leonard argues that this way of describing FGC has become sostandardized in its form, she has termed it “the standard tale” (Leonard, 2000,2021). It can be seen as a form of standardized package of knowledge about what
FGC is. The standard tale provides answers as to what FGC is, why it isperformed, who performs it, what its consequences are, and what it means forgirls and women exposed to it (Leonard, 2021). The sociologist Lori Leonard
identifies that the FGM standard tale:
includes methodical descriptions of the different ways a woman’s genital can be cut– or, as many prefer to say ‘mutilated.’ … What is cut, how much is cut, at what age
it’s cut, with what implement, and by whom; these are all elements of the standard
tale. So is the litany of consequences: hemorrhage, shock, infection, infertility, sexual
dysfunction, problems in childbirth, death and so on. (2000, p. 213)

In the standard tale, FGC is described as a deeply rooted cultural practice,primarily working as a means for men to control female sexuality (Leonard, 2000,
2021; Njambi, 2007). Sometimes it invokes strong images of un-sterile
conditions, rusty razor-blades, violence and coercion (Rogers, 2009). Used31

primarily in the context of abolishment, it is also strongly connected to morals.
Here is an example capturing the tone and perspectives of the standard tale in the
Swedish context. This excerpt was published in a newspaper editorial in one of
the larger national newspapers:
Last week, 50 girls had to be taken to a hospital in Burkina Faso. They had fallen
victim to ill-performed female genital mutilations. Note that the fact that thecustom even exists is bad enough but, in addition, the procedure can result in thegirl bleeding to death, something that happened to three Somali girls during thesame week … Female genital mutilation is a custom that is so cruel that it isdifficult to fully comprehend. It is believed that this abomination dates back 3,000
years … There are many reasons why the tradition is still upheld, and it is hardly
surprising that it is about the deeply deplorable belief about female impurity thathas characterized hatred against women throughout history. The mutilation will
ensure that women remain virgins until marriage. Paradoxically, they disfigure
women’s genitals in order to make them pure and beautiful. It is not only theprocedure itself, which is almost exclusively carried out without anesthetics andwith pieces of broken glass or rusty razor blades, that is torture. If you survive, youwill suffer permanent injuries. Constant urinary tract-infections, severe menstrual
pain, and a ruined sex life. [Upsala Nya Tidning, 25 September 2018, mytranslation from Swedish]In this description, more or less scientific “facts” are merged into an image about
the reasons for and outcomes of FGC. It also reveals a common element of what
the British anthropologist Melissa Parker (1995) has called a “sexual death”: thatis, the conviction that FGC prevents a young girl from ever having a gratifying
sexual life. In an international context, the epitome of this narrative would be thebestseller Desert Flower by the Somali supermodel Waris Dirie. In Dirie andMiller it is asserted that even the mildest form of FGC “will prohibit the girl fromenjoying sex for the rest of her life” (Dirie & Miller, 1998, p. 218). Variations of
the FGM standard tale can be found in a range of forums, such as advocacy
efforts, news media, fiction including best-selling novels, documentaries, andscholarly papers. As such, the standard tale is what is publicly most known about
female genital cutting.

Critiques of anti-FGM discourse
The anti-FGM discourse has not, however, been without its critiques. In responseto earlier writings on FGC, critical scholars started questioning the terminology
and language of condemnation (Wade, 2012). Not necessarily disagreeing withthe conviction that the practices must end, authors have nonetheless highlighted

32what is seen as problematic aspects. Some of this criticism is still evident, as
reviewed in a recent summary (Earp & Johnsdotter, 2021).
One point of criticism has been that anti-FGM rhetoric utilizes a top-down
perspective. With the increasing global political engagement with the practices in
the late 1970s came also scholarly interest in researching and understanding thepractices. During the 1980s and 1990s, anthropological and ethnographic studies
emerged that aimed to understand the contextualized meanings of FGC(Gruenbaum, 2020). These contributions investigated meanings attributed to thepractices in their specific contexts. These studies underscored FGC as anembodied experience not necessarily perceived as harmful to sexuality by womenin practicing communities nor as inevitably linked to erased abilities for pleasureand orgasm4 (Abusharaf, 2001; Ahmadu, 2000; Gruenbaum, 2001; Lightfoot‐Klein, 1989). In terms of women’s involvement with FGC, these studies also
focused on the complex role of women in the continuance of the practices. Theseand subsequent studies have showcased how FGC is intergenerationallytransmitted, where women may be the ones initiating FGC while men sometimes
are the strongest opponents of its continuation (Shell-Duncan et al., 2021;
UNICEF, 2013).
Against this background, some of the early Western feminist approaches have
gradually fallen from favor in academic scholarship. Although many still see thecontinuation of FGC as based in social norms including gender inequality,
patriarchal theory has been deemed insufficient as the sole analytical tool forunderstanding subjective experiences or the continuation of FGC.
With analyses informed by US Black feminist scholars and postcolonial
thinkers (Crenshaw, 1991; Hill-Collins, 2000; hooks, 1989; Mohanty, 1988),
some have demonstrated how intersecting factors such as class, religion,
ethnicity, and nation alongside gender, produce a diversity of experiences among
women (Abusharaf, 2001; Ahmadu, 2000; Njambi, 2000). Based in ethnographic
studies in contexts where FGC has been practiced, these scholars have provided
accounts demonstrating the complex social meanings attached to the practices.
The tendency in anti-FGM advocacy to dismiss such accounts as inauthentic has
led to accusations of anti-FGM politics being imperialist, using ethnocentric
perspectives, and not taking seriously the diverse voices of women (Ahmadu,
2007; Gunning, 1992; Njambi, 2004; Njambi, 2007; Obiora, 1997; PPAN, 2012).
A related point of criticism regards how people involved in the practices areframed. In analyses of Western media and advocacy representations, scholars
report a tendency to use sensationalist accounts drawing on strong images of themost damaging forms of FGC (Gruenbaum, 2005; PPAN, 2012; Rogers, 2009;
4 The pioneering quantitative study by Lightfoot-Klein (1989), demonstrated that around 90% of

the infibulated Sudanese women she interviewed, reported having experienced orgasm (on a scalefrom Always to Seldom.)

33

Wade, 2011). Here the practices and the people involved are sometimes describedusing terms such as barbaric, cruel, primitive, ignorant, and savage (Abusharaf,
2000; Gunning, 1994; Rogers, 2009; Wade, 2012). For example, in a discourse
analysis of the feminist scholarly debate over FGC, Lisa Wade (2012) finds thatin Western scholarship:
Some scholars portray people in communities that practice FGCs as cruel. For
example, implying cruelty on the part of men (and sometimes women), scholars
call FGCs ‘horror’, ‘brutal’, ‘cruel’, and ‘torture’, describes ‘unfeelinghusbands[s]’, claims that mothers are ‘keen for their daughters to experience pain…’ Indeed, FGCs are frequently called ‘inhuman’, a term that calls into question
the very humanity of those who choose it for their children. [Wade 2012, p. 37,
references in the original have been removed for readability purposes]

As has been pointed out by many, this dominant discursive construction of FGC
resonates with colonial images and civilized/savagery binaries (Carver, 2024;
Njambi, 2000; Nnaemeka, 2005). As described above, the motivation for theefforts to abandon FGC is grounded in its potential harmful effects for girls andwomen. Yet the way medical claims have been presented in anti-FGM advocacy
has also been the target of serious reservations. Primarily this relates to the
problem with conflating all types of FGC under the FGM-umbrella. Earp andJohnsdotter (2021) notes that medical claims often fail to discriminate between
types of FGC or to the academic rigor supporting particular claims; “theirseverity, their typical or likely consequences, the means by which they are carriedout, the context in which they occur, the reasons for which they are done […] oreven the capacity of the affected person to consent” (p. 197).
These contestations over FGM-politics are still under debate in the FGC
research field. At the center of this critique lies a concern that representations of
women and groups associated with FGC are being oversimplified (PPAN, 2012,
p. 19). While some writers in advocacy literature confess to a belief that “telling
the gruesome stories of FGM is necessary to wake up governments andauthorities whose role it is to protect vulnerable girls” (Omar, 2015, p. 118),
others have raised concern over the negative ramifications of the FGC-rhetoric
employed to reach recognition of FGC as a global concern (PPAN, 2012).
Some argue from the perspective of intervention efficiency, highlighting theneed to be careful to acknowledge the plurality in practices and variations in harm
“to assure that change efforts are designed to maximize respect, appropriateness,and effectiveness” (Gruenbaum, 2005, p. 430). Others highlight the risk that
dominant framing contributes to nurturing harmful and negative stereotyping ofpeople affected by the practices (Njambi, 2007). Yet others focus on the potential
stigmatizing and harmful effects of current dominant framings for self-esteem,34

body-image, and sexual self-image, which may create a new vulnerability anddouble victimization (Earp, 2021; Parikh et al., 2020).
This debate over approaches has a bearing also on the Swedish national FGCpolitics. This section has addressed some of the critical points in this debate.
Although most countries have legal bans against FGC, also subscribing to antiFGM politics as suggested by the WHO, approaches vary depending on thesociopolitical contexts (see e.g., Hodžić, 2017; Malmström, 2016 for empiricalexamples). In the next section, the Swedish approach to FGC will be discussed
and how the practice has been approached both as a health concern and as an
issue for social work.

FGC work in Sweden
As the first country in the West, Sweden in 1982 passed a specific ban on FGC.
During the decades to follow, numerous initiatives have been mediated throughSwedish governmental programs for the development of policies, advancementof prevention and prosecution strategies, and health provisions (Östergötland
County Administrative Board, 2016). These initiatives should be viewed in lightof the fact that, since the 1980s, Sweden has had a steady influx of families andindividuals who have migrated from FGC-practicing countries (Johnsdotter &Johansen, 2020), many from the Horn of Africa (Swedish National Board of
Health and Welfare, 2023).
This development has raised attention to how Swedish welfare workers mightprovide care for girls and women affected by FGC, and how society can work tochallenge the practices (Johnsdotter & Johansen, 2020). FGC-programs havesince encompassed production of guidelines and education materials, training for
professionals, awareness-raising targeting professionals and immigrant groups,
and national support for local initiatives in the work against FGC, to name a few
examples (Östergötland County Administrative Board, 2016).

FGC as a form of honor-based violence
In Swedish policy, FGC is currently organized under gender equality work andhonor-based violence. This is motivated by an understanding of FGC as one
means of protection of family honor by controlling women’s sexuality (Swedish
Ministry of Health and Social Affairs, 2018). Swedish authorities, such as social
services, use a risk assessment tool to judge risk of honor-based violence, inwhich FGC is included as one form of violence (Kropp et al., 2013). Thus, social
workers are identified as key actors in prevention and support in relation to FGC(Swedish National Board of Health and Welfare, 2022). Through government
funding for gender equality work and honor-based violence, ongoing initiatives
against FGC have been directed at various levels: at community, municipality,35

county, and state levels (Swedish Ministry of Health and Social Affairs, 2018;
County of Östergötland, 2016).

Health and human rights approach
In Sweden, government activities to end FGC are approached both as a healthand violence issue, and as one of gender equality and human rights (Swedish
Ministry of Health and Social Affairs, 2018). Activities have focused on
developing appropriate health-care and raising awareness about consequences of
FGC for girls and women among professionals and immigrant groups (Swedish
Ministry of Health and Social Affairs, 2018). This work also aims to promote andprotect human rights, including children’s right to bodily integrity.
Measures to promote human rights stressed in the Action Plan may include
promoting negative attitudes toward the practices through sensitization activities
about Swedish FGC-legislation, or information about potential healthconsequences from FGC. It also more generally entails efforts to fostering “norms
and values on which the Swedish legislation and international conventions rest”(Swedish Ministry of Health and Social Affairs, 2018, p. 8). Funding to prevent
FGC through this approach has been allocated to various children’s rights
projects and gender-equality initiatives. It includes school-based projects led byvarious actors such as school staff, social services staff, and community healtheducators, or Civil Society Organizations (CSOs) such as Save the Children or
the Swedish Association for Sex Education (RFSU). Preventive measures may
also relate to protection and safeguarding. For welfare professionals, this canentail identifying girls potentially at risk of FGC and reporting to social
authorities or the police if there is a well-founded fear that a child is at risk
(Swedish Ministry of Health and Social Affairs, 2018).
In recent years there have been changes in the Swedish political climate in the
direction of harsher punishments and a focus on “law and order.” Also efforts at
prevention of honor-related violence, including measures to prevent FGC, haveintensified (Cinthio, 2023). For example, in 2022, FGC as an aspect of honorbased violence was accentuated in school curricula (Swedish National Agency
for Education, 2024). Previously this work was included under the broader aimof school education to prevent discrimination and violation (Swedish National
Agency for Education, 2024). There is also an increased political focus on
repressive measures to prevent and safeguard young women from honor-based
violence in Sweden (Cinthio, 2023). For example, the government issued
extended authority for social services to post an exit travel ban for a girl if theyfear she risks being taken abroad for FGC. Such a ban also authorizes Swedish
authorities to withdraw passports or prohibit them from being issued (Prop.
2019/20:131).

36

Social work and FGC
Various actors work with FGC in Sweden. The government has issued three
official bodies to work with the issue; the Swedish National Board of Health andWelfare, the Swedish Gender Equality Agency and Östergötland County
Administrative Board. They are responsible for knowledge production anddissemination of knowledge to professionals and Swedish authorities. One of thebodies has since 2015 continuously provided manuals and FGC-training for
professionals (Östergötland County Administrative Board, 2016). The news
media has also been active in the FGC-debate and raising public awareness on
the issue (Östergötland County Administrative Board, 2015).
There is also a great deal of work conducted by CSOs, even when not with avery visible public profile (e.g., Swedish Gender Equality Agency, 2022, 2023).
Other important actors shaping Swedish work on FGC include medical experts
from the largest special care unit for FGC-affected women, the AmelClinic in
Stockholm, which provides specialized healthcare for women from acrossSweden. Since 2017, this clinic has also been responsible for a major national
FGC-training program for healthcare professionals, the Amel-project(Södersjukhuset, n.d.). Doctors from the clinic have been visible in news andsocial media. Two other specialized clinics are located in the second largest city,
Gothenburg, and in Uppsala, close to the capital city. They receive patients fromtheir regions.
In the Swedish FGC policy, it is explicitly stated that not only medical
professionals are expected to be important in the FGC-work, but that also social
workers, teachers, educators, and other school staff are central to government
efforts to target FGC in Sweden. These professionals are all charged with
implementing FGC laws, policies, and sensitization projects (Swedish Ministryof Health and Social Affairs, 2018, p. 12). Social workers are specificallyaddressed as key actors in protecting people from FGC and providing support for
those already affected (NCH, n.d.; Swedish National Board of Health andWelfare, 2022). In recent guidelines from the Swedish authority responsible for
the FGC issue, the role of the social services is explained thus:
Female genital mutilation is a form of violence and thus it is also the responsibilityof the social services to prevent and combat female genital mutilation and tosupport girls and women who have been subjected to female genital mutilation.
Female genital mutilation can be a part of honor-related violence but can also occur
outside of an honor context. Regardless of the context, female genital mutilation isalways a form of violence against children and women. (Swedish National Boardof Health and Welfare, 2022, p. 3).

37

Guidelines provide social workers with templates for how to ask questions about
FGC (Swedish National Board of Health and Welfare, 2022). Social authorities
are to provide social support and help girls and women in need of care to navigate
the healthcare system. To safeguard girls from FGC, preventive measuressuggested for the social services includes outreach work or counseling for newparents, including information about the Swedish ban on FGC (Swedish National
Board of Health and Welfare, 2022). Social authorities are also authorized to takea young girl into state custody if there is a well-founded suspicion that sheotherwise risks being exposed to FGC (SFS 1990:52). They are, like otherprofessionals, are also mandated to report to the police if they suspect there is arisk that a girl will be subjected to FGC.
In Swedish estimations of “girls at risk,” all girls born to a parent from a highprevalence country are deemed at risk of FGC. This includes both so-called firstand second- generation immigrants (Swedish National Board of Health andWelfare, 2023). This distinguishes FGC-work from other forms of work withviolence or vulnerability, in that the girls and women professionals encountermay be understood both as victims of violence and as potential future offenders(Swedish Ministry of Health and Social Affairs, 2018). Here a tension in thewelfare work emerges: how to balance a dual role of providing care and support
to girls and women already affected by FGC, and to prevent future occurrencesof the practices. This question of working to promote social change while
simultaneously providing social support, will be further interrogated in thefollowing chapters.

38

3. RESEARCH ON FGC, GENDER, ANDSEXUALITY

The following section provides a brief overview of how the literature has
understood various motives behind FGC as related to gender and sexuality, andtouches on how FGC is usually conceptualized within the Somali context.
Thereafter follows a review of the literature in migratory contexts, focused on
research discussing changes of perceptions in migration and gaps in knowledge.
Finally, the literature is discussed that engages with welfare encounters inmigratory contexts, and Sweden in particular.

Gender and sexuality in contexts of origin
Ethnographic research displays that FGC is not a monolithic practice. Researchin contexts where it is practiced reveals a wide range of procedures, beliefs, andunderstandings of the practices, including cross-cultural differences in how it isperformed, for what reasons, and its associated meanings (UNICEF, 2013). It
demonstrates that although women may report regretful childhood memories of
the cutting event, also recognizing the serious health risks that may be involved,
positive values may also be attached to the practices (Catania et al., 2007; ShellDuncan, 2008). These may include adhering to context-specific standards as
regards ethnic/national/cultural or religious identity and conforming to genderedideals and gendered expectations on sexuality (Ahmadu, 2000; Malmström,
2016; Nik Mat et al., 2023; Njambi, 2007; Powell et al., 2020). Studies show thatdifferent groups may not attribute all aspects equally. What aspects are attributed
value may also vary within and across generations and within one and the samefamily (Einstein et al., 2019).
Most studies investigating the motives and meanings of the practices describe
various motivations that can be connected to the construction of gender identityand attaining full womanhood (see review by Einstein et al., 2019). For instance,
women describe how FGC offers status and full membership in the community,

39

sometimes as a rite of passage to adult womanhood (Ahmadu, 2000; Dellenborg,
2007; Njambi, 2004). In many contexts, it is also perceived as a necessity for
marriage (Abusharaf, 2001; Shell-Duncan et al., 2021; Talle, 2007). In somecontexts, for example as reported in studies among Somalis and in Sierra Leone,
FGC is perceived as an instrument to feminize the body (Ahmadu, 2000; Talle,
2007; Wahlberg et al., 2019). This is in some cases linked to perceptions of theclitoris/clitoral hood as being a masculine body trait, as reported in Abusharaf’s
study among Sudanese women (Abusharaf, 2001, p. 122f; Ahmadu, 2000, 2007;
Talle, 2007). Paired with stigmatization of intact genitals, a closed or trimmed
vulva has also sometimes been described as a beauty ideal (Abusharaf, 2001;
Barnes & Boddy, 1994; Wade, 2009).

Sexuality in context
A number of scholars have highlighted that, in many regions, FGC is, amongst
other things, practiced as a way to instill sexual morals in women. In Somalia,
infibulation has, for example, traditionally been seen a means to protect girls’
virginity and signal a woman’s virtue (Fried et al., 2013; Johnsdotter, 2002; Talle,2007). Other studies show that FGC is in many places seen as reducing female
sexual libido and helping women to control their sexuality (Abathun et al., 2016;
Abusharaf, 2001; Jirovsky, 2014; Nik Mat et al., 2023). In such contexts, FGC is
understood as a means to promote girls’ development according to contextspecific standards of appropriate gendered behavior (Malmström, 2016;
Wahlberg et al., 2019).
Scholars have interpreted the idea of reduction of sexual libido in different
ways. Early Western radical feminist scholarship focused on sexual harms
described by women with FGC as “sexual mutilation” (Hosken, 1979/1993).
Most notable was the work of the physician and feminist writer Nawal El Sadaawi(1980). She provided accounts from her clinical practice in Egypt describing
women with infibulation having painful sex and problems in marriage due tosexual difficulties. In the early Western feminist scholarship, empirical data thatcountered conclusions of inevitable sexual harm were dismissed as “ignorance of
scientific information” (e.g., Thiam, 1986, p. 66ff). In this line of reasoning,
women who have undergone FGC in childhood cannot truly know what sexualpleasure is (Hosken, 1979/1993, p. 72). Later anthropological work tends tounderscore FGC as an embodied experience linked to sociocultural norms(Abusharaf, 2001; Ahmadu, 2007; Gruenbaum, 2001). This latter research has
discussed sexual experience as context-bound.
Research investigating conceptualizations of FGC in relation to sexuality in
FGC-practicing contexts is now quite extensive (e.g., Abusharaf, 2001; Esho &Kumar, 2023; Malmström, 2009; O’Neill & Pallitto, 2021). It demonstrates thatwhile a common motive for FGC is to reduce sexual feelings, excision of the40external part of the clitoris is often described as having no negative effect on
female sexual enjoyment (Abusharaf, 2001; Ahmadu, 2007; Johansen, 2022;
Malmström, 2016). Sometimes this notion is described as parallel to lack of
expectations for women to enjoy sex, as in a study among Eritreans andAustralian-Eritreans (Dopico, 2007). More often, however, this notion is reported
to exist simultaneously with expectations among cut women to enjoy sex(Abusharaf, 2001; Ahmadu, 2007; Malmström, 2016). Sometimes thisunderstanding relates to a view of female sexuality as exceptionally strong, assuggested in a study among Egyptian women (Malmström, 2016). At other times
FGC is meant to equalize women’s sexual urges with their male spouses(Jirovsky, 2019). In this context, FGC has been interpreted as serving as afunction by which heterosexual gender ideals are performed and naturalized andinscribed in the body (e.g., Ahmadu, 2007; Jirovsky, 2014; Malmström, 2016). It
has also been related to a view of clitoral sexuality as excessive and as having noessential function for sexual pleasure within marriage (Abusharaf, 2001;
Ahmadu, 2007; Malmström, 2016). An illustrative example of this view isprovided by an interviewee in Malmström’s study in Egypt referring to having aclitoris as “having six fingers instead of five” (p. 113) – the underlying meaning
being that nobody needs an extra finger (Malmström, 2016).
In many qualitative or ethnographic studies, such as Malmströms’s, women
assert that female sexual pleasure is important and self-evident (Malmström,
2016; Njambi, 2004). In their review, Einstein et al. (2019) note that “it is notcommon in cultures that practice FGC to talk of sexual dysfunction” (p. 44).
There are at least two possible ways to understand this: One is that socializationin the positive meanings of FGC outweighs any potential adverse physical sexualconsequences. It can also be that the cultural context does not provide a sufficientlanguage and conceptual framework for expressing feelings or experiences interms of sexual dysfunction. It can also be a combination of the two.

Social change
Social meanings of gender and sexuality should not be seen as static. There areseveral examples of how social meanings in contexts of origin have changed withsociopolitical processes. Decline in support for the practices have been describedin several contexts of origin (Gruenbaum, 2020; Powell et al., 2020; UNICEF,
2013). Changes in social meanings related to gender and sexuality have also been
discussed in research (Hodžić, 2017; Malmström, 2016; Nyarango, 2016). In
Somalia, there has long been reported a decline in support of infibulation, which
is otherwise common among older generations of Somali women (Fried et al.,2013; Johansen, 2022; Johnsdotter, 2002; Lunde & Sagbakken, 2014; Powell etal., 2020). Some research suggests, however, that this may be more of a discursivechange than in a factual anatomical sense i.e., sunna cutting may in practice still41

be equalized with the more extensive type III cutting (Johansen, 2022). Among
Somalis, decline in support for infibulation has been attributed to international
campaigning, local activism, and to religious leaders pronouncing theiropposition toward FGC (Powell et al., 2020). In this discursive change, sunna
cutting is perceived as associated with lesser health risks and as aligning withreligious teachings (Powell et al., 2020). In other FGC-practicing contexts, antiFGM campaigning and also modernization processes have been described ashaving enforced changes in attitudes (e.g., Hodžić, 2017; Malmström, 2016;
Nyarango, 2016).
The migration context is another example of social norms in flux that has beenfound to have an impact on attitudes towards FGC (O’Neill & Pallitto, 2021).
This will be discussed below, also pointing to current gaps in research and where
this study places itself in relation to previous research.

Sexual health research
It is now well established that FGC can be associated with negative sexual healtheffects (Abdulcadir & Catania, 2021; Bazzoun et al., 2021; Lurie et al., 2020;
Sylla et al., 2020). Yet, the research is fraught with methodological andtheoretical problems and there are several limitations with the existing data.
Reviews continuously evidence shortcomings as regards control groups,
sampling methods, sample size, and theoretical concepts/methods for analyzing
and accounting for cross-cultural varieties affecting experiences (Berg &Denison, 2012; Johnsdotter, 2018; Obermeyer, 2005; Sharif Mohamed et al.,2020). Despite these shortcomings, a few points can still be made from theaccumulated literature.
From a physiological perspective, fibrosis from the cutting, gyno-urologicalproblems, and clitoral neuroma may appear due to the cutting itself (Abdulcadir& Catania, 2021; Abdulcadir et al., 2015). These conditions may contribute togenital pain and impact sexual function (Lurie et al., 2020). Infibulation has also
been found to be associated with long-term genital and sexual pain (Taraldsen,2023). From a psychological perspective, women may suffer from painful
memories of the cutting, feel sorrow and regret over having been exposed to FGC
without ability to consent, or experience distress due to the violation of autonomy,
or not feeling fully whole as women. Such outcomes have been reported in somestudies with cut women in the diaspora expressing feelings of loss upon migrationand encounters with other cultural beliefs about FGC (Schultz & Lien, 2013,2014).
Generally, more extensive forms of FGC are associated with more adverse
outcomes (Berg & Denison, 2012; Hassannezhad et al., 2024; Johnson-Agbakwu,
Fox, et al., 2023; Obermeyer, 2005). Yet, as discussed by some scholars, the42degree of discomfort women feel does not necessarily correlate with the form of
FGC performed (Sharif Mohamed et al., 2020). As seen among women opting
for clitoral restoration surgery, a woman may display great discomfort and pain
when a minor procedure has been performed – and the reverse, a woman who has
undergone clitoridectomy and infibulation, may be without health problems andhealth complaints (Abdulcadir, 2019; Sharif Mohamed et al., 2020).
While many studies thus highlight increased health risks, and for example havefound higher likelihood of reportings of genital pain or less sexual satisfaction incomparison to uncut women in control groups (Berg & Denison, 2012; Lurie etal., 2020) other studies on sexuality among women with FGC document frequent
reports of orgasm, desire and satisfaction (Abdulcadir et al., 2016; Catania et al.,2007; Johnsdotter, 2018) or small or no statistically significant differences instudies comparing women with and without various types of cutting (Johnsdotter,
2018; Villani, 2019). For example, in a mixed methods study in Italy/US, thegroup of women that had undergone some form of FGC showed higher levels ofdesire, arousal, orgasm, and satisfaction compared to the uncut Italian control
group (Catania et al., 2007). They also found that 86% in the group of cut womenreported having orgasm often or always. Qualitative studies that have addressedsexual function in relation to FGC have provided rich descriptions of women’s
experiences. Some report on sexual enjoyment and satisfaction among womenwith various forms of FGC (Ahmadu, 2000; Dopico; 2007; Gruenbaum, 2006;
Malmström, 2016). Other studies display mixed accounts of sexual desire,pleasure, orgasm, and genital pain (Abdulcadir & Catania, 2021). The scatteredresults display some of the challenges, addressed above, in conducting researchon sexual function, pleasure and pain.

Limitations of Western models of sexuality
The Western understanding of sexual function has been informed by Masters andJohnson’s (1966) model, The human sexual response cycle. In its updated
version, by Leiblum, it focuses on four critical features in human sexual response:
desire, arousal, orgasm, and resolution. Its focus on genital activity and bodily
responses to sexual stimuli has informed understandings of sexual dysfunction in
women and men, for example as seen in the diagnostic manual for sexual
dysfunction and other mental disorders, DSM-IV (American Psychiactric
Association (APA), 2013). The linear model and resulting interpretations, as forexample used in the DSM-5, have been criticized for under-emphasizing social
context and having too strong an emphasis on genital responses (Forbes et al.,2014; Sungur & Gündüz, 2014). Although the updated version addresses
sociocultural aspects to a greater extent than previous versions, Western models
of sexuality are still recognized as being genitally focused (Sungur & Gündüz,
2014).

43

The fact that many people have had their vulvas subjected to involuntary andsurgical procedures (e.g., gynecological cancer operations, gender affirming
operations/trans-surgeries, female genital cosmetic surgeries) and still reportsexual pleasure and sensation (Bergmark et al., 1999; Goodman, 2011; Greimel
et al., 2009; Lobato et al., 2006), further illustrates the flaws of an overly genitally
focused approach. In contrast, recent discussions on sexuality recognize sexualfunction as multifaceted and contingent on a complex interplay of factors (Tiefer,2004). Recent research acknowledges how people’s sexual experience isdependent on factors that are: physiological (e.g., anatomical, hormonal, presenceof diseases or other conditions, neurophysiological), mental (e.g., presence ofshame, distress, depression or other conditions, discomfort, previous negative
sexual experiences, violence or abuse, body-image, self-esteem), relational (e.g.,partner relationship, trust), and sociocultural (e.g., taboo, sexual literacy and sex
education, gender norms, satisfaction and adaptation of cultural norms,
satisfaction in terms of conformity or transgression of gender or sexuality norms)(Basson, 2003; Elmerstig, 2012).
The limitation of this model and its narrow focus on genital function is evident
also in research on sexuality after FGC. The great range in cutting procedures andphysical and social circumstances surrounding them makes the likelihood of
potential physical and sexual outcomes difficult to establish and predict. To
illustrate: a woman who has experienced cutting may suffer from genital pain due
to the cutting (physiologically) (Abdulcadir & Catania, 2021; Lurie et al., 2020),
yet perceive the cutting as having made her more attractive, feminine, and in
conformance with standards of normalcy (psychologically) also feeling in placein her sociocultural context (socioculturally) (Catania et al., 2007; Elmerstig,
2012; Schultz & Lien, 2014).
Such a situation will arguably affect the overall subjective estimation of healthand well-being or experience of harm in relation to cutting experienced by theindividual. The sexologist and sexuality scholar Eva Elmerstig (2012) discusses
this in a model of sexual response, showing that the overall sexual response andexperience is dependent on the combination of all those factors. Outcomes
reported in studies investigating consequences for physical and sexual health willprobably also depend on the degree of acceptance of the cutting in its specificcultural context (Schultz & Lien, 2013, 2014).
Yet, although it emerges as important to acknowledge that not all women suffer
sexual problems from FGC, this does not mean that it has no impact on sexual
responsiveness, in the words of Earp “this does not mean that sex would be nodifferent if one still had one’s glans” (Earp, 2016, p. 14) It is also fully possible
to have orgasm and pleasure, yet also suffer from genital pain from FGC that canbe treatable (Abdulcadir & Catania, 2021).

44Change of social meanings in migration
Former reviews show how ascribed meanings of FGC change in migration tocountries where FGC is prohibited and/or stigmatized (Johnsdotter, 2018;
Johnsdotter & Essén, 2016). There is now a large body of literature in various
Western countries showing declines in support of FGC in the diaspora. For
example, studies in Scandinavia, the UK, and the US show that girls growing up
in Western countries are less likely to have undergone FGC than if still living ina country where FGC is customary (Akinsulure-Smith et al., 2023; Johansen,
2022; Johnsdotter & Essén, 2016; Karlsen, Mogilnicka, et al., 2019; Lunde et al.,2021). Values of FGC are also less likely to have been transferred to younger
generations raised in the diaspora, as suggested by studies in Canada and Norway(Koukoui et al., 2017; Lunde et al., 2021). Furthermore, in studies of immigrantgroups from practicing communities in Sweden and Norway, attitudes towards
uncut girls are in general positive, with men also reporting a preference formarrying uncut women (Axelsson & Strid, 2020; Gele et al., 2015; Lunde et al.,2021). Research among Somalis in the Nordic countries find continued support
for ideals of virginity and female chastity, common grounds for performing FGC(Isotalo, 2007; Johansen, 2017; Johnsdotter & Essén, 2004). However, in thediaspora, the external regulation of sexuality through FGC is found to be replaced
by increased emphasis on inner self-control, or sometimes also increased social
control (Isotalo, 2007; Johansen, 2022).

Body, sexuality, and identity construction
Research investigating women’s experiences of living with FGC in Westerncountries suggests that also understandings of one’s body, sexuality, and sense of
self may become reinterpreted in migration (Ahmadu, 2007; Johansen, 2007).
This research has primarily highlighted how a new vulnerability, or double
victimization, may be created in migration to countries where FGC is stigmatized(Berggren et al., 2006; Lien & Schultz, 2013). A small but growing literature has
explicitly addressed psychosexual well-being, sexual norms, and the construction
and reconstruction of sexual identities in relation to FGC (Ahmadu, 2007; Catania
et al., 2007; Johnsdotter, 2008; Johnsdotter & Essén, 2004; Lunde et al., 2021;
O’Neill & Pallitto, 2021; Villani, 2019; Ziyada et al., 2020). In particular, thisresearch discusses the possible impact of living in a context with a condemnatory
discourse on FGC. This research shows that internalization of new ideas about
FGC has come to shape women’s perceptions in terms of self-understanding, selfesteem, body-image and sexual self-image (Johnsdotter, 2018; Min et al., 2023;
Parikh et al., 2020).
Several studies have focused on how women may come to question thenormalcy of their bodies while living in a context where their body is atypicaland framed as mutilated (Catania et al., 2007; Lien & Schultz, 2013; Villani,45

2009). For example, FGC-affected women in studies in Sweden describe howinterviewees dealt with feelings of stigma, inferiority, and shame in relation to
healthcare staff or peers (Ahlberg et al., 2004; Berggren et al., 2006). Similar toother European studies among women seeking clitoral reconstructive surgery(Foldès et al., 2012; O’Neill, 2019; Villani, 2009; Villani, 2019), a Swedish study
shows how women with FGC kept it a secret to partners and peers, and hoped to
repair their “damaged genitals” (Jordal et al., 2022). Others hope surgery will
help restore feelings of having disfigured genitals and feeling less of a woman(Jordal et al., 2022; Jordal et al., 2021; Villani, 2017, 2019).
These studies indicate how feelings of the body and femininity may change
from being viewed as complete to impaired (Catania et al., 2007; Schultz & Lien,2014). For example, in a study among young FGC-affected women living in
diaspora, Catania et al. (2007) describe how young women’s sense of femalecompleteness “was transformed and given negative meanings: female mutilation,social stigma; they were depicted as victims of family violence and barbarity.
Their sense of beauty changed into ugliness” (p. 1675). A similar theme is raised
in a Swedish study among FGC-affected Eritreans and Ethiopians. The study
demonstrates a sense of loss in relation to sexuality, which the women attributed
to having adopted a Swedish mindset regarding FGC (Johnsdotter et al., 2009).
This research underscores the importance of psychological expectations andsociocultural norms in the interpretation of sexual experience. According to thisperspective, women learning that they are “mutilated” may, through expectancy
effect, come to expect body dysfunction and sexual impairment, potentiallyinfluencing future embodied experiences of health or sexuality (Catania et al.,2007; Johnsdotter & Essén, 2004). Overall, the tendency highlighted in thisliterature, is how some women in migration come to view themselves in terms ofbody deficiency, sexual inadequacy, and loss of identity (Johnsdotter, 2018;
O’Neill & Pallitto, 2021).

Impact of migration
As seen above, notions of FGC as disfiguring, or damaging to sexuality or femalecompleteness are not common in contexts where FGC is customary. Previous
studies has identified how change of perception as regards body, sexuality, andsense of self, are spurred by the change of social contexts – from one where FGC
is a social norm to one in which it is stigmatized (Johnsdotter & Essén, 2016).
Internalization of new ideas about FGC (e.g., that the practice is unlawful, isatypical, or messages about sexual deprivation) have been found to play a role
(Lien & Schultz, 2013). For example, having peers questioning FGC, informationin news media, or knowledge that FGC is not a norm among other women in thesame or other ethnic or religious groups seem to propel change of perceptions(Gele et al., 2015; Johnsdotter et al., 2009; Jordal et al., 2022). In research on

46

sexuality and FGC, additional factors such as having a western sexual partner,
uptake of egalitarian gender equality norms, and embracing a clitoris-centeredsexuality have also been suggested to play a role in reshaping women’s selfperception and identity (Jordal et al., 2022; Lunde et al., 2021; Ziyada et al., 2020).
The role of social networks in women’s coping with FGC in migration have juststarted to be explored (Akinsulure-Smith et al., 2023). For example, studies among
FGC-affected communities in Norway and Switzerland suggest that women incohesive networks representing social norms in the host society share more similarviews to the majority population than do women tied only to traditional networks(Johansen & Ahmed, 2021; Villani, 2019; Ziyada et al., 2020)
Qualitative studies that have compared attitudes between groups in migration,
within or between countries, suggest that identification with the social norms in
the host society, including the internalization of anti-FGM discourse, seems toplay a role in how personal experiences of living with FGC play out (Catania etal., 2007; Einstein et al., 2019; Johnsdotter et al., 2009; Villani, 2019). In a
Swedish study, Eritreans and Ethiopians expressed feeling Swedish, being wellintegrated into Swedish society and having adopted a Western view of FGC as“mutilation.” The Somali group, on the other hand, was less so (Johnsdotter &Essén, 2004; Johnsdotter et al., 2009). In terms of sexuality, they did not express
sentiments of mutilation but displayed a positive sexual self-image. The authors
hypothesize that this could be explained by the many differences in theimmigration experiences of the groups (Johnsdotter & Essén, 2004).
As a result of acculturation, being at a younger age growing up with FGC in asociety that condemns the practices seems to put younger generations at greaterrisk of developing negative body-image, self-esteem, or sexual self-view(Ahmadu, 2007; Catania et al., 2007; Johnsdotter, 2008; Johnsdotter & Essén,
2004; Malmström, 2013; Ziyada et al., 2020). One example in this direction is a
Norwegian study among Sudanese and Somali women, where the authors foundthe younger generations struggling with images of being sexually mutilated
victims (Ziyada et al., 2020). Similar tendencies have been reported in qualitative
studies among Somali and Sierra Leonean women in the US and Italy (Ahmadu,
2007; Catania et al., 2007).
While this overview may render the impression that all FGC-affected womenin diaspora report suffering from negative self-views, the research on women’s
experiences has not been that one-sided. For example, among a diverse sampleof Somalis in Norway, many report negative attitudes towards infibulation, yetseem not, overall, to have adopted a negative self-view or a view of themselves
as mutilated (Johansen, 2022). Another Norwegian study among FGC-affected
African women specifically analyzed girls’ resilience against trauma from FGC(Schultz & Lien, 2014). They found that girls had learned to cope with thepotentially traumatic cutting event as it was placed in meaningful framework ofunderstanding. Yet, they also found that some interviewees came to reinterpret

47

their experiences in light of new cultural understandings, encoding FGC as a
violation and a genital mutilation (Schultz & Lien, 2014). Schultz and Lien’s(2014) study is one of few that focus on girls and women’s resilience and coping.
Generally, more attention has been directed at healthcare needs and vulnerability
in relation to FGC.
To conclude, it has been shown from this review that migration and exposure
to Western discourses of FGC may change peoples’ perceptions also of their own
bodies and sexuality. Thus it seems that an adverse effect of adoption of antiFGM views is its potential negative influence on self-understanding and sexual
self-esteem. Yet while internalization of anti-FGM views seems to play a role inwomen’s experiences and self-perceptions, its mechanisms are not fully
understood. Many recent studies have sampled data from women opting for
clitoral reconstructive surgery, thus already being negatively inclined towards
their FGC (Jordal et al., 2022; Villani, 2019). Thus experiences in the general
population not seeking such surgeries are still not well-known.
At the intersection of different cultural understandings of FGC, questions arisethat pertain to the field of sexuality and health, such as identity formation, selfesteem, and self-perception. In what ways these questions play out is not yet fully
explored. As suggested by previous studies in practicing contexts, interpretationsof body modifications will most likely vary greatly depending on the specificsociocultural and political context in which the woman lives. It is from thisviewpoint that this study seeks to further the understanding of women’s
experiences of FGC and sexuality in a context of migration.

Welfare encounters in migration
Several studies, in Sweden and in other diaspora contexts, show that both patientsand healthcare professionals report lack of competence and knowledge in caring
for women with FGC. In terms of care and support, practitioners in Sweden often
report they lack readiness to care for women who have undergone FGC (Swedish
National Board of Health and Welfare, 2020), which has similarly been reported
in other migration settings (Reig-Alcaraz et al., 2016). Limited knowledge,
training, and lack of confidence in providing care and support in relation to FGC,
are some factors mentioned. Many practitioners also report they lack knowledgeof different types of FGC and struggle to comprehend the cultural intricacies
linked to such experiences, and how they may affect experiences of sexuality andhealth (Leval et al., 2004). Both healthcare providers and female immigrantpatients highlight issues such as distrust, suspicion, perceived discrimination, andproblems with communication regarding this matter (Carver et al., 2023; Filippi
et al., 2014; Karlsen, Carver, et al., 2019; Khaja et al., 2010; Michlig et al., 2023;
Pavlish et al., 2010). In a Norwegian study, birth clinic staff avoided broaching48

the topic out of fear it would be taboo or sensitive to women. They also based
health work on imagined ideas about perceptions infibulated women may hold,rather than clarifying them through dialogue (Johansen, 2006, p. 561).
While the extent of these challenges is not well known in Sweden, previous
studies suggest they apply also to the Swedish context. For example, among
midwives, Leval with colleagues (2004) found they grappled with their own
strong emotional responses. They also struggled to make sense of women’s
experiences when these differed from providers’ preconceived ideas about FGC.
In another study among Swedish midwives, Berggren et al., (2006) describedwomen feeling different and exposed in the healthcare encounters. Women
described being stared at and having to manage staffs’ facial expressions andexpressions of disgust. Several studies have described how women engage inemotional and cognitive preparations to manage healthcare professionals’
reactions and responses to FGC (Berggren et al., 2006; Jacobson et al., 2022).
The work women undertake to manage outsiders’ expectations on FGC in thehealthcare setting can be understood as them conducting "emotional health work”(Jacobson et al., 2022).
There are also studies pointing to situations when care and support works well.
Especially this seems to be in relation to women who have sought FGC-related
care at specialty clinics (e.g., Johnson-Agbakwu, Fox, et al., 2023; Michlig et al.,2021). A possible interpretation of these findings is that FGC-trained
professionals, in combination with a context where women have chosen care for
FGC, is associated with less friction than when FGC-affected women encounter
healthcare in general.
While much research thus has highlighted lack of competence and care inproviding for FGC-affected women, less is known about what professionals dowith the knowledge of FGC they have acquired. In light of the uncertain research
evidence on health consequences of FGC, as reviewed in an earlier section, a
relevant question is how welfare workers understand and respond to knowledge
gained from FGC training, campaigning, and information.
Whereas much is known about providers’ and women’s experiences ofhealthcare, reviews show that the role of social work and counseling for womenwith FGC is still an under-researched area (Okomo et al., 2017; Villani, 2023).
This is also true for other FGC-interventions such as education efforts, FGC
awareness raising sessions or other group activities outside of healthcare settings.
An important finding is that several studies among women opting for clitoral
surgery indicate that sexual health counseling can be helpful without any further
medical intervention being needed (Abdulcadir, 2019; Abdulcadir et al., 2016;
O’Neill, 2019; Sakr et al., 2023). This suggests that social and psychosexual
counseling have a significant role to play also considering the women who
experience problems but who do not seek medical procedures.

49

Most studies in the diaspora are conducted with a focus on welfare
professionals caring for adult women. To the best of my knowledge, perspectives
from professionals caring for young women are lacking. Yet, in the face of theresearch demonstrating that challenges in navigating and comprehending new
discourses on FGC may be even more salient among young women, the questionof social counseling and care for young FGC-affected women living in diaspora
seems pertinent to explore.
Against this background, I wanted to investigate how welfare professionals
working with young people understand and respond to FGC, with particularattention paid to sexuality issues. What knowledge and understandings do
professionals bring into the welfare encounter? How do they handle potentiallyconflicting ideas about FGC?

50

4. THEORETICAL FRAMEWORKThis chapter describes the overall theoretical approach that has informed thisthesis. Related theories and concepts that are used to elaborate and discuss theimplications of the results will also be introduced.

The social construction of FGC
The thesis is guided by a social constructionist theoretical framework. This
perspective takes that social reality, as it appears for people, is not simply natural
but is by nature socially constructed (Foucault, 1976; Rubin, 1984; Tiefer, 2004).
That is, how people interpret and perceive the world is always influenced by, andgiven meaning, in a certain social context. The theoretical approaches used in thethesis and the papers respectively, are all related to social constructionism.

Social problems formulations
In the analysis, Foucault’s concept of discourse is of guidance. Based on
Foucault’s thinking, discourse can be described as a specific order ofrepresentation that defines what a phenomenon is. A discourse becomes dominant
when legitimized through science and politics (Foucault, 1976). Dominantdiscourses form the taken-for-granted knowledge and “truth” about reality andhave tangible consequences for people as they materialize in practices when
institutionalized and set in work (Bacchi & Bonham, 2014; Foucault, 1972,1976). The Foucauldian perspective is interested in “the practices of knowledge
formation by focusing on how specific knowledges (“discourses”) operate andthe work they do” (Bacchi & Bonham, 2014, p. 174). There are always several
alternate discourses in a given context. Yet discourses are charged with different
power. Discourses become dominating when they are diffused and backed up by
governments, law, policy and institutions, say through welfare work, healthcare
systems, or educational systems (Foucault, 1976, 1991). Such dominating
discourses have more authority and validity than others (Foucault, 1976). It is in51this sense I understand the anti-FGM discourse – with its associated claims andapproaches – as a dominating discourse.
The current dominating global discourse of FGM is the result of the Western
feminist activism that rallied support for its abandonment on a global scale in thelate 1970s (Hosken, 1979/1993; Thiam, 1983). From this perspective FGC cameto be understood as health hazard and a form of men’s violence against women,
designed to control female sexuality (Shweder, 2005; Thiam, 1983). It came tobe understood as a social problem, to use Donileen Loseke’s term (2003).
Following a social constructionist perspective, what is represented as a social
problem, is not a mere question of objective conditions, but is a matter of beingsocially constructed as such. According to Loseke, who in her work explores
understandings, categorizations, and responses to societal issues, social problems
are “conditions that we believe are troublesome, prevalent, can be changed, andshould be changed” (Loseke, 2003, p. 7). The process of claims-making is central
to Loseke’s theory about social problems formulations (Loseke, 2003). Claimsmaking is the process by which a social problem is defined; describing what itmeans, who are affected, who are responsible, why it exists, and what can andshould be done about it (Loseke, 2003).
The Western women’s movement’s efforts to gain recognition of FGC as aninternational social problem that requires attention and intervention, can beunderstood as a claims-making process, that eventually resulted in the recognitionof FGC as a global concern (Hosken, 1979/1993; Loseke, 2003; Shweder, 2005;
Thiam, 1983). The claims made about FGC, as in the dominant FGM discourse
and the FGM standard tale (described in chapter 2), can be seen as package ofknowledge that describes and defines what FGC is and what shall be done aboutit (Loseke, 2003).
In Sweden, and internationally, there are now multiple actors, policymakers,
activists, scholars, and practitioners across disciplines that strive for theeradication of FGC. In the Swedish dominating FGM discourse, female genital
cutting is regarded as a form of gender-based violence and infringement onchildren’s and women’s rights. It is also considered a mutilation due to its
possible and alleged harmful emotional, physical, and sexual effects (Swedish
Ministry of Health and Social Affairs, 2018). An essential part of the constructionof FGC as a social problem in Sweden is also a belief that there is a significant
risk that girls residing in Sweden will be subjected to FGC (Swedish Ministry of
Health and Social Affairs, 2018; Swedish National Board of Health and Welfare,2023). Accordingly, the work targeting FGC has traditionally aimed both todevelop strategies for safeguarding and for developing services to help those who
suffer negative effects from FGC. Anti-FGC work has also aimed for politicaland normative change to prevent the practices from being perpetuated.
As addressed in chapter 2, there is an ongoing debate among scholars about
how the problem of FGC should be defined and represented (Earp & Johnsdotter,52

2021; Wade, 2012). Although most agree that FGC must be treated as a social
problem that must end, there is still considerable contestations among academics
over how the causes, consequences, and solutions should be described andunderstood (Earp & Johnsdotter, 2021; Wade, 2012). Following a Foucauldian
perspective, the change efforts to make FGC end, are all characterized by power
hierarchies (Foucault, 1976; Hodžić, 2017). They embed context-specific values,
where educational campaigns and anti-FGC advocacy, imbued with moral
notions and beliefs about right and wrong, seek to encourage social change in
different moral directions (Foucault, 1976; Rubin, 1984). The theory of social
problems formulations is useful to understand how particular claims, or a packageof knowledge, informs and produces certain responses (i.e., law, guidelines, andinstitutional practices) to social problems, having certain power-effects(Foucault, 1976; Loseke, 2003). Foucault have investigated how power may
operate at an institutional level regulating the body, sexuality, and health, throughwhat he calls biopower (Foucault, 1976). Below, I will develop how I understandand use this concept in the analysis.

Governing of the body
To address how power relations are produced and reproduced in the context ofhuman bodies, Foucault introduced the term biopower (e.g., Foucault, 1976). In
this thesis I approach power not as inherently negative but as evident in all
relations, and as working through various means having different effects(Foucault, 1976, 1991). Foucault identified how governments pursue different
forms of power and the ways it operates when governments seek to address anddeal with various conditions in the society (Foucault, 1991). At the heart of hisanalysis of modern institutions is how power operates, not only through legal
enforcements and social control, but in the ways in which individuals regulate
and govern themselves according to societal norms and expectations, by meansof discipline, normalization, and internalization (Dean, 2009; Foucault, 1991).
Foucault’s term biopower focuses on how institutions work to regulate humanlife through reproduction, body, sexuality, and health (Foucault, 1976). In his
book History of Sexuality (vol 1), one of Foucault’s analytical points is how
biopower works through medical knowledge, measurements, statistics, andpractices working to govern people’s bodily practices, and detect and deter theabnormal (Foucault, 1976; Lupton, 2013). As such, biopower operates bypromoting and enforcing certain norms or controlling aspects of individuals’
behavior in the context of bodies, health, and sexuality (Foucault, 1976). Central
to Foucault’s thinking about how biopower operates, is that norms and values
concerning the body and sexuality are internalized and incorporated by theindividual (Foucault, 1976). A trait in this form of governance is the anticipationthat individuals will take responsibility for and engage actively in their own

53governing whilst state agencies retreat from more direct involvement (Alftberg& Hansson, 2012; Foucault, 1976). Thus, in the quest to improve the life andhealth of a population also lies power through disciplining and normalizing
elements (Iguchi et al., 2023; Lupton, 2013). Here, welfare workers play a keyrole in regulating, surveilling, disciplining, and pronouncing what should beconsidered desired/undesired, normal/abnormal or healthy/pathological(Arousell, 2019; Arousell et al., 2017; Foucault, 1976, 1991; Mulinari et al.,2023).
Scholars from various disciplines have demonstrated how public health,
medicine, and educational systems are entwined authoritative institutions
affecting how individuals understand, perceive, and experience their bodies,sexuality, and health (Berkhout, 2014; Foucault, 1976; Hacking, 1999, 2004;
Lupton, 2013). In their Malaysian study on female genital cutting, Iguchi et al.,(2023) understands medicalization of the body as a central aspect of this form ofgoverning of FGC. Public health makes use of medical knowledge to target thehealth of a population in the society. At the level of individual care and guidance,
medical discourse and practices are directed at individuals in the context ofwelfare encounters (Foucault, 1976; Lupton, 2013). In the context of the clinicalencounter, Foucault’s analysis of the medical gaze describes how bodies areconstituted and disciplined by medical discourse (Foucault, 1976; Lupton, 2013).
In academic literature on health encounters in Sweden, the medical gaze is related
to how the medicalization of the body, through medical discourses, articulate anddefine some bodies as normal whilst stipulating others as pathological (Fioretos
et al., 2013).
With a starting point in the presented perspectives, I approach FGC work notonly as a form of solution and help, but also as a normative practice and as a siteof power and governance of the body. The Foucauldian perspective thus allows
for a critical analysis in terms of the social effects the approach produces. A
central assumption of the social constructionist perspective is that notions of what
is good or bad, healthy, and unhealthy, normal and abnormal, can never be valueneutral, but are inevitably affected by culture-specific ideas and values that areshaped through social interaction and thus will vary over time and place(Foucault, 1976; Rubin, 1984). In different societies and groups, various
discourses evolve and gain legitimacy, establishing what is perceived as normal
or abnormal, reproducing assumptions that become taken-for-granted and seen as“truths” (Foucault, 1976, 1991). From this perspective, female genital cutting andrelated societal responses are socially constructed.
The way FGC and its bodily manifestations are understood and experienced is,from a social constructionist perspective, inevitably interpreted and made senseof through a lens of pre-existing social meanings, discourses and belief-structures(Foucault, 1976; Grosz, 1994). Through this perspective, subjectivity andidentity-construction is a process of becoming, through construction,54

reconstruction, and negotiation in relation to available discourses (Foucault,
1976). Individuals make sense of themselves and others in relation to thesecategories and related assumptions (Foucault, 1976; Hacking, 1996, 2004). In thethesis I, thus, employ the social constructionist approach both in terms of how it
constructs and produces a phenomenon and associated categories, and how it
produces subjectivities and impacts social life (Foucault, 1976; Loseke, 2003).
Here it is relevant to ask what subjectivities are created and made possible
through discourses on FGC and related societal responses, and also how womenassociated with the practices respond to classifications defining them, not least in
face of changed discourses defining what FGC is in the new social context.

Classifications and subjectivities
Following Foucault’s theories on subjectivities, the self comes into being throughsystems of discourse, knowledge, and power (Foucault, 1976, 1991). This
discursive condition “precedes and conditions the formation of the subject”(Butler, 1993, p. 226). Once individuals are classified, classifications havematerial effects, shaping how people perceive themselves and are perceived byothers, thus reinforcing and perpetuating the classification itself (Foucault, 1976).
To further the analysis on how people, as agents, interact with discourses andclassifications defining them and working on them, I use the Canadianphilosopher Ian Hacking’s concept interactive kinds (Hacking, 1999, 2004).

Interactive kinds
Hacking suggests that, through the process of categorization and classification, a
specific kind of person comes into being when named and attributed certain traits(Hacking, 1999, 2004). This way, classifications make up people, he argues.
Being systems of knowledge, classifications formulate general truths about
people and who they are (Foucault, 1976; Hacking, 1999).
In anti-FGM discourse and related representations that rhetorically constitutecategories e.g. in news media, policy papers, and action plans, different kinds ofpeople are constructed (see e.g., Carver 2024 for a recent empirical example fromthe UK). The present work will focus on two kinds that are constructed in thework of defining FGC as a social problem: the mutilated woman and the potential
upholder. “The mutilated woman” is the person FGC-work intends to help. She
is the person who in the Swedish FGC agenda is constructed as “mutilated” andas a victim of violence with potential health consequences (Johnsdotter, 2020;
Swedish Ministry of Health and Social Affairs, 2018). “The potential upholder,”on the other hand, is the person FGC-work aims to protect others from and whom
the social work aims to change or influence in a direction toward abandonmentof FGC. The category responds to an understanding of girls residing in Sweden

55

being at risk of being exposed to FGC. FGC-work is distinguished from someother forms of work with violence and vulnerability in that these two kinds ofpeople may be attributed to one and the same person. That is – a girl or a woman
in the victim-construction labeled “the mutilated woman,” may also become afuture mother of daughters constructed as potentially in need of protection from
FGC. Thus “the mutilated woman” may simultaneously be constructed as “thepotential upholder.”In his work, Hacking demonstrates how classifications and the individuals
classified interact when an individual become self-aware as being of a certain
kind. Becoming into existence through classifications, interactive kinds change
the people thus classified as they bring specific ways of framing andunderstanding of one’s experiences (Hacking, 1996). Self-knowledge is central
to this process (Hacking, 1999). In empirical studies on mental health, Hacking
provides examples of how classifications work on individuals, yet are also
actively responded to by the people defined by them (Groneman, 1994; Hacking,
1999; Johannisson, 1994/2013). Hacking calls this the looping effect (Hacking,2004). Looping effect goes both ways, in that “classifying changes people, but
the changed people cause classifications themselves to be redrawn” (Hacking,
2004, p. 279). Classifications may be incorporated, internalized, and transposed
among people as agents. When people interact with classifications, they may
cause feedback effects, loops, in unpredictable ways, which calls on the category
to be modified (Hacking, 2004). Classifications may be endorsed or strongly
objected to by the person classified. They may be too narrow or feel wrong or canoffer language and frames of understanding one’s experiences of difficulties andtroubles (Hacking, 1996).
Hacking shows how classifications of people as certain kinds also operate on
people without necessarily being adopted or endorsed by the individual (Hacking,1996). When classifications are reproduced through for example legal systems,
medical care, mass media, and everyday interaction, they may influence how
people treat the classified person. Classifications can for example generate
sanctions or rewards, approval or disapproval, empathy or resentment (Berkhout,
2014; Hacking, 1996). Thus, regardless of people endorsing or refuting
categorizations of themselves, it may affect how other people think and feel about
the person so classified – changing the persons social ambience, as Hacking putsit (Hacking, 1996). Classification thus can be internalized whether endorsed by
the individual or not, as the classification is evident in the social interaction withothers (Berkhout, 2014; Hacking, 1996, 1999).
Here, the feminist scholar Sara Ahmed’s (2014) concept of associations as“sticky” can be helpful in understanding what women in the study describe as
how ideas about FGC and mutilation, as a specific kind, shape their social
interactions in everyday life and in interaction with welfare workers. In Ahmed’s
framework, sticky associations refer to the ways in which meanings and56

assumptions become attached, or stick, to people or ascribed social categories(Ahmed, 2014). Disrupting these categories may be a challenge as they areconnected to wider cultural beliefs and ideas; thus they are sticky (Ahmed, 2014).
Thus, in sum, classifications not only categorize individuals but also contributeto the formation of subjectivities by shaping how individuals understandthemselves and are positioned within society (Ahmed, 2014; Foucault, 1976;
Hacking, 2004). Subjectivities are thus produced and regulated throughcontinuous interaction between individuals and the classifications that define andgovern them (Foucault, 1976; Hacking, 2004). Here, Ian Hacking’s concept isused to further explore how individuals as agents interact with classifications thatshape and transform subjectivities, highlighting the complex interplay between
systems of knowledge, discourse, and classification. Together, the theoreticalperspectives allow for an analysis of power and agency, and how welfare workers
and women interviewed interact with, and respond to, conflicting discourses of
FGC and classification of the woman with FGC as a specific kind of person.

57

58

5. METHODSThe thesis is based on two empirical materials consisting of qualitative interviews
and focus groups with welfare professionals and with Somali girls and women
living in Sweden. In the following, the methods that have been used are presented
and discussed. The chapter also extends on methodological and ethicalconsiderations raised by the research in this particular field of study.

Study design
The study was explorative, having employed a flexible design to assess theperspectives of the participants on the topic. An inductive approach was used thatprivileges professionals’ and women’s own viewpoints, experiences, andascribed meanings. The interview process and analytical process were iterative;that is, data collection and initial analysis were conducted simultaneously, withthe preliminary analysis informing subsequent data collection.
A combined method was chosen, encompassing individual interviews andfocus groups, in the thesis together referred to as “interviews.” While focus
groups aimed to provide knowledge about social norms, individual interviews
provided more detailed accounts of participants’ experiences and beliefs(Lambert & Loiselle, 2008). In focus groups, group interactions may accentuateshared and contested opinions through “interaction data,” providing additional
information on prevailing conventions and social norms (Duggleby, 2005). Focus
groups were also useful for eliciting a range of perspectives and experiences, as
they stimulated participants to reflect upon perspectives and experiences ofothers, which they might not have thought of themselves raising (Lambert &Loiselle, 2008). In this way, the combination of the two methods allowed for thegeneration of complementary data, with focus groups shedding light on important
themes that were then further elaborated on and contextualized in individualinterviews.
Interviews and focus groups were semi-structured with open-ended questions,which allowed for predetermined themes to be explored while still providing

59

opportunities to explore themes from the interviews as they arose in the course of
the study. Basic interview guides were used, containing the broader themes
addressed. The guides were revised and adjusted as the study progressed.

Interviews with welfare workers
The empirical material
Twelve individual interviews and three focus groups of three participants eachwere conducted. In total, twenty-four professionals (Paper I = 20 and Paper IIfour additional = 24) were interviewed between 2016 and 2020. One professional
participated both in an individual interview and a focus group. Participants weresocial workers, nurses, midwives, physicians, and health educators[utbildningssamordnare] who worked as generalists in various settings such associal services, child residential homes, youth clinics, primary care, and schools(Table 1). They were recruited from across the country. None of the participants
were from a country where FGC is customary. Participants worked with young
people aged 13-23 years, a few only with minors, whereas most encountered bothyoung women who are minors and women over 18. Eligible to participate were
welfare professionals working with young women, who in their work had someexperience of providing information, care, or support with regards to FGC.
Hence, all had some experience with discussing FGC with young women.
Recruitment
Most young women with FGC in Sweden were subjected to FGC prior to
migration (Swedish National Board of Health and Welfare 2023). Recruitment
was therefore intentionally directed at professionals working with migrant youth
or in areas with a significant migrant population. Various channels foradvertisement of the project were used. In most cases, participants were recruitedwhen I advertised the project at interdisciplinary seminars or meetings addressing
sexual and reproductive health and rights issues including violence against
women. One seminar was arranged by Malmö University within a recurring open
seminar on sexuality studies for professionals. Two seminars were arranged byinterdisciplinary networks at the municipal level. A few participants were
snowballed. Many were also recruited through emails sent to professionals
working with migrant youth. I accessed their contacts by searching on the internet
for email-addresses to organizations working with youths and young migrants.
In cases where people declined to participate, lack of experience in broaching
the topic was mentioned. A few also cited that they did not work with affectedgroups. Most in the sample had taken part in some form of FGC-training, which
stands out by national comparison (Östergötland County Administrative Board,60

2016). It thus seems that the study has attracted those with a vested interest in theissue. It probably also reflects the recruitment strategy targeting professionals
working with migrants. In the Swedish context, education in honor-based
violence where FGC is included has continually been offered professionals who
work with migrants (Östergötland County Administrative Board, 2015).

The interviews
Interviews were typically carried out at the participant’s workplace or by phone
if preferred by the interviewee, also partly owing to restrictions during the covid
pandemic. Studies comparing in-person interviews with phone interviews withinsocial science, have found that for most part, little difference in quality of theinterview can be seen (Johnson et al., 2021; Novick, 2008). The most salient
difference and benefit of in-person interviews seems to be in terms of more turntaking and probing (Johnson et al., 2021). In-person interviews thus potentiallyprovide more depth and richness relative to telephone interviews (Johnson et al.,2021). As part of a larger empirical material, I do not consider the remoteinterviews to have been a hindrance for the understanding of the phenomenon asa whole. Focus groups were used to generate knowledge about general opinions
and beliefs among the professionals. Two focus groups were, however,characterized by less interaction, greater interviewer involvement, and “thin”
interactional data. This was the case when participants were unwilling to attend
individual interviews, or otherwise preferred group interviews. They also tended
to state that they lacked experience with FGC, which might explain the preferenceof participating in group.
A basic interview guide was used as starting point for the conversations.
Interviews focused on professionals’ FGC knowledge and training, when andhow they had broached the topic in encounters with young women, and examplesof challenges and strategies used. Focus groups lasted for 1.5-2 hours andindividual interviews ranged from 60 to 80 minutes. All but one interview wasaudio-recorded and transcribed. During the interview that was not recorded, notes
were taken, and the interview was summarized immediately afterwards.
Table 1. Composition of participants according to profession and workplace (n)SchoolSocialHealthcare
Countyservices
level

Total

Medical providers
12
1
3
16
(nurse/midwife/physician)Social worker
1
5
6
Health educator*
1
1
2
Total
24
* Health educator refers here to people who coordinate intervention programmes[utbildningssamordnare], including FGC education targeting immigrant groups and professionals
at either local or county level

61

Interviews with Swedish-Somali women
The empirical material
I conducted nine focus groups and twelve individual interviews with a total of
fifty-three young and older Swedish-Somali. Included in the study were
immigrated Somali women fifteen years or older. Participants had varied
backgrounds in terms of age, education, occupation, and duration of time in
Sweden (Table 2). Ages spanned several generations, from women in their midteens to those in their sixties. Some had lived in Sweden for several years, others
had recently migrated there. Most had lived in Sweden between 2-8 years, while
women well-established in Sweden were fewer. Women were born in Somalia orin neighboring countries and were calling themselves Somalis. Interviews wereconducted between 2014 and 2022. This period includes a pilot-study in 20142015 among unmarried Swedish-Somali women, 15-25 years old. Interviewing
for the PhD project started in 2016 and was later extended to include also older
women to allow for comparisons between different generations of women.
Different generations of women were included to investigate how differences ofage, point of immigration, and marital status (as proxy for sexual experience) may
generate diverse experiences from the viewpoint of the research questions.
Recruitment
Snowball sampling was employed and multiple strategies and contact points wereused to reach participants of different ages and with varied experiences and life
circumstances. Efforts were made to include people of diverse ethnic
backgrounds as this might have provided valuable insights into how aspects suchas previous sexual scripts and the sociocultural context of immigration intersectwith perceptions of sexuality and FGC in the new context. However, after having
spent some time trying to establish contact with various stakeholders, only Somali
women had responded affirmatively to the contacts. Thus, I eventually zeroed inon women of Somali background. Initially, some time was also spent meeting
young Somali women born in Sweden, whom parents had referred to me, but as
it became apparent that most had not heard about genital cutting of girls and theirparents confirmed that they themselves had chosen not to talk to their children
about FGC, I decided to limit recruitment to immigrated Somali women.
Access was obtained through various approaches to making contact withstakeholders who could spread the word about the research in their networks. In
most cases, prospective participants were invited into the study by Swedish
and/or Somali female representatives at three Civil Society Organizations. One isa Somali community organization working to improve the situation for young
Somalis in Sweden. Another is an organization for immigrated women, and thethird is a youth organization working with support and awareness-raising in

62relation to FGC. The organizations are located across the country andrepresentatives were identified using my professional network. The womenhelped with recruitment employing snowball sampling (Atkinson & Flint, 2001).
Yet others were approached through personal contacts. Young participants wereadditionally recruited with the help of school nurses or a Somali-speaking
research assistant.
A known risk with snowball sampling is the possibility of gatekeeper bias
(Bloch, 2007). One such bias could be clan affiliation – known to be ofimportance also among the Somali diaspora in Sweden and elsewhere (Isotalo,2007; Johnsdotter, 2002). By using varied entry points into the studied
community, also recruiting people across Sweden, I aimed to limit the possibility
for selection bias that can result from snowball sampling (Bloch, 2007).
Table 2. Participants, (n=53)
Sociodemograpic characteristics

Number of participants

Age
15-25
25-35
35-45
45-55
55-65

19
10
11
6
7

Place of residence
Large city
Medium/small city
Rural village

12
30
11

Occupation
Employed
Student
Retired
UnemployedUnknown

12
9
1
9
22

Years of resicendy in Sweden
<1
1-5
6-10
11-15
>15
Unknown

6
17
11
3
3
13

The interviews
Interviews were conducted in-person at premises frequented by the Somali
women, often at CSOs or sometimes at private rooms in public libraries.
Individual interviews took around 60 minutes and group interviews ranged from
1.5 to 3 hours. Focus groups contained 2-7 participants each, except for one where63seventeen women unexpectedly showed up. Some interviews with young women
were performed in a dyad, here called a focus group. This was due either to anindividual preferring to be interviewed together with a friend, or to otherparticipants not turning up to a planned focus group. Some of the womeninterviewed individually had also participated in focus groups.
While the group interview with seventeen older women provided vivid
discussions and several perspectives at one and the same occasion, the large sizeof the group came at the expense of ability to moderate, translate, and elicit
perspectives from all participants. A combined method where some women
afterwards took part of individual interviews helped contextualize themes fromthe group interviews and let other perspectives come forward. On the other end,
some focus groups with young women resulted in only two participants due todropouts, what in the focus-group literature has been called a dyadic interview(Morgan et al., 2013). The dyadic interviews did not provide the private context
of an individual interview, which may have contributed to information being
withheld that otherwise might have been shared (Morgan et al., 2013). These
interviews, however, often turned out to be rich in descriptions, probably because
participants had room for elaborating on their perspectives, yet also were
informed by input from the other participant. Thus, dyadic interviews sharesimilarities with the focus group where participants “co-construct their versionsof the research topic” (Morgan et al., 2013, p. 1277), although not providing
information about shared social norms, as many of the other focus groups did.
Most focus groups were conducted with younger and older women separately.
The people who assisted with recruitment helped plan and organize the focus
groups. They also acted as interpreters during focus groups held in a mix of
Swedish, English, and Somali. They translated simultaneously or madesummaries during discussions. One of them also acted as an interpreter during an
individual interview held in Somali. In one focus group a professional interpreter
who was known to the women was used.
Interviews followed a semi-structured interview guide and focused on
women’s understandings of sexuality in relation to FGC. Questions on FGC
included: previous knowledge and information, perceived advantages anddisadvantages, perceptions of FGC pre- and post- migration, and FGC in relation
to marriage and sexuality. In interviews with young unmarried women, vignettes
were also used to facilitate elaboration on the topic. Former research has foundvignettes to be a useful method for discussion on topics when participants maylack personal experiences (Barter & Renold, 1999). Allowing for reasoning froma depersonalized perspective, vignettes are also suitable in the study of sensitive
topics, as participants can chose what information to disclose (Barter & Renold,
1999, 2000).
Four vignettes were composited and covered aspects such as marriage,
sexuality, and body ideals, and related changing norms upon migration. These64

were drawn from real cases in Swedish newspaper articles or excerpts fromresearch among young Somali women. To verify that the stories were seen as
meaningful and made sense to the interviewees, vignettes were piloted andrevised thereafter. This also served to check if the follow-up questions were able
to stimulate discussions in a direction that was relevant for the research questions.
One example of the final vignettes used is provided in Paper IV, here is anotherexample:Leylo is 21 years old and lives in Sweden. She has been sad lately because her
relationship recently ended with her Somali boyfriend. She is careful to say [to thereporter] that they never had sex. She explains “He never tried. It was good. He
knows how it is with us Somali girls.”

Vignettes were introduced at the end of the interviews with young women to
allow for further elaboration on the themes. By using vignettes which lack details,
participants are allowed to fill in the gaps, which may expose important
information on taken-for-granted ideas.
All but two interviews were audio-recorded and transcribed in full. Whenparticipants preferred not to be recorded, detailed notes were taken andsummarized immediately after. Transcription followed the principle of whatmight be called interactional transcripts, detailing also the tone and social
interaction between participants and interviewer.

Data analysis
The four papers are focused on different aspects of the overarching researchquestions, by looking at how participants understand and navigate divergent
understandings of FGC and its implications for women’s sexuality and sexual
health. Focus was directed to the ways meaning of these notions were ascribed,
navigated, negotiated, and influenced by various sources of knowledge.
Qualitative techniques for data analysis were used (Alvesson & Sköldberg, 2018;
Braun & Clarke, 2006). The analytical work was conducted in parallel with thedata collection, and preliminary themes and tentative analyses have been further
interrogated in subsequent interviews and then developed and refined in theprocess of writing.
Analysis was inductive, and broadly followed procedures of inductive thematic
analysis as described by Braun and Clarke (2006). In a first step, transcripts wereread repeatedly, and aspects related to the research questions as well as otherrecurring themes were coded using a broad range of codes. Codes were groupedby topic, forming sub-themes and overarching themes. All transcripts weresearched with a particular focus on the different ways they relate to sexuality and65

FGC. In this process of interpretation, I focused on three broader themes in theinterviews with welfare workers and Somali women. These themes, including
sub-themes, were: 1. Information and knowledge of FGC (e.g., information,
education, experiences, talk-silence) 2. Perceptions of FGC (e.g.,advantages/disadvantages of various types of FGC, morality, social norms,
stigma) 3. Meanings for marriage and sexuality (e.g., sexual responsiveness,
marriageability, virginity).
In line with the social constructionist perspective, empirical data wereapproached as representations of lived reality, that is – divergent perspectives andinterpretations that draw on varied discourses and which constitute and shapesubjectivities and social realities (Alvesson & Sköldberg, 2018; Herz &Johansson, 2013). Analytical attention was focused both to the content of thestatements and the movement between varied subject positions the interviewees
assumed in their talk, and what discursive resources they drew on (Gubrium &Holstein, 2009; Plummer, 1995).

Methodological reflections
Some methodological considerations have already been touched upon. Here
aspects such as the role of the social context and the role of the interviewer is
expanded on.

TrustworthinessIn terms of ontology, the study is anchored in an understanding of knowledge associally constructed (Foucault, 1976). It suggests that there is no pre-existing
unmediated “truth” to be discovered by the researcher but emphasizes thatknowledge is always (co-)produced, interpreted, and represented (Alvesson &Sköldberg, 2018; Foucault, 1976). In line with a social constructionist approach,qualitative research asks whether the research is coherent, with trustworthy andtransferable interpretations. One aspect of academic rigor is whether the researchis transparent (Stahl & King, 2020). This can be achieved by using quotes anddescribing the coding process that guided the analysis and selection of quotes. It
is my intention to have made the analysis and interpretations transparent. Anotheraspect is how the research relates to findings and interpretations in former studies,so called triangulation (Stahl & King, 2020). This means comparing andcontextualizing findings in relation to previous studies. In this particular study, itmeans offering tentative hypotheses or explanations for the findings that bothconfirm and diverge from conclusions in previous research (see Discussion inchapter 7).
The research may also reach for transferability, that identified patterns
described or theories developed are applicable also to other contexts (Stahl &66

King, 2020). This can be checked by setting the results in relation to other study
contexts. In this thesis, I have aimed for developing concepts or hypotheses thathave such theoretical transferability.

Interviews as co-produced
From a social constructionist perspective, the social context of interviewing iscentral to the interpretation of the interviews. According to Hammersley andAtkinson (2007) “interviewees’ conception of the nature and purpose of social
research, of the particular research project, and of the personal characteristics of
the interviewer may, therefore, act as a strong influence on what they say, andhow they say it” (p. 176). In the context of FGC being a criminalized andstigmatized phenomenon in Sweden, the matter of self-representation is salient in
the research. In addition, there is a dominant discourse of what FGC is, also
adding to the foundation against which the interview accounts are told. This may
have affected the interview situation both with welfare professionals and withwomen, and is an aspect I have been cognizant of during the analysis andinterpretation of the data. In interviews with professionals, a sharedunderstanding of FGC was often assumed. Sometimes it meant interviewees
leaving out details or stating, “well, you already know how it is.” I handled thisby, for example, stating an interest in learning from the welfare worker’s
experiences and perspectives, or asking what information they have found useful.
With FGC being both stigmatized and an indictable practice in Sweden, there
is a possibility of social desirability bias in interviews with people associated withthe practices (Johansen, 2020). A Norwegian study has compared data conductedby researchers positioned either as “insiders” or “outsiders” (Johansen, 2020).
The author concludes that “cultural positionality may affect study findings,
though probably to a limited extent” (Johansen, 2020, p. 210). Instead, an
important factor affecting how FGC was presented, was the motivation of theinterviewees to reduce risk of stigma and moral condemnation in relation to thewider Norwegian society (Johansen, 2020).
In the present study, me being regarded as an “outsider” often encouraged
participants to detail their reasoning and contextualize their experiences. Women
related their responses to popular images in news media associating Somalis with
FGC affecting how FGC was presented during the interviews (cf. Johansen, 2020;
Wahlberg, 2017). I interpret this as stigma-management in relation to their selfrepresentation, both in relation to me as an interviewer and to the wider society(see Research Findings and Discussion in chapters 6-7). Following the theoreticalperspectives employed in this thesis, I also understand this crafting of accounts
as a social activity related to subjectivity and identity formation (Herz &Johansson, 2013). In striving for coherence, people need to negotiate theiraccounts in relation to the listener in order to appear as an intelligible and morally67good person – in the eyes of themselves and the other (Linde, 1993; Loseke,2007). When people relate accounts, these are regulated by conversational andsocietal norms and are always told in relation to what is expected to be common
knowledge (Gubrium & Holstein, 2009). They are also told in relation to power
hierarchies and in relation to a future audience (Gubrium & Holstein, 2009;
Plummer, 1995).
In social science research, it is widely recognized that dominating discourses
can have an impact on what experiences people find possible to express (forempirical examples and extended discussion see Denzin, 1985; Loseke, 2003,
2007; Plummer 1995). It typically takes special efforts to account for experiences
or perspectives assumed to be too out of line, or that previously have not beenrecognized (Plummer, 1995). Here, the role of the interviewer, who probes,
interrogates, and coaches, as well as what interviewees take the interviewer torepresent, plays a part (Hammersley & Atkinson, 2007; Plummer, 1995). Being
cognizant of this, I made efforts to offer room for a range of experiences to be
expressed. For example, interview questions were constructed to allow for several
possible meanings and experiences to come forward. This could be an open-ended
question such as: “People I have talked to have said… others have said … what
do you think?”. Also vignettes were intentionally vague in order to encourage
participants to fill in the gaps. Yet, as suggested by the Norwegian study, the social
context and assumed intentions and perspectives ascribed to the researcher may
still affect how experiences are expressed (Johansen, 2020). This might explain
why few expressed condoning attitudes toward sunna cutting, while quantitative
studies have found some support or acceptance of that type of cutting among
Somalis in Norway and Sweden (Gele et al., 2012; Wahlberg et al., 2017).

Strengths and limitations
A strength of the study is the diverse sample of Swedish-Somali women, also
including young women. However, additional background information regardingclass and clan-affiliation would have been useful to deepen the analysis. Also,
efforts failed to include women with (a stated) non-heterosexual identity.
Organizations for queer migrants were contacted, yet resulted in no interviewees.
Relying on gatekeepers for recruitment might mean an under-representation of
women not cohesive in social networks (Atkinson & Flint, 2001; Van Meter,
1990). The recruitment strategy also resulted in many focus groups consisting of“natural groups,” that is, a group of friends or acquaintances (Leask et al., 2001).
A limitation of natural groups is that group conformity may be more accentuatedin comparison to constructed groups (Leask et al., 2001). This may have resulted
in less divergent opinions than if participants were intentionally selected for theirvaried opinions. Yet, instances of silences and agreements were also taken as
important interactional data that contribute to the understandings of social norms

68

(e.g., Acocella, 2012; Duggleby, 2005). Focus groups were typically chatty andanimated, often with lively discussions expressing divergent opinions. Individualinterviews on the other hand provided more depth and detail, letting lessdominant perspectives and experiences come forward. Individual troubles theinterviewees related to FGC were also aired to a greater extent in the individualinterviews (cf. Johansen 2020). Here, a strength of the study was the combined
methods used.
Not sharing a common language has also created a limitation. Many preferredspeaking Somali, and conducting interviews in Swedish and English may havecompromised the meanings and nuances intended by the interviewees. Relying
on interpreters for translation also reduced the flow and interrupted interactionsin the conversations. In focus groups, not sharing the same language also made itdifficult to follow threads in discussions that sometimes occurred simultaneously.
Having translators known by the interviewees might also have had the benefit ofengendering trust. In Sweden, distrust is otherwise a recognized problem whenusing formal interpreters in discussions of sensitive issues (Gustafsson et al.,2022).
Among welfare professionals, those working with young women who had
recently migrated to Sweden were over-represented. Perspectives from those whohave discussed the topic also with other young women could have added
perspectives to the research questions; for example, if professionals have raised
the issue also with girls born in Sweden, sometimes called second generation
immigrants, or professionals providing help or information to immigrated young
women who have been in Sweden a longer time.

Ethical considerations
In conjuncture with several scholars, I maintain that research ethics are best seen
as a continuous process of evaluation and negotiation by the researcher/s during
the entire research process (McAreavey & Das, 2013). These ethical evaluations
extend well beyond the initial ethical decisions in the development of a study.
Some of these decisions and negotiations made in this project have already been
touched upon, other will be elaborated on in this section.
Maintaining participants’ integrity has been paramount in the research.
Information about participants’ location has been withheld although it could haveprovided important contextual understandings. Other information that could
endanger the confidentiality of a participant has also been left out or changed in
the transcribed and presented material. All have been given pseudonyms. If
interviewed both individually and in group, participants have been given different
pseudonyms to limit the possibility of identification by other group participants.

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A well-known risk with focus groups is the problem of confidentiality duringgroup interaction (Leask et al., 2001; Morgan et al., 2013). Mindful of this,questions were posed on a generalized level to reduce risk of disclosure of
personal experiences. A related question is that of audio-recordings. When
women were unwilling to be audio-recorded, as was the case in one individualinterview and one focus group, careful notes were taken. This has possibly
created distance in the interviews and come at the cost of focus and flow in theinterviews.
In terms of the formal aspects, ethical vetting was not a requirement for the
study involving professionals, according to the Swedish Ethical Review Act. This
is normally the case in studies focusing on professional’s work practices in
Sweden. The study among young and older women required ethics clearance
from an ethics review board. Initial ethics approval was provided for a study
including young women (Dnr 2014/620). The project was later extended toinclude more young participants and also older women, and a new ethics
clearance was provided (Dnr 2020-00724; Dnr 2023-03890-02). Verbal informed
consent was obtained from the participants at the beginning of all interviews,
which were audio-recorded.

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6. RESEARCH FINDINGSThis chapter presents the results from the articles included in this thesis,
describing the main arguments and findings from the respective articles.

Paper I
Sexual health counselling targeting girls and young women with female
genital cutting in Sweden: mind-body dualism affecting social and healthcare professionals’ perspectives. Published.
This article explores the problems of how to counsel and address FGC while
having a difficult dual role – working to protect future generations from thepractice while simultaneously encouraging and empowering those for whom it
has already been done, without undermining body image or sense of sexual
capacity. Informed by semi-structured interviews (12) and focus groups (3) witha total of 20 professionals working as healthcare professionals, school nurses,
social workers, and health educators [utbildningssamordnare], the study shows
the struggles the interviewed professionals are having to find a good balance
between their desire to be compassionate and helpful and their lack of clear
understandings of the facts around sexual issues the cut young women might face.
The matter of FGC exposes tensions between varying cultural ideas about
bodies and sexuality. These tensions are brought to the fore in settings where
professionals provide sexual counseling to young women with FGC in Western,
multicultural societies. In Sweden, professionals are required to work with bothsupport and prevention in relation to girls and women with FGC (Swedish
Ministry of Health and Social Affairs, 2018). Support may include providing
counseling on sexual or other health matters, making an assessment of whether ayoung woman is in need of medical care or social support, finding proper
treatment, and/or making a referral to other resources. Prevention, as stated in the
Swedish Action Plan, may entail promotion of negative attitudes toward FGC,
informing about FGC legislation, and/or reporting suspected cases of child abuse71to Swedish authorities (Swedish Ministry of Health and Social Affairs, 2018).
Sometimes a girl in need of help and support may herself be a young mother or afuture mother; thus she may also be a target of prevention measures. The
professionals need to navigate these manifold undertakings, finding a balance
between working to promote well-being among those who have already been
subjected to the procedure while not condoning the practice.
The study found that a key problem is the over-reliance on medical models of
sexuality that tend to have a reductionist focus on bodily functions (and thegenitals specifically), perhaps under-emphasizing the role of the mind, emotions,and the sociocultural environment. For example, the genitally focused approach
often led professionals to conclude that FGC precludes sexual functionality. It
was also within a biomedical discourse that solutions and strategies to promote
girls’ sexual well-being were sought. In efforts to promote sexual well-being inyoung women with FGC, this body-focus led professionals to (i) avoidance of thesubject, as FGC was seen as irreversibly damaging to sexuality; or, more often,(ii) providing brief information about possible future sexual complications; (iii)suggesting repair of what is lost (i.e., defibulation surgery, or sometimes clitorisreconstructive surgery); or (iv) to inform about clitoral anatomy and clitoral inner
structures and possibilities of sexual pleasure in terms of exploring the capacities
of one’s own body.
The results showed professionals must handle a stressful balance between
being empowering and working preventively against FGC. Diagnosis andsuggested treatment were often based on brief consultations and without physicalexamination. The results show a tendency to negligence on professionals’ part to
explore women’s own experiences and perceptions. This may potentially open up
room for professionals’ projecting their own perceptions, albeit unintentionally.
The limitations of the current sexuality discourse and genital reductionism were
evident in situations where professionals encountered other ideas, for example inrelation to young women hesitant to defibulation surgery. Here, their available
frames of reference did not provide sufficient guidance for adequately
understanding the young woman’s situation as subjectively experienced. The
study concludes there is room for improvements regarding the actual listening to
the girls’ own stories and experiences.
The final discussion highlights the implications for health policies andsupportive interventions. There has been a decades-long global public discourse
condemning FGC, and efforts aimed at its abolition/eradication often highlight amultitude of possible adverse health outcomes from FGC, including messages
about erased sexual function. As noted by the participants, few representations
exist that provide girls, women, or professionals with positive examples of how
sex can be pleasurable also after FGC, although there is a lot of research insupport of this (Berg & Denison, 2012; Esho & Kumar, 2023; Johnsdotter, 2018).
The article concludes that a genital reductionist approach might work well if the72interpretation of the young woman’s situation is shared between them andsupportive measures are accepted by the young woman. Future policy making in
the field of sexual health among young women with FGC would benefit fromtaking a broader holistic approach to sexuality. Professionals need to find ways
to work with support and empowerment on the one hand, and prevention on theother, without evoking body shame or feelings of loss of sexual capacity among
those affected.

Paper II
Adolescent sexual and reproductive health counseling in relation to female
genital cutting: Swedish professional’s approach to menstrual pain as anempirical example. Published.
Based in individual interviews (16) and focus groups (3) with welfare workers(24), this article explores how professionals relate to acquired knowledge about
FGC, using counseling on sexual and reproductive health matters as the context
of exploration.
Welfare workers in Sweden are urged to acquire knowledge about possible
negative sexual and reproductive health effects of FGC in order to tackle
prevention and care in relation to the practice. The purpose, according to the
Swedish guidelines, is manifold: In being mindful about symptoms related to
FGC, professionals can identify girls and women in potential need of care andsupport. They will also be able to identify potential illegal instances of FGC,
and/or to sensitize on the possible harms of FGC to prevent future occurrences ofthe practice. Meanwhile, however, scholars have cautioned that many popularbeliefs about health risks rest on inconclusive evidence, partly owing to thechallenges in accounting for the complex interplay of physical, mental, relational,
and sociocultural factors affecting subjective experiences of health, ill-health,sexual pleasure and pain.
The way professionals understand and respond to health information about
FGC has in this context largely been left unattended. This paper investigates theseissues from the viewpoint of welfare professionals’ encounters with potentially
FGC-affected young women. While previous research shows that professionals
in Western countries lack confidence and experience in caring for women with
FGC, calling for increased awareness of the practice, this paper furthers ourunderstanding about what professionals do with the knowledge they obtain – howthey understand and construct meaning of FGC in light of knowledge attained,
and how this knowledge is practiced and plays out in their professional work.
During the process of writing this paper and concurrent initial coding andanalysis, menstrual pain was identified as a salient theme. I found that73

professionals, regardless of their professional discipline, seemed to give
menstrual pain a certain weight in encounters related to FGC. To delve further
into the meanings of FGC-knowledge on menstrual pain, additional interviews
were conducted adding to the previous 20.
The analysis suggests that there was a tendency in counseling to differentiate
young migrant women’s menstrual complaints from ordinary menstrual pain,with professionals understanding pain complaints either in terms of FGC or interms of culture. The study shows how professionals navigated their various
sources of knowledge, where FGC-awareness worked as a lens through whichyoung women’s health complaints were understood. Here, biomedical knowledge
about menstrual pain was interpreted in light of FGC-knowledge to understandwhat was previously learned in FGC education.
Another important finding was that menstrual pain was used as a working toolin professional practice, alerting professionals to the possibility of FGC, and/or
was used as a starting point for conversations about the practice. This strategy
related to both the legal context and organizational contexts. Among workers inorganizations that had not formalized their FGC- work, professionals found a way
to broach the topic this way when other approaches were lacking. Using medical
symptoms to raise the issue was a strategy for professionals to approach the topic,
in what they regarded as a neutral way. Careful to raise the questions in ways thatwould not frighten, alienate, offend, or stigmatize, they avoided approaching
FGC in terms of a moral question of right and wrong, or a legal one about
reporting to Swedish authorities. Instead, they emphasized approaching FGC asa matter of health – and care and support. This was often regardless of girls’ actual
experience of FGC or not.
In a context such as Sweden, where non-medically trained staff are urged to beattentive to medical conditions such as menstrual pain in order to identify girls
and young women with FGC, either as a safeguarding or preventive measure, or
in order to provide care and support, this question is pertinent.

Paper IIIThe relationship between dominant Western discourse and personal
narratives of female genital cutting: exploring storytelling among SwedishSomali girls and women. Published.
The article examined the relationship between dominant Western discourse andpersonal narratives on female genital cutting. It is based on focus groups (9) andindividual interviews (12) with Somali women of different generations. In thepaper, “narrative” is used in a colloquial way, to stand for all lengthy textual or
speech representations i.e., interviewees’ accounts or media reporting.

74

Previous literature has pointed to a gap between international condemnatory
discourse, on the one hand and, on the other, how women typically make senseof their FGC experience as meaningful and necessary, albeit painful, in thecontext of origin (Nnaemeka, 2005; Obiora, 1997). Through eradication efforts
combined with migration and globalization processes through which Western
norms and human rights agendas long have been diffused, however, a change ofascribed meaning have been reported (Catania et al., 2007; Hodžić, 2017;
Malmström, 2016). Scholarship has identified a change in self-categorization,from seeing oneself as normal to abnormal, whole to damaged (Jordal et al., 2022;
Villani, 2019). Against this background, this study investigated how participants
make sense of their FGC experience in a post-migration setting that stigmatizes
FGC. How do they construct and communicate their understandings about FGC
in this new setting marked by a radically different dominant discourse around
FGC?
In the article, the construction of the narratives is the subject of the analysis.
The article analyzes not only the content of the interviews but also the ascribedmeanings conveyed by the strategies used by the interviewees in their talk.
Particular attention was paid to how the interviewees relate to contrastingunderstandings about FGC as evident in the migration context and the Western“FGM standard tale” (Leonard, 2000) in making sense of their experiences. For
this enterprise, bell hook’s (1989) concept, “talk back” and talk through, wasused, which proposes that people subordinated to dominant discourse cannot
speak outside these, but must talk through or against them. This perspective
allowed for an analysis of how participants, through their storying, understandand position themselves in light of different discourses present in the diasporacontext.
The article demonstrates that participants, in efforts to make sense of theirexperiences, navigated what they assumed to be the listener’s expectations andbeliefs about FGC, including the so-called “FGM standard tale.” Navigation was
conducted both at an intrapersonal level, through continuous identity work, andin relation to the social context in interpersonal encounters, i.e., with me as aninterviewer, with service providers and others.
The article found that participants talked back and talked through to various
parts of dominant Western discourse. In terms of women’s own experiences, theytalked back to dominant Western discourse. As regards health and sexualcomplications this was particularly salient among young, sunna-cut participants.
In contrast, they talked through condemnatory discourse and pursued acondemnatory language in part identical with international Westerncondemnatory discourse in general discussions on FGC or in talk about other
women than themselves. For example, FGC was described as being un-religious,
traditional, harmful, and in need of ending. Participants simultaneously
constructed a separation between sunna and pharaonic cutting, where pharaonic75

was posited as representing the stigma associated with FGM. Simultaneously, itcreated possible space for sunna-cut girls and women to escape the stigma of
FGC. In the article, we argue that for sunna-cut participants, and for those who
had chosen sunna cutting for their daughters when living in Somalia, thisconstruction provided space for a positive identity accommodating to bothprevious cultural frameworks that required FGC, positioning it as desired and asocial norm, as well as to the new position as opposed to the practice.
In making sense of experiences in the new condemnatory setting, participants
used various narrative strategies such as contextualization, emphasizing agency,
engaging in change talk, or positioning their experiences in contrast to an
imagined cut woman, that can be seen as ways to resist stigmatizing categories
or binaries, such as victim/abuser, civilized/barbaric, typical/atypical, bodily andsexually functional/dysfunctional, expected to be believed in by the outsidesociety.
In the article, we used Sara Ahmed’s (2014) concept of “sticky association” tocapture participants’ feelings and experiences of FGC as a category that sticks totheir bodies and Somali appearance, regardless of personal experience with FGC,or their own (often outspokenly negative) attitudes toward the practice. In relation
to FGC being a sticky association connected to Somalis in Sweden, participants
conducted emotional and cognitive preparations to respond to anticipatednegative emotional reactions to FGC in their encounters with outsiders. Others
have called this work “emotional health work” when conducted in the healthcare
setting (Jacobson et al., 2022). The present study found that this work was
conducted also outside of the healthcare context, and regardless of having
personal experience of FGC or not.

Paper IV
Sexuality constructions in relation to female genital cutting. Young and older
Swedish-Somali women on sexual responsiveness. Submitted manuscript.
This article explores subjective experiences and perceptions of sexuality inrelation to female genital cutting (FGC) among different generations of Somali
women living in Sweden. It is based on focus groups (9) and individual interviews(12) with Somali women of different generations.
In Somalia, FGC is traditionally associated with the creation of a tempered
sexuality in accordance with gendered sexual norms prescribing modesty inwomen (Fried et al., 2013; Powell et al., 2020; Talle, 2007). On the other hand,in efforts to end the practice, it is continuously stressed that FGC aims at
depriving women of their sexual fulfillment. Effects of FGC on sexual pleasurehas been one of many themes discussed in the research field. There is an ongoing76

debate regarding the relation between FGC and female sexual pleasure. In linewith the public discourse on FGC, scholars often arrive at the conclusion that all
types of FGC can have devastating effects on female sexuality. This statement isalso commonly used as an argument for abolishing practices of FGC (e.g.,
WHO/UN, 2008). Reviews, however, conclude that the empirical evidence tosupport this claim is weak due to methodological shortcomings in FGC researchon sexuality (Berg & Denison, 2012; Johnsdotter, 2018; Obermeyer, 2005).
Cut women living in Sweden, who have been socialized in a context where
FGC traditionally is highly valued, thus must deal with contradictory information
about FGC and their own sexual function. Previous literature suggests thatinternalized values about FGC, body image, and sexuality may come to be reevaluated in migration (see review by O’Neill and Pallitto, 2021). This article
explores such negotiations at an individual and community level, and relate theseto the dominant understandings in Swedish society.
In Western discourses on sexuality, sex has traditionally been reduced togenital activities (Basson et al., 2004; Tiefer, 2004). However, recent discussions
on sexuality recognize sexuality as multifaceted, involving also psychologicalfactors, such as self-esteem and psychological well-being, and socioculturaldimensions, such as gender norms and body ideals. This broader approach tosexuality and sexual pleasure, in which it is acknowledged that discourses have abearing on a person’s sexual life, accentuates the importance of discussing current
discourses regarding sexuality in relation to FGC.
The article highlights the changed role of FGC in assisting women in aligningwith gendered sexual norms in the new migration context. Consistent withprevious research (Johansen, 2022; Johnsdotter, 2002), the study suggests thatthe migration context have contributed to a move from external control via FGC,
to an inner self-control managed through social behavior and respectability only.
In the article, I reason about this in terms of an increasing emphasis onrespectability (Skeggs, 1997) communicated through self-discipline andresponsibility in managing to keep within ascribed a “charmed circle” (Rubin,1984) of perceived acceptable sexual behavior.
Another important finding was that interviewees apparently were influenced
by anti-FGC discourse, with basically all women expressing opposition toward
the practice. For example, interviewees often cited the litany of healthconsequences almost verbatim from anti-cutting campaigns. Yet in terms of selfperception, most women resisted and rejected the view of themselves as sexuallymaimed, placing emphasis on other cultural models and sexuality discourses thanthat of anti-cutting campaigns. This was evident among women of all ages, andregardless of form of cutting.
Notably, however, and contrary to what could be expected from previous
literature, younger women seemed less influenced by condemnatory discourses
in terms of their self-understanding than did the older women. In the article, a77

possible explanation is discussed in terms of the constructed separation between
pharaonic and sunna cutting. Affected by discourses of change in Somalia, sunnacut women seem to be able to enjoy a valued self-identity, as the practice isconsidered as a step away from pharaonic cutting and associated stigma. Sunnacut women and families and parents who have avoided pharaonic cutting for theirdaughter choosing sunna cutting instead, thus can avoid some the stigma attached
to FGC. Further support for this interpretation is provided by recent researchamong Norwegian-Somalis (Johansen, 2022) that highlights the impact of sunna
cutting as an avenue to a positive self-identity in relation to both anti-cutting
discourse in western countries, and in Somalia.

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7. DISCUSSION

In this thesis I explore social constructions of sexuality and sexual health inrelation to FGC, as construed through welfare work and from the perspectives ofdifferent generations of Swedish-Somali women. In this final chapter, I highlightand discuss important findings from the research and provide a joint theoretical
discussion of the research. Further analytical perspectives on the research results
are also introduced.
I begin with discussing how FGC has been constructed as a social problem in
Sweden, and how women with FGC have come to be constructed as specific kinds
in the work of defining FGC as a social problem. Thereafter, I analyze and discuss
how welfare workers address FGC in terms of health and the tendency to employ
a genital reductionist approach. I focus on how medical discourse on FGC in
Sweden is used both as a form of help and as a form of solution for prevention tocontribute to normative change. I argue that the focus on medical knowledge canbe seen as a form of empowerment yet also as a site of power and governing of
the body. I then go on to discuss findings based in the interviews with Somali
women. The findings are discussed in relation to how women interact with andrespond to construction of FGC and related classifications in the Swedish context.
At the end of the chapter, I elaborate on possible implications of the findings inrelation to social work and welfare work in a broader sense.

Framing FGC as a social problem
The enforcement of universal norms defining FGC as harmful and a violation ofbasic human rights, can be understood as a result of the claims-making efforts by
the Western women’s movement that started in the 1970s to reach recognition of
FGC as a global concern (Shweder, 2005; Thiam, 1983). These efforts led to aninternational mobilization against FGC and of FGC being widely recognized asa social problem, to speak with Loseke’s term (2003). According to Loseke, aphenomenon becomes a social problem only when identified and defined as such;as wrong/harmful, widespread, and as something that can and should be changed79

(Loseke, 2003). Through claims-making processes, FGC has come to be defined
as a social problem, materialized in the global dominant anti-FGM discourse, theFGM standard tale, and related approaches discussed in chapter 2 (Essen &Mosselmans, 2021; Johnsdotter & Essén, 2010). The process of claims-making
is central to Loseke’s theory about social problems formulations (Loseke, 2003).
Claims-making involves the process of explaining what a phenomenon is, why it
exists, who is responsible for it, who is the victim, and what can or should bedone about it (Loseke, 2003). Thus, claims-making entails the social processes
involved in defining and presenting an issue as a problem that requires attention
and intervention (Loseke, 2003). In this sense of the term, FGC has in global
politics gone from being understood as a cultural practice that the cultural
outsider should not interfere with to being regarded as a social problem of global
concern (Hosken, 1979/1993; Thiam 1983; WHO/UN 2008). This process
eventually has led to the enforcements of anti-FGC policy, law, and moral
condemnation on a global scale (Shweder, 2005; Wade 2012).
In Swedish FGC-politics, FGC is primarily understood as a form of gender andhonor-related violence, and seen as a means for men and families to control girls
and women’s sexuality (e.g., Swedish Ministry of Health and Social Affairs,2018). In the conceptualization of FGC as a matter of violence, it entails bothconcerns over girl’s and women’s health and wellbeing, and their right to bodily
integrity (Swedish Ministry of Health and Social Affairs, 2018; Swedish National
Board of Health and Welfare, 2022). Consequently, suggested solutions havefocused on providing care and support for already affected women, protection ofgirls at risk, and changing social norms (Swedish Ministry of Health and Social
Affairs, 2018).

“The mutilated woman” and “the potential upholder”
In the construction of FGC as a social problem, a woman with FGC is categorized
as a specific kind, to use Hacking’s term (1999). One essential part of theconstruction of FGC as a social problem is its potential and alleged medical andsexual consequences (Loseke, 2003; Swedish Ministry of Health and Social
Affairs, 2018,). Having been subjected to FGC is in the Swedish dominantdiscourse understood as being a victim of violence, associated with trauma,
emotional and physical sequelae (e.g., NCH, n.d.). Also, as demonstrated inchapter 2, common in public depictions is the notion that a woman with FGC is
deprived of her sexual autonomy and pleasure (Johnsdotter & Essén, 2004). The
same images are diffused in Swedish FGC education, handbooks, policy, andpublic health information (e.g., Swedish Ministry of Health and Social Affairs,
2018; Östergötland County Administrative Board, 2015). The “mutilation” label
further accentuates the construction that the woman with FGC is maimed,
incomplete, disfigured, or broken. She is constructed as a mutilated kind.

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Another essential part of the construction of FGC as a social problem, is theestimates of girls at risk. Estimates of the prevalence of the problem are central
to warranting attention to an issue (Loseke, 2003). Recent estimates of girls at
risk of FGC in Sweden have widened its scope to include all girls born to a parent
from an FGC-practicing context, even though some distinction is made in relation
to impact of migration on attitude change (Swedish National Board of Health andWelfare, 2023). Hence, daughters or future daughters of young, immigrated
women with FGC whom welfare workers encounter are, according to thisestimation, regarded as at risk of FGC. This construction may be reinforced bymedia renderings of FGC as being a widespread but secretly upheld activity in
Sweden. This situation has been discussed in previous research, concluding thatsuch statements have been unsubstantiated (Johnsdotter & Mestre i Mestre,2017). In this construction of FGC as a social problem, young women who aremothers or potential mothers to be, are constructed as a potential upholder kind.
Thus, on the one hand, FGC is treated as a social problem creating vulnerability
and a disadvantaged position in affected girls and women. This construction
emphasizes women as victims of violence and sexual mutilation. On the other
hand, FGC is also approached as a social problem in which the mutilated victim
kind simultaneously is construed as a potential upholder and offender – thepotential upholder kind, where all girls born of a parent from an FGC-prevalentcountry are declared “at risk” of FGC, in Swedish governmental estimations (e.g.,
Swedish National Board of Health and Welfare, 2023). Hence, in theconceptualization of FGC as a social problem, the mutilated victim kind, and thepotential upholder and offender kind, may be embodied in one and the same
person. Welfare work aims to improve the wellbeing of the former group by
providing care, help and support, while the latter group is targeted as in need ofsurveillance, sensitizing activities, and social change – so as not to perpetuate thepractice of FGC. The solving of the social problem is thus successful if it manages
to improve the health of already FGC-affected women, and if it succeeds infostering social norms of FGC as wrong.
Welfare workers are thus tasked with the dual role of empowering those whohave already been subjected to FGC, while working to prevent future occurrencesof the practices, without evoking feelings of inadequacy, body shame, or stigma
for those already affected. The welfare workers in this study balanced these dual
undertakings; their wish not to condone the practice, and at the same time not tostigmatize young women who are already cut. The approaches used by welfare
professionals, will be discussed, and further elaborated on in the next section.

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Welfare work, health, and biopower
Based on interviews with professionals in healthcare, social care, and education
Paper I and Paper II discuss professionals’ approaches in youth counseling or
education regarding FGC. The results suggest that staff in individual counselingprioritized harm reduction and provision of care and support, downplaying
elements of prevention. In both their quest to work with support and prevention,
they addressed FGC in terms of health. This seemed to be motivated by anunderstanding of FGC mainly as a health issue and not, for example, a social issue
or one of safeguarding in cases when young women were already cut. Addressing
FGC as a health issue was also considered a non-intimidating way to initiate allkinds of discussions about FGC, and a way to deter young women fromcontinuing FGC, using information about possible harmful bodily and sexualconsequences. From this outset, counseling and education regarding sexual
matters was characterized by a genitally focused paradigm and sexuality
discourse. The welfare workers’ strategies to improve the lives of the young
women they encounter, and to prevent future generations from practising FGC,
can be interpreted as trying to solve a social problem through health and sexuality
education. In this section I will develop a discussion that elaborates on this main
finding.

Health approach, prevention, and self-regulation
In Swedish FGC policy, welfare workers are identified as being in a key position
to work with prevention and support in relation to FGC, for example bysafeguarding, sensitizing activities, and identifying illegal cases and girls andwomen in need of help (Swedish Ministry of Health and Social Affairs, 2018).
Paper I and Paper II explored welfare workers’ approaches to FGC in informationand counseling targeting young women. The results show that they prioritizedharm reduction, downplaying elements of prevention (Paper II). Several
described how they avoided talking about FGC in terms of right and wrong,stating their main role as providing care and support (Paper II). Support wasframed in terms of medical care and counseling and not, for example,
psychosocial counseling. Yet, by focusing on FGC as negative for health, welfare
workers also aimed to contribute to normative change and to deter young womenfrom perpetuating the practices (Paper I, Paper II).
Preventive measures proposed for welfare workers in Swedish FGC policy andhandbooks include information about legislation, health consequences, and social
norms about children’s rights versus parents’ rights (Swedish National Board of
Health and Welfare, 2022; Swedish Ministry of Health and Social Affairs, 2018;Östergötland County Administrative Board, 2015). By focusing on FGC from ahealth perspective, and not from a legal or sociocultural perspective, welfare
workers in the present study aimed to avoid scaring, stigmatizing, or creating82

distrust among young women, so as not to jeopardize rapport. By maintaining
trust, they hoped to be in a better position to provide care and prevention in thelong term (Paper II). Professionals described, for example, how they in particularutilized menstrual pain or other medical symptoms as an indirect way to initiate
discussions about FGC (Paper II). Thus, although prevention did not appear to bea main concern for professionals in this study, it can be interpreted that thepotential upholder kind guided aspects of their work. This can be seen in theirefforts to influence attitudes and behaviors through focusing on FGC as a healthissue.
Previous scholarship has discussed how social work and healthcare encounters,
as forms of solutions and help, are always “moral occasions” (Cook, 2014) thatentail governance and power (Cook, 2014; Fioretos et al., 2013; Herz et al., 2022;
Mulinari et al., 2023). From a perspective that critically analyses power, thewelfare workers’ approach in the present study, can be viewed as a form ofgoverning through instances of biopower (Foucault, 1976; Hodžić, 2017). In
Foucault’s use of the concept of power, and as I use it here, power is notinherently negative but exists in every relation, producing different effects.
Biopower works through medical knowledge, measurements, statistics, andpractices working to govern people’s bodily practices, to promote the wellbeingof a population (Foucault, 1976). As such, it enforces certain social norms. Herealso lies power through disciplining and normalizing elements (Foucault, 1976;
Iguchi et al., 2023; Lupton, 2013).
In previous research on preventive and safeguarding FGC work in diaspora, aresearch team in the UK has examined effects from policy that fuses support andhealthcare with surveillance and criminalization approaches (Ali et al., 2023;
Carver et al., 2023; Karlsen et al., 2020). The UK policy approach to safeguarding
is characterized by greater emphasis on repressive legal regulation andsurveillance, with welfare workers encountering FGC in minors having an
absolute duty to report to the police (Karlsen et al., 2020). This approach has
resulted in several unintended consequences, with women reporting distorted
communication, decreased trust, and unwillingness to seek care. Women also
reported feeling that healthcare professionals were too occupied with extracting
information about FGC for safeguarding reasons, so that health needs were set
aside (Karlsen et al., 2020).
A similar approach has been suggested by government- appointed FGCexperts in Sweden. The approach has not been implemented or reached any wider
recognition, however. Recent changes in legislation and guidelines regarding
honor-based violence, including FGC, do provide social authorities withincreased authority to withdraw passports to prevent girls from traveling abroad
if they suspect FGC (Prop. 2019/20:131). Previous research in Sweden has also
highlighted that a disproportionate number of involuntary genital examinations
are performed on girls to detect illegal cases of FGC, set in relation to the actual83cases confirmed (Johnsdotter, 2019). While these measurements are meant toprotect young women from being subjected to FGC, they infringe on other rights
such as right to bodily integrity. Previous research has shown they also risk
adverse effects such as potentially undermining important relationships between
welfare workers and young women and their families, as reported in the UK
studies (Ali et al., 2023; Karlsen et al., 2020). Or, as the UK study also shows, it
may risk silencing girls if they fear negative consequences for their families orfor themselves, in the case of raising the issue with welfare workers (Karlsen etal., 2020).
Welfare workers in the present study wanted to avoid such effects, using what
they perceived as a non-intimidating way to discuss FGC. With reference to theirprofessional ethics, welfare workers distanced from more authoritative
approaches for prevention e.g. surveillance or reporting previously performed
FGC to authorities. They also described avoiding stigmatizing language ortalking about FGC in terms of right and wrong (Paper II). Instead, they utilized ahealth approach for prevention, which they deemed would be more acceptable tothe young women they encounter. This can be interpreted as welfare workers
choosing to rely on the young women’s own ability to draw conclusions about
the practice, based on the information they provide (Paper I, Paper II).
In the literature on healthcare encounters in Sweden, similar strategies havebeen discussed in terms of biopower and self-regulation (Alftberg & Hansson,
2012; Hansson, 2007). Self-regulation can be understood as the way institutions,such as healthcare, education, or social care, place responsibility on individuals,
and anticipate that individuals will engage actively in their own regulation andmanagement (Alftberg & Hansson, 2012; Foucault, 1976; Patton, 2015). Foucault
understood this practice as an essential part of modern social institutions(Alftberg & Hansson, 2012; Foucault, 1976). In terms of the FGC encounter, it
can be understood as young women being expected to, through information,
develop an understanding of FGC as harmful, and this way themselves come tostop the practices from being carried on.
The strategy to focus on FGC mainly as a medical issue, corroborates with how
FGC has been dealt with also in other diaspora contexts (Villani, 2023). By
contrast, less attention is paid to gender norms and sociocultural factors, as
reviewed elsewhere (Villani, 2023). What would happen if welfare workers
addressed FGC as an issue of sociocultural norms? To the extent that the healtheducation strategy works as a non-intimidating way for communicating about
FGC, it seems like it has the intended effect of establishing a trustful dialogue.
Yet, overseeing the need for dialogue on sociocultural norms, seems on the other
hand to leave young women with the responsibility to grapple with and manage
the sociocultural aspects of FGC on their own. Some of the interviews with theyoung women describe struggles to comprehend and navigate newunderstandings of FGC in the new social context (Paper IV). Another aspect of84

avoiding addressing FGC as a matter of social norms relates to prevention in
relation to potential pressure from older generations during visits in highprevalent contexts, as described in a Norwegian study (Johansen & Ahmed,2021). Thus, while focusing on FGC as a health issue may seem a neutral andnon-intimidating entrance to discuss and change norms about FGC, the strategy
may leave young women with the responsibility of managing to comprehend andprotect future daughters from FGC, on their own (Foucault, 1976).

Help and support through medical discourse
While welfare workers to some extent worked to prevent FGC from being
perpetuated, they framed their role primarily as being about providing help andsupport (Paper II). The counseling described in relation to FGC was characterized
by a biomedical and genitally focused approach, with welfare workers primarily
addressing FGC in terms of health. In this sense, they primarily understood young
women with FGC as victims of a harmful practice and mutilation, responding to
the idea of women with FGC as a mutilated kind.
Welfare encounters were characterized by brief consultations, often without
physical examination. In this situation, one part of counseling centered on
identifying if the young woman before them suffered from their FGC, and if so,suggest proper treatment or refer her to a specialist (Paper I, Paper II). For
example, in relation to menstrual pain, welfare workers tended to differentiate
young migrant women’s menstrual complaints from “normal” menstrual pain,with professionals understanding pain complaints either in terms of FGC or asculturally influenced (Paper II). To assess, they used FGC knowledge as a lensguiding diagnosis and suggested treatment (Paper I, Paper II). In some cases, it
seemed welfare workers described how they had jumped to conclusions that
health complaints were caused by FGC, when this had been shown not to be thecase (Paper I, Paper II). This was also described in the interviews with Somali
women, where young and older women described how healthcare staff had
insisted on FGC in relation to menstrual pain when women were uncut or when
they themselves had not interpret their pain that way (Paper III). There were also
welfare workers describing a more cautious approach, being careful not to assume
too readily that complaints were caused by FGC. In these cases, they used FGC
knowledge as a working hypothesis that can be used as an alert and a way to be
attuned to the possibility that FGC could play a role (Paper I, Paper II).
To identify potential health needs or medical conditions from FGC, one cansay that welfare workers used their medical gaze (Foucault, 1976). In scholarly
work on health encounters, the medical gaze has been related to how the
medicalization of the body and sexuality, i.e., medical discourse and knowledge
explaining the body, is used by healthcare to detect and deter health andpathology (Fioretos et al., 2013; Lupton, 2013). The medical gaze was used not85

only to identify medical conditions related to FGC; but through medical discourse
on FGC and health education the medical gaze was also transferred to young
women.
Welfare workers described how they also focused on educating young women
about potential health and sexual complications from FGC and ways to reduceand manage potential problems in the future for example by defibulation (Paper
I). Based in medical discourse, they used FGC knowledge to equip young womenwith tools to manage sexual and medical risks of FGC in the future (Paper I, Paper
II). For example, welfare workers described how they in counseling highlighted
how menstrual pain could be a symptom of being sewn closed (Paper II), or
explained “normal anatomy” versus cut anatomy, and provided information aboutrisk of sexual problems and reduced sexual responsiveness in the future (Paper
I). I think of the strategies as welfare workers providing young women with maps
to interpret and read bodily symptoms or sexual problems, present or forthwith,
with the aim to provide women with resources to mobilize appropriate ways tohandle or reduce potential negative impacts of FGC in the future.
It can also be understood as applying a medical gaze that is transferred to theyoung woman as she is expected to direct the gaze at herself, being able to tell –in the future – if her FGC caused her any problems, and if so, what can be done
about them. The concept is closely connected to biopower, suggesting that bymeans of health education, people will be bestowed with the knowledge andinformation needed to be better able to take care of themselves (Alftberg &Hansson, 2012). Scholars in Sweden have provided several examples of how selfcare is central to Swedish healthcare (Alftberg & Hansson, 2012; Fioretos et al.,2013; Hansson, 2020; Mirsalehi, 2021). The health education approach employed
by welfare workers in this study encourages young women to become aware of
their bodies, and to reflect upon how their (cut) bodies feel, and if they potentiallyexperience health problems in relation to their body. Or if not, to be wellinformed so as to recognize illness in the future, and have sufficient knowledge
about available paths for help and support (Paper I).
As discussed in Paper I, in such a situation, the transmission of knowledge
about the cut body may be empowering to a young woman, providing her withknowledge and resources to navigate health systems or increasing health-literacy.
To detect medical problems and ill-health, it is inevitable to classify bodies andbodily states in terms of health or pathology. Yet, as pointed out, in this also lies
implicit a moral judgment of which bodies are considered normal, or pathological(Hansson, 2007; Lupton, 2013). As such, it also works as a normalizing practicewhere young women themselves are expected to direct the medical gaze towards
themselves, and become the knowing subject (Fioretos et al., 2013), where they
are taught, so to speak, to read their bodies in terms of pathology.
Professionals often seemed to neglect exploring the young women’s own
experiences and perceptions of their situations (Paper I). Herein lies a risk with86the health education strategy, where young women with FGC, who might notconceive their bodies as abnormal, pathological, or at-risk, are socialized into
reading their bodies in such terms (Kavanagh & Broom, 1998; Kenen, 1996).
Classifying bodies as abnormal simultaneously governs bodies, stipulating whichbodies are the desired ones. Such medical discourse, with associated claims, may
impose social identities and cultural beliefs and meanings of FGC that are notgenerated from the young women’s own understandings (Paper I). It raises
questions also about how organizations can provide opportunities for a space fora dialogue to take place where welfare workers have the time and resources to
explore and consider the perspectives of young women on their own situations.

Monotrait myopia in counseling
Paper I and Paper II, show how welfare workers approach FGC in careencounters, education, and social work. They were also attuned to help in theirbest way, yet lacked a clear view of how health and sexuality may be affected by
FGC. The results show that in terms of sexuality, counseling and education wascharacterized by a genitally focused paradigm and an understanding of sexuality
which emphasizes the role of the clitoris for sexual pleasure (Paper I). Sometimes
this starting point led welfare workers to conclude that FGC erases or at least
essentially reduces sexual and bodily functionality (Paper I). In Paper I, thegenitally focused paradigm characterizing the professionals’ descriptions of theirpractices is discussed as a genital reductionist approach, that is, the tendency toan over-reliance and (potential) over-emphasis on the genitals in sexual healthcounseling. This plays out through situating both problems and solutions in the
cut genitals (Paper I). Problems could be menstrual pain complaints (Paper II),
constipation, or erased ability to enjoy sex in the future (Paper I). Solutions wereframed in terms of undoing the FGC by defibulation surgery, clitoral repair, oraddressing potential future sexual and health consequences from FGC or,
sometimes, by addressing the significance of the inner clitoral structure for sexualpleasure (Paper I).
The choice, seen in research and in professional practice, to focus narrowly ona stigmatized or marginalized experience, identity, or practice when interpretingand treating a complex phenomenon, can be seen as a case of what I callmonotrait myopia. The term, in essence, meaning being myopic or shortsighted,
conveys the idea of a narrow focus on a single trait to the exclusion of otherpotential factors of a multifaceted issue. Monotrait myopia is not limited tocounseling in relation to FGC, but situations that might be characterized as
monotrait myopia has been reported also in other contexts of sexual healthcounseling in relation to people with stigmatized or marginalized sexual identities
or experiences. For example, in the Swedish context such an approach has beenreported in relation to counseling on LGBT groups and in relation to persons with87

experiences of BDSM, selling sex, or having polyamorous lifestyles (Björkman& Malterud, 2009; Carlström & Andersson, 2019; Holmström, 2015; Lantto &Lundberg, 2022; Larsdotter et al., 2011). When professionals are (potentially) too
preoccupied with or have an over-determined focus on a single trait ininterpreting a person’s situation, it may inadequately capture other importantfactors affecting a given situation.
In previous research on healthcare encounters among women with FGC,
authors have highlighted how women experience that healthcare providers put
too strong a focus on the women’s genitals even when they seek help for otherproblems (Bergstrom et al., 2013; Karlsen et al., 2020; Khaja et al., 2010). This
was also reported in the present research with young and older women, claiming
they continually had to answer about FGC when having menstrual pain, or one
example with the young uncut woman who sought help after having anappendectomy (Paper III). This mirrors a tendency in public discourse on FGC,
to take associations for causal evidence, assuming all conditions reported by the
woman must be caused by the FGC5. Yet, as reviews show, the independent
contribution of FGC to negative outcomes on health, sexuality and body-image,is not easy to determine (Einstein et al., 2019; Johnson-Agbakwu & Warren,
2017; Sharif Mohamed et al., 2020) see also Earp 21019 (Johnson-Agbakwu,
Michlig, et al., 2023), not the least in relation to subjective experience of healthand ill-health, pleasure and pain, being contingent of multiple aspects such as
physical, mental, relational, and sociocultural (Elmerstig, 2012; Tiefer, 2004).
This further underscores the importance of a more cautious approach indiscussions of “health consequences.”

Looping effects and identity constructions
In the previous section I focused on how health and sexuality education is used
to solve FGC as a social problem. Various expressions and implications of thisapproach, including how this contributes to construct sexuality and sexual healthin relation to FGC, was also discussed. In this section, I turn to the consequences
the biomedical health approach may have for how women view themselves inrelation to discourses about FGC in Sweden. I discuss how the Swedish-Somali
young and older women in this study made sense of FGC in relation to sexuality
in a post-migration setting where FGC is stigmatized. I also discuss how the
women interact, adopt, modify, and contest socially constructed categories ofthem as mutilated kinds and potential upholder kinds.

5 I thank the anonymous reviewer on one of the papers for this comment.

88Discursive change
Previous studies among Somalis in diaspora show how ascribed meanings of
FGC change in migration to countries where FGC is prohibited and/or
stigmatized (Gele et al., 2012; Isotalo, 2007; Johansen, 2022; Karlsen,
Mogilnicka, et al., 2019; Wahlberg, 2017). In line with these findings, the Somali
women in this study described a discursive change as regards FGC. The findings
in Paper III suggest that younger and older women interviewed had internalized
an ideology of FGC as being wrong. Conceptualizations of FGC as wrong was
attributed to change efforts in Somalia. Women were also affected by FGC beinga criminalized and stigmatized phenomenon in Sweden. They described thepractice as traditional, uneducated, un-Islamic, painful, and potentially harmful,whilst opposition to FGC was associated with knowledge (on health and religion)
and modernity (Paper III). Consistent with previous research, change wasattributed to anti-FGC campaigns and discussions about health risks in Somalia(Powell et al., 2020), lessened social pressure and illegality of performing FGC
in diaspora, and increased Islamization in Somalia and in the diaspora (Fried etal., 2013; Powell et al., 2020; Wahlberg et al., 2019).
The new context had called upon, or sometimes reinforced, processes ofrenegotiation of traditional values associated with FGC (Paper III, Paper IV). In
many sites where FGC is practiced, including Somalia, it is seen as a means toassist women in internalizing and embodying social values and norms of female
sexual virtue, health, hygiene, and modesty (Abusharaf, 2001; Ahmadu, 2007;
Jirovsky, 2019; Powell et al., 2020; Talle, 2007). To uphold ideals of premaritalvirginity was generally supported by the women in this study, albeit the means toachieve it seem to have changed (Paper IV). Change is manifested in how external
regulation of sexuality through FGC to protect female chastity and virginity, isreplaced by increased emphasis on inner control and self-discipline (Paper IV).
The implicated change to an emphasis on inner self-control, confirms previous
research among Somalis in Norway, Sweden, and Finland, suggesting increased
reliance on trust and sometimes social control, or yet less common, decreased
importance placed on preserving premarital virginity (Isotalo, 2007; Johansen,
2022; Johnsdotter & Essén, 2004; Ziyada et al., 2020).
In Somalia, FGC has traditionally been categorized into two broader types:
infibulation (or pharaonic cutting), or sunna cutting, that may include all otherforms of cutting other than type III (Johansen, 2022). A salient finding was thatwomen constructed a binary between pharaonic cutting and sunna cutting wheremuch of the stigmatization of FGC was attributed to pharaonic cutting (cf.
Johansen, 2022).

89Sunna-pharaonic binary
What might the implicated change mean in terms of women’s own selfunderstandings? Previous research suggests that processes of attitude change,
spurred for example by anti-FGC efforts and sociopolitical processes in diaspora
and contexts of origin, also may come with adverse effects. Villani (2017)
discusses how women, particularly in diaspora, “have seen their body image, theirself-esteem or their gender model undermined because of the stigmatization of
the practice in a migratory context” (p. 264). Growing evidence supports thisobservation, as previously reviewed (Johnsdotter, 2018; O’Neill & Pallitto,2021). Studies show younger women potentially being at greater risk ofdeveloping a negative self-understanding, including body-image and sexual selfimage (Catania et al., 2007; Malmström, 2013; Ziyada et al., 2020).
The present study displays how the women interacted with existing social
categorizations and stigmatization of FGC in ways that were not unidirected. The
research shows that women navigated dominant framings and categorizations that
put women with FGC in a stigmatized position. The navigation included
negotiating claims from FGC initiatives in Sweden constructing the mutilated
woman as a specific kind (Hacking, 1999). It also included negotiating ascribedmeanings of FGC in the Somali context, where infibulation is increasingly
discussed as wrong and harmful (Fried et al., 2013; Lunde & Sagbakken, 2014;
Powell et al., 2020).
An important finding was how women, both younger and older, seemed to
draw on a binary separating pharaonic cutting from sunna cutting (Paper III).
Young and older women drew on medical discourse of infibulation as harmful tohealth and sexuality. They also referred to pharaonic cutting as an unreligious
practice, not least in relation to Islamic notions of “doing no harm.” Sunna
cutting, was simultaneously disconnected from much of the stigma attached to
FGC. The presence of a seal was central to the discussions. For example, while
many young sunna cut women were occupied with health problems from
infibulation, notably absent in their talk was any discussions of clitoridectomy ashaving inflected on them any long-term sexual or other harm (Paper III, Paper
IV). In relation to young and older women with infibulation, they reflected a
notion that life was expected to be fine once the seal was opened (e.g., throughdefibulation surgery, or at intercourse, or childbirth). Using Foucault’s andHacking’s theories on social classifications, this can be seen as a case of how
people internalize, incorporate, and transpose social categorizations (Foucault,
1976; Hacking, 1996).
One of Foucault’s and Hacking’s central points, is that stigmatization,
normative labels, and social identities are formed by societal responses (e.g., law,policy, institutions, regulations), and by social opinions drawing boundaries
between right and wrong, desired, and undesired, healthy, and unhealthy, creating90

possible subjectivities and social identity categories (Foucault, 1976; Hacking
1999, 2004). These labels, categories, and identities are then responded to bypeople who appropriate, refuse, or identify with the categories (Hacking, 2004).
Hacking refers to these feedback effects as looping effects (Hacking, 2004). In
women’s interaction with classifications of them as victimized from “mutilation,”
it can be interpreted as producing different looping effects.
In women’s navigation of categorizations that defines FGC, they reinforced
categorizations of the most extensive form of FGC, pharaonic cutting (type III)as stigmatized and harmful. For example, almost verbatim, some young women(sunna cut and uncut), had adopted language of condemnatory discourse, drawing
upon images of the mutilated kind (Paper III). They cited short-term and longterm health consequences of FGC and images of sexual impairment, or “sexual
death” as expressed by one interviewee (Paper III and Paper IV). When young
women cite WHO lists of medical and sexual consequences of infibulation,
existing classifications reappear and are reinforced in a kind of loop (Larsson &Johnsdotter, 2015). This can be seen as an example of a looping effect reinforcing
existing classifications within a mutilation discourse (Hacking, 2004; Larsson &Johnsdotter, 2015).
As regards sunna cutting, other loops were produced. Young women
positioned against pharaonic cutting were dis-identifying with the FGC-category
as integral to their own self-definition. Sunna was made sense of in terms of one
having been “spared,” implicated by health awareness, religious knowledge, andthus modernity (see also Johansen, 2022; Powell et al., 2020). In doing so, sunna
cutting were disconnected from much of the stigma attached to FGC. The
separation between pharaonic and sunna cutting seemed to provide an avenue toa valued social position and identity in relation to sunna cutting both for girls who
have been sunna cut and for families who have decided to avoid pharaonic cutting
for their daughters (Paper III, Paper IV).
This can be seen as an example of how women responded to categorizations ofsunna cutting and pharaonic cutting, as evident both in Sweden and Somalia,
modifying them and providing them new meanings (Hacking, 1999, 2004). In
terms of subjectivity formation, the mutilation discourse focused on potential
harms from infibulation provides little room for subjectivities to be created otherthan those of FGM being about infibulation and extreme harm. The interviewees’
separation of sunna and pharaonic cutting can be seen as reinforcing a looping
effect of being sewn closed as mutilation, simultaneously making room for otherexperiences as sunna cut. With the separation, a valued subject position is createdwith the sunna construction. It draws on discourses of change in Somalia, offering
a valued social identity position that can accommodate both discourses of change
in Somalia and condemnatory discourse and opposition to FGC in Sweden(Johansen, 2022).

91

This construction is not that dissimilar from the Swedish public discourse on
FGC seen in media, policy papers and FGC-training for professionals. While antiFGC work in Sweden includes all types of FGCs, there is tendencies in advocacy
efforts in Sweden to focus only on the most severe health outcomes of infibulation(e.g., Östergötland County Administrative Board, 2015). This may
unintentionally add to previous cultural constructions de-coupling of sunna
cutting from FGC. The risk with such a narrow way of discursively framing
possible FGC experiences, is that women with other experiences feel wrongly
targeted, or as seen in the present research, deem FGC initiatives to be irrelevantto their own situation. Such a situation has been described in contexts where FGC
is customary (Villani, 2023). Or the other way around – some women might
expect “the worst” from their cutting, irrespective of their own experiences from
FGC (Earp & Johnsdotter, 2021). These findings further underscore the value of
discerning between various kinds of cutting and their specific likely or possible
effects.

Positioning on axes of wrong and harm
A way to comprehend the complexities of women’s subjective experiences andperceptions of FGC, as displayed in Paper III and Paper IV, is by thinking interms of how women moved along axes of FGC as wrongful and harmful, andhaving been/or not having been wronged and harmed. The concepts
wrongful/harmful, often discussed in the context of medical ethics and ethicaldecision-making, highlights the complexities of subjective experience (Archard,2007). Wrongfulness refers to the moral or ethical wrongness of an action ordecision, while harmfulness pertains to the potential harm or negative
consequences that can result from an action (Archard, 2007). In the context of
FGC scholarship, the concept has been used to discuss the eventual wrongfulnessof also less physically harmful genital procedures on children, for example bymedicalization (i.e., procedures performed in a medical setting by trained medical
practitioners, under sterile conditions, with antiseptics and medication) (Brussels
Collaboration on Bodily Integrity, 2019). The authors argue that a less physicallyintrusive procedure “does not necessarily make it any less harmful. A person canbe wronged without being harmed, and vice versa” (p. 18).
I here transfer the concept to the context of understanding individual
perceptions and experiences of genital cutting, with the ambition of illustrating
how someone can position herself on axes of feeling wronged but not harmed,
and simultaneously claim an experience as potentially harmful and/or wrongful.
These axes can be seen as representing different dimensions of an individual’s
subjective experiences and perceptions. In the example of genital cutting, as
discussed in Paper III, woman A may claim FGC to be wrongful because it isperceived to be potentially harmful and/or violates personal values (e.g.,

92autonomy, personal choice, or religious values). She also reports feeling harmed
and wronged by the FGC. Or, as was more often the case in the empirical material
among young sunna cut women in this research, woman B may perceive theexperience as ethically and morally wrong as it has violated her integrity andbodily autonomy and exposed her to danger, yet asserts she does not personallyfeel harmed (e.g., no suffering of long-term emotional or physical complications)or wronged (e.g., because she accepts and reconciles why the procedure was
performed, having perceived it as meaningful in context). Woman C, may on theother hand claim the procedure to be physically harmless in the long term, still
perceiving the situation as potentially harmful in terms of the cutting moment, oras potentially effecting long-term emotional or psychological well-being, such as
experiencing distress due to the violation of her autonomy.
Following Hacking, subjective experiences and how individuals categorize andinterpret their own experiences may change over time (Hacking 1999). In theirstudy among FGC affected immigrated women in the UK, Parikh et al., (2020)
for example found how impacts of FGC “emerged alongside specific life events,”
for example adolescence, marriage, and starting a family (p. 1922). Categories
are not fixed, but emerge through ongoing interactions between individuals andthe concepts used to describe them (Hacking, 1999, 2004). Thus, the framework
conceptualizes how women can have complex and multifaceted subjective
feelings and values about an experience, positioning along different axes of harm
and wrongness. This is depending on individual perspectives and how one
interprets a situation, which is contingent of an interplay between personal
experiences, social interaction, and social norms and available categorizations ofexperiences (Foucault, 1976; Hacking, 2004).

Constructions of sexual responsiveness in relation to FGC
Paper IV, but also Paper III, explores understandings of FGC in relation tosexuality. Women were affected by notions about reduced sexual responsivenessas portrayed in Somalia and in Western discourses on FGC, and navigated andnegotiated normative discourses in relation to their understandings of themselves
as sexual selves. Women described how FGC, in the Somali context, was meant
to assist women in governing sexual urges, before and within marriage (Paper
IV). This intervention was not understood to preclude sexual enjoyment andsexual desire, but to govern and mold it in a socially proper direction – ideallywithin heterosexual marriage and (potentially reproductive) intercourse (Paper
IV). Although most understood sexual response to be more or less reduced byclitoridectomy (at sunna cutting or pharaonic cutting), women drew onunderstandings of sexuality where clitoridectomy was not expected to have anegative impact on sexuality within marriage. Overall, women conveyed positive
expectations on sex, expressing taking sexual desire and sexual pleasure as93

important and self-evident (Paper IV). Expectations were linked to an Islamic
discourse stipulating that both sexes have a right to sexual satisfaction within
marriage (Paper IV) (e.g., Malmström, 2016). Expectations were also linked to aview that sexual response is something inborn and/or Godgiven that no human
can take away. By these arguments, women also disqualified previous important
rationales for performing FGC (Paper IV).
In contrast to Western beliefs about destroyed sexual response after FGC,
women understood sexual response to be inborn and latent within women. Whenthe body was opened, through defibulation and/or deflowering at the weddingnight, young and older women understood the access to sexual response as having
been opened (Paper IV). It relates to a construction of clitoral sexual pleasure assuperfluous and can be likened with what an interviewee in Malmström’s (2016)
Egypt study refers to “as having six fingers” when you only need five. I
understand the view of the outer, clitoral sexuality as excessive to relate to apremiering of sexual interdependence, heterosexual marriage, and intercourse(e.g., Ahmadu, 2000; Malmström, 2016). The desired behavior – a modest female
sexuality without an excessive sexual response, women argued, could bemanaged without the external control of the body and merely by means of selfdiscipline (Paper IV).
Not as evident but nonetheless surfacing, were more ambiguous views on how
FGC might negatively affect women’s sexual responsiveness. In the face ofschool education about the significance of clitoral response to sexual pleasure andanti-FGC messages in Sweden, young women questioned notions of FGC as notaffecting sexual desire and sexual pleasure. The Swedish discourse on FGC, as
the Somali discourse alike, presupposes that both sexual desire and sexualpleasure is affected by FGC (albeit in fundamentally different ways). In thisresearch, this understanding was linked to perceptions of the clitoris as importantfor sexual receptiveness (Paper IV). Particularly this view was evident among
young, sexually inexperienced women and was influenced by knowledge about
FGC diffused by professionals in schools and experts at FGC education targeting
schools and immigrant groups.
Among younger and older women who were married and had sexual
experience, such notions were uncommon. Among older generations, who
generally had undergone infibulation, reconsideration of the negative impact of
FGC on sexuality was attributed anti-FGC efforts in Somalia situating theharmful effects of FGC in relation to pharaonic cutting (Paper IV). With antiFGC efforts, sexuality after FGC has become politicized (Hodžić, 2017; Jirovsky,
2019; Malmström, 2016; Nyarango & Griffin, 2019) yet also visible(Gruenbaum, 2006). Previous research suggests that looping effects of “sexual
mutilation” will increase women reconfiguring their sexual-self understandings(Johnsdotter, 2020; Malmström, 2013). Women in this study responded indifferent ways to such classifications. Most seemed to dis-identify with them,94placing sexual mutilation with pharaonic cutting and the presence of a seal. Other
held more ambiguous views, having feelings of potentially having missed out onsomething as regards sexuality. Or as in the case of young sexually inexperienced
women – being worried and pondering about the eventuality of being at risk of
having sexual problems in the future.

Becoming self-aware of FGC
The research shows that imageries and dominant framings of FGC affected how
women are perceived by others, or how they expected others to perceive them,also affecting women’s self-understanding. Women were influenced by FGC
being a criminalized and stigmatized phenomenon in Sweden. They were also
well aware of the FGM standard tale as expressed in Sweden, and navigated its
elements in their efforts to make sense of their experiences. This took varied
expressions. For example, it was seen in how women used strategies that can beinterpreted as managing and navigating stigma, explored in Paper III. Strategies
included for example contextualizing their FGC experiences in light of previous
cultural context, engaging in talk about attitude change, explicitly taking a stanceagainst FGC, or positioning against assumed imaginaries of cut women, andstressing FGC as a heterogenous experience (Paper III). Stigma management was
conducted both in relation to me as an interviewer, and in relation to others in thewider society such as service providers. Navigation was also conducted inrelation to their own self-understanding and identity work. I understand thesestrategies as being prompted by the social context where women navigatedassumed, or experienced, expectations from outsiders about what FGC is. (Paper
III). This can also be understood as women negotiating various claims about FGC
and an ascribed social category and identity as a mutilated kind and a potential
upholder kind and related associations (Hacking, 1999; Loseke, 2003).
While the previous section describes how the mutilation classification, for themost part, was not endorsed or adopted by the women in this research, theydescribed becoming self-aware of FGC upon immigration to Sweden. Sometimes
this process of self-awareness in relation to FGC had started already in Somalia,
where discursive changes have contributed to stigmatization of pharaonic cuttingin parts of Somalia (Lunde & Sagbakken, 2014; Powell et al., 2020).
One important aspect of this self-awareness is related to FGM-knowledge andwhat can be characterized as being exposed to a medical gaze (Foucault, 1976).
Young women described how anti-FGM sessions and biology lessons in school
had made them aware of possible or alleged medical implications of FGC for
health and sexuality, for example reduced or destroyed sexual responsiveness ordifficulties with urinating, menstruation, or intercourse (Paper III, Paper IV). For
some, being exposed to the teacher’s or the expert’s transmission of medical
knowledge of FGC (Paper IV), questions about menstrual pain (Paper III), or95

healthcare providers’ reactions to their genital appearance (Paper III), had led to
an introspection, triggering reflections and questions about the normality of FGC.
One young woman described it as having been born with a birthmark that no one
talks about, and suddenly becoming aware that this is not perceived as the normal
state in Swedish society (Paper IV).
Being exposed to medical discourse or a medical gaze at one’s own body, hadfor some meant starting to question their own bodily capacities and health: Willsex be any good for me? Do I feel like other women feel? Are my troubles
connected to FGC? were questions asked by women. This can be interpreted as
women having adopted a medical gaze toward their own body – an introspection
and self-awareness in relation to FGC that they had not previously had (Paper III,
Paper IV). Thus, while not outright adopting Western norms and understandingsof FGC, some had adopted a medical gaze, making them negotiate previous viewsof FGC and dominant Western discourse on FGC (Iguchi et al., 2023; Villani &Bodenmann, 2017). Thus although most sunna cut women claimed notexperiencing long-term harm by having undergone FGC, many described how
they – in light of medical knowledge of FGC had started questioning their own
health in relation to FGC. In a sense, this meant negotiating an “at- risk” status(Kenen, 1996; Kavanagh & Broom, 1998). In their article about at-risk
embodiment, Kavanagh & Broom (1998) explains that people classified as at-riskof developing ill-health must negotiate statistics found on a group level andtranslate them into individual terms. They must consider what it means to be atrisk of countering problems in the future, although not necessarily having
symptoms at present. In this sense, women exposed to medical FGM-discourse
may be produced as at-risk. Through this discourse women learn that FGC is amutilation, and that it might have destructive effects on their bodies and sexuality.
Women related to medical discourse on FGM in different ways. For some, isseems to have contributed to an understanding and a validation of feelings andconcerns already experienced. This is one benefit often described in relation to
medicalization and diagnostic classifications (e.g., Hacking, 1996; Tiefer, 2004).
As such it may also provide recourses to manage one’s troubles, having
knowledge that helps to interpret and understand one’s own body. On the other
hand, knowledge of oneself as being at-risk may also, through expectancy effect,
create iatrogenic disease (Earp, 2021; Johnson-Agbakwu & Manin, 2021). In thisprocess of classification and medical discourse new subjectivities are produced
that impact how the women navigate themselves through life and in relation totheir own self-understanding (Foucault, 1976; Hacking, 2004). In this sense, it
can be interpreted as women become aware of themselves as a mutilated kindthrough the other’s gaze at them, classifying them as victim of mutilation.
The women also became self-aware in relation to social interaction withinterpersonal encounters e.g. with welfare workers, and the wider society,whether they adopted a medical gaze of themselves or not. Here, the feminist

96

scholar Sara Ahmed’s (2014) concept of “sticky association” can be useful tounderstand what women in the research described as how ideas about FGC andmutilation were attached to their Somali appearance (Paper III). Women
described how they had to negotiate others’ expectations on them as potential
upholders of FGC, speaking to an idea of them, or the Somali group, as potential
upholder kinds. Through others’ gaze in contacts with authorities, healthcare
encounters, or school information or other social settings, they negotiatedexpectations of themselves as associated with FGC (Paper III).
Based on Sara Ahmed, meanings, stereotypes, and assumptions can get “stuck”
to people, objects, or social categories (Ahmed, 2014). She refers to the way inwhich associations stick to bodies as “sticky associations.” The way in which the
FGC categories got stuck to the Somali women’s bodies, can make it relevant tospeak of them as “sticky associations.” They are sticky, because they can bedifficult to remove or escape from, as they often reflect dominant social norms
and cultural ideas, repeated in everyday interactions (Ahmed, 2014). They may
stick to the person even though not endorsed or even when not belonging to thecategory – for example the young woman with the appendectomy that had notherself been cut (Paper III). Women in this study, like in a previous study among
Somalis in Sweden, described how the FGC association was something they
expected from welfare workers and could not hide from (Wahlberg, 2018).
This is an example of what Hacking (1996) suggests, that the process ofsubjectivity construction takes place even when people do not actively endorse
classifications. Through interaction and imagery, these categorizations influencesocial interaction, having material effects. One young woman, for example,
described how a to her unfamiliar person at the local store approached her,demanding of her to speak out against FGC as a Somali tradition (Paper III).
Other young and older women described making preparations in relation to
healthcare encounters, or other welfare encounters or school sessions, in order tomanage strong emotional reactions from others in relation to FGC – what in the
FGC literature has been described as conducting “emotional health work”(Jacobson et al., ref). Yet another uncut woman was sent for a gynecologicalexam to rule-out FGC after having complaints in relation to an appendectomy(Paper III). She described how the healthcare staff kept insisting on her maybe
having symptoms because of FGC, even though she asserted she was uncut. She
was thus materially affected by the classification despite not even being a memberof the group thus classified (Berkhout, 2014).
These examples illustrate that classifications not only categorize individuals,
but also contribute to formations of subjectivity by shaping how people
understand themselves and are positioned within society (Ahmed, 2014;
Foucault, 1976; Hacking, 2004). Despite not necessarily endorsingclassifications, they are internalized and have material effects as they may change
the person’s social ambience and the way other people respond and react to them97

(Hacking, 1996). Ideas about women with FGC as mutilated kinds and potential
upholder kinds, affected women in this study, both in terms of their selfunderstanding and how they managed themselves through life. These ideas about
women with FGC as mutilated kinds or potential upholders are institutionalized
discourses in Swedish society – they provide knowledge and understandings
about what FGC is, which is reproduced through legislation and societal
responses on FGC. This study further emphasizes what previous research hassuggested, namely that it appears as paramount to acknowledge the power thatlies in these discourses, as well as being cautious not too readily assume that they
resonate with people’s lived experiences.

Implications for practiceThis thesis has investigated what happens to perceptions of body and sexuality inrelation to female genital cutting in light of changing social norms of FGC postmigration to Sweden. The thesis also examined how FGC is understood andmanaged from the perspectives of welfare workers providing counseling and carein relation to young women with FGC. The study illuminates the complexity of
FGC in a context of immigration, particularly highlighting FGC in relation toindividual care and counseling in welfare encounters.
On a global level, the framing of opposition to FGC has changed from FGC asa health issue towards increasingly adopting a human rights framework(Gruenbaum, 2020; Shell-Duncan, 2008), including addressing FGC in terms ofsocial norms (Gruenbaum, 2020; Villani, 2023). Yet, as displayed in a review
over approaches and responses to FGC, interventions remain largely legal or
medical in nature in Western migration settings (Villani 2023, p. 1). In a similarline, welfare workers in this study predominantly address FGC from a healthperspective, often adopting a genital reductionist approach.
Medical discourse plays a dual role: On the one hand, it has the potential of
empowering women. By transmission of knowledge, it can provide concepts andlanguage to understand one’s body and experiences, or provide knowledge
necessary to navigate systems of support such as healthcare or social care
(Hacking, 1999). Education approaches also have the potential of dispelling
myths, for example among peers or at the community-level, such as those of the“frigid cut” or “nymphomaniac uncut” woman discussed in this thesis.
Differences between perceived normalcy and other peoples’ attitudes,
experiences, and behaviors, may create unnecessary feelings of inadequacy andabnormality that can easily be ameliorated by providing limited information inline with the work described by the welfare workers in this study (e.g., throughbrief sexuality education or information on genital anatomy) (Annon, 1976).

98

On the other hand, while having the potential of empowering women throughtransmission of knowledge, medical discourse also exert control and draw
boundaries of some bodies as normal, and others as pathological. Here policy,
guidelines, and education for professionals have an important role to play inproviding with nuanced information and approaches including being cautious
about how health risks are discussed. A related question is the significance ofdiscerning between various kinds of cutting and their specific likely or possible
effects (Earp & Johnsdotter, 2021). Hitherto there has been a tendency in Swedish
FGC work to direct attention to potential harmful effects of the most extensive
form of cutting (type III). However, as suggested by this research among
Swedish-Somali women, such a strategy obscures differences in experiences of
FGC. As a result, it positions women with infibulation as inevitably harmed,
while women with other types of cuttings may not be recognized as in need ofcare and support.
If welfare workers are expected to provide sensitive and attentive care andsupport for FGC-affected women, they will need to consider a range ofinterrelated dimensions of subjective experiences and meaning-making in
relation to FGC, such as physiological, emotional, relational, sociocultural, andlegal (Johnson-Agbakwu & Warren, 2017). Ideally, assessment should start withthe woman’s own situation, exploring her own understandings and perceptions.
This also requires organizations to provide time and organizational frames thatallow for such a dialogue to take place. The thesis has also shown that welfareorganizations must find ways to address FGC in women without singling out
women on the basis of their ethnic group. One way would be fine-tuned in raising
the question with girls and women who are presumed to be affected. Thisapproach, however, risks falling into generalized or stereotyped assumptions ofparticular groups. Another way could be to take a more universalist approach togenital surgeries that includes all types of involuntary genital surgeries, on all
people of all genders.
In Sweden, FGC is framed as a social problem, shaping how affected womenare perceived and understand themselves. It also affects women’s expectations of
the welfare encounter, shaping interactions, and shaping what stories women
expect there is room for to be told. A lesson from the study is that it seems crucial
to find ways to create space for a dialogue where women’s own understandings
and experiences may come forward, in whatever directions these may take. There
must be room for sharing feelings of victimization and vulnerability in relation to
FGC, and equally important, to provide space for a sense of self as being wholeand adequate. Or for those experiences that are mixed or that fluidly change
depending on the influence of shifting life circumstances, relations, or social
norms.
This thesis discusses how a health approach was privileged before addressing
socio-cultural factors and social norms in relation to FGC. Meanwhile the crucial

99

role of psychosocial counseling has been highlighted to support diaspora women
who grapple with problems in relation to FGC (Abdulcadir, 2019; Smith & Stein,2017). In the Swedish context, promising efforts have been made by civil society
organizations, both at a group level and in the form of individual counseling(Swedish Agency of Gender Equality, 2023). Here, social workers, social work
techniques and perspectives, which consist of analyzing and responding topeople’s situations, using knowledge of human development and behavior, socialand economic institutions, and the interactions of all these factors, may bevaluable in the management of FGC in the diaspora (Villani, 2023).
This thesis has highlighted the complexities of experiences and interactions
with social categories and global discourses on FGC. It has also discussed therisk that welfare initiatives, developed to change practice and social behaviors,
may have unintended consequences when complex, socially embedded, personalunderstandings of FGC are inadequately explored. Instead of being empowering,these may reduce women’s sense of adequacy and produce a feeling ofmutilation.
Still a crucial question is how welfare initiatives can work to protect girls frombeing subjected to FGC, while simultaneously encouraging and empowering
those for whom it has already been done, without undermining their body image
or sense of sexual capacity. If not being mindful of how the categories createdhave material effects and a tangible bearing on people’s lives, this may
unintentionally create new vulnerabilities for the very people the efforts intend to
help.

100

FUNDING

This work was supported by the Swedish Research Council (Vetenskapsrådet),
the Swedish Research Council for Health, Working Life and Welfare (FORTE),Skåne County Administrative Board (Länsstyrelsen Skåne), Ottarfonden,
Stiftelsen för främjandet av Malmö Universitets utveckling, Uppsala University,and Malmö University.

101

102

POPULÄRVETENSKAPLIGSAMMANFATTNING

Kvinnlig könsstympning, eller kvinnlig omskärelse (eng. female genital cutting,FGC) som jag valt att kalla det i denna avhandling, är ett paraplybegrepp för
ingrepp på flickor som förändrar eller skadar de yttre kvinnliga könsorganen utan
att det finns någon medicinsk grund. Tidigare forskning påvisar stora variationer
i hur ingreppen utförs, med vilka medel, av vilka anledningar, och vilka
konsekvenserna blir. Att det leder till lidande och långsiktiga besvär för många
finns det vida belägg för, även om det är viktigt att säga att långt ifrån alla
upplever problem. Sedan 1980-talet pågår ett nationellt och internationellt arbete
för att motverka sedvänjan. Många länder har lagförbud och handlingsplaner för
att få stopp på praktiken, både i länder där det varit tradition och i länder av
migration.
Världshälsoorganisationens (WHO) definition av ingreppen är den som oftast
används inom lag, forskning och policy. WHO delar in ingreppen i fyra
huvudtyper: typ I innefattar ingrepp där klitoris yttre del och/eller klitorishuvan
tas bort, typ II är ingrepp där klitoris yttre del och de inre och/eller yttre
blygdläpparna tas bort, typ III inbegriper ingrepp där delar av de inre och/eller
yttre blygdläpparna tas bort för att sedan sys ihop för att förminska den vaginalaöppningen, detta görs med eller utan borttagande av klitoris. Typ IV innefattar
alla andra skadliga ingrepp på de yttre kvinnliga könsorganen som utförs utannågon medicinsk anledning, såsom exempelvis prickning.
Kvinnlig omskärelse är ett kontroversiellt ämne och synliggör spänningar
mellan olika kulturella uppfattningar och värderingar om kropp, hälsa, ochsexualitet. I Sverige uppfattas kvinnlig omskärelse som ett socialt problem och
som en praktik ämnad att kontrollera kvinnors sexualitet, där nationella insatser
länge verkat för att motverka sedvänjan. Personal inom skola, hälso- och sjukvård
och socialt arbete (som i denna avhandlingen kallas välfärdsarbetare), har en
nyckelroll i att tolka och implementera detta arbete, vilket gör välfärdsmötet till
ett sammanhang där ibland motstridiga kulturella uppfattningar om kvinnlig

103omskärelse, kropp, och sexualitet möts. I den här avhandlingen undersöker jag
vad som händer med uppfattningar om kropp och sexualitet i relation till kvinnlig
omskärelse när man flyttar från en plats där ingreppet är normaliserat till en
kontext där helt andra föreställningar råder. Avhandlingen undersöker också hur
ingreppet förstås och hanteras utifrån välvärdsarbetares perspektiv och praktik.
Baserat på individuella intervjuer (16) och fokusgrupper (3) med
välfärdsarbetare (24) inom socialt arbete, hälso- och sjukvård, och utbildning,undersöker jag hur kvinnlig omskärelse, sexualitet och sexuell hälsa hanteras irådgivning och information riktad till unga kvinnor som potentiellt kan varapåverkade av kvinnlig omskärelse. Genom individuella intervjuer (12) och
fokusgrupper (9) med yngre och äldre svensk-somaliska kvinnor (53) undersöker
jag hur kvinnor relaterar till kvinnlig omskärelse och begripliggör egna
erfarenheter av praktiken i ljuset av förändrade sociala normer och dominerandeföreställningar om kvinnlig omskärelse efter migration till Sverige. Jag diskuterar
hur uppfattningar om kvinnlig omskärelse, kropp, sexualitet och sexuell hälsa
navigeras och förhandlas genom att undersöka betydelser de olika aktörerna
tillskriver kvinnlig omskärelse. Jag belyser också hur förståelsen av dessa
föreställningar förändras och är påverkade av ett komplext samspel av
individuella erfarenheter, social interaktion och global politik om kvinnlig
omskärelse.
Avhandlingen består av fyra artiklar. De första två artiklarna utforskar
komplexiteten i att ge vägledning och lyfta frågor om kvinnlig omskärelse ivälfärdsmöten samtidigt som välfärdsarbetaren har en dubbel roll – att arbeta för
att skydda framtida generationer från kvinnlig omskärelse och samtidigt
uppmuntra och stärka dem som redan blivit utsatta, utan att undergräva
kroppsuppfattning eller känsla av sexuell förmåga. I den första artikeln
konstateras att ett centralt problem är tendensen att överbetona medicinska
perspektiv på sexuell funktion som bidrar till att reducera fokus till enbart
könsorganens betydelse för sexuell njutning. Samtidigt underbetonas den rollsom kognitioner, emotioner och sociokulturella faktorer spelar för upplevelser av
den egna kroppen och sexualiteten. Detta synsätt fick ofta välfärdsarbetarna att
dra slutsatsen att kvinnlig omskärelse oundvikligen påverkar sexualiteten och densexuella hälsan negativt. Det var också främst inom ett biomedicinskt paradigm
som välfärdsarbetarna sökte lösningar och strategier för att främja unga kvinnors
sexuella välbefinnande.
Den andra artikeln undersöker hur välfärdsarbetare förstår och använder
medicinsk diskurs i relation till kvinnlig omskärelse, med hjälp av rådgivning om
menstruationssmärta som ett empiriskt exempel. Studien visar att
välfärdsarbetare navigerar mellan sina olika kunskapskällor, där förvärvad
kunskap om kvinnlig omskärelse fungerade som en lins genom vilken unga
kvinnors situationer förstods. Medicinsk diskurs, och i synnerhet
menstruationssmärta, användes också som utgångspunkt för att diskutera

104

nackdelarna med kvinnlig omskärelse, i syfte att motverka unga kvinnor från att
föra vidare praktiken till kommande generationer.
Den tredje artikeln belyser hur kvinnor navigerar dominerande diskurser om
kvinnlig omskärelse i sina försök att begripliggöra sina erfarenheter. Studien
visade att föreställningar och dominerande framställningar av kvinnlig
omskärelse påverkar hur kvinnor uppfattas av andra, eller hur de förväntar sig att
andra ska uppfatta dem, vilket också påverkar kvinnornas självförståelse.
Kvinnorna "talade tillbaka" till och talade igenom förväntade kategoriseringar av
kvinnlig omskärelse vilka sätter omskurna kvinnor i en stigmatiserad position.
Genom att göra detta förstärks kategoriseringar av den mest omfattande formen
av kvinnlig omskärelse (typ III, faraonisk omskärelse) som stigmatiserad och
skadlig, medan mindre omfattande former av kvinnlig omskärelse (typ I-II, IV,sunna omskärelse) på detta vis frikopplades från en del av det stigma som ärkopplat till kvinnlig omskärelse.
Den fjärde artikeln undersöker subjektiva erfarenheter och uppfattningar om
sexualitet i relation till kvinnlig omskärelse. Studien visade att kvinnlig
omskärelse har betraktats som ett sätt att forma en dämpad kvinnlig sexualitet ilinje med kulturella genusnormer, men att både normerna och sätten att uppnå
dessa har förändrats under påverkan av migration och globalt förändringsarbete
mot kvinnlig omskärelse. Resultaten tyder på att yttre reglering av sexualiteten
genom kvinnlig omskärelse för att skydda kvinnlig kyskhet och oskuld har ersatts
av ökad betoning på inre kontroll och självdisciplin. Kvinnor i studien avfärdadevad som varit viktiga motiv bakom upprätthållandet av praktiken genom att
ifrågasätta kopplingen mellan ingreppet och minskad sexuell responsivitet.
Sexuell responsivitet beskrevs bland många som inneboende och som något som
inte med nödvändighet påverkats negativt av kvinnlig omskärelse, men
beskrivningarna av dessa upplevelser varierade. Medan merparten gav uttryck för
positiva förväntningar på och upplevelser av sexualitet, framträdde bland vissaäldre och yngre kvinnor också mer blandade förståelser. Dessa var förknippade
med uppfattningar om klitoris som betydelsefull för sexuell lust och njutning,vilket skapade osäkerhet eller fick kvinnor att ifrågasätta sin kroppsliga ochsexuella tillräcklighet och förmåga. Sådana förväntningar ska ses i ljuset av idéer
om dämpning vilket ytterligare förstärks i den svenska kontexten som betonar
ingreppens negativa inverkan på sexualitet.
Sammanfattningsvis belyser denna avhandling komplexiteten vad gäller
kvinnlig omskärelse utifrån en migrationskontext, särskilt i relation till vård,information och rådgivning i välfärdsmöten. I Sverige framställs kvinnlig
omskärelse som ett socialt problem, vilket påverkar hur kvinnor som förknippas
med ingreppen uppfattas och förstår sig själva. Välfärdsarbetare tar främst upp
kvinnlig omskärelse ur ett hälsoperspektiv, ofta med en snävt fokus på
könsorganen. Den medicinska diskursen spelar en dubbel roll: den kan verka
stärkande genom kunskap samtidigt som den disciplinerar och utövar kontroll105över kroppen och drar gränser för vissa kroppar som normala och andra som
patologiska. Intervjuerna med svensk-somaliska kvinnor belyser deras
interaktion med konstruktioner av kvinnlig omskärelse i den svenska kontexten,
och illustrerar ett komplext samspel mellan sociokulturella, individuella och
globala influenser.

106

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I

Sexual and Reproductive Health Matters

ISSN: (Print) 2641-0397 (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm21

Sexual health counselling targeting girls and young
women with female genital cutting in Sweden:mind–body dualism affecting social and healthcare professionals’ perspectives
Camilla Palm, Birgitta Essén & Sara Johnsdotter
To cite this article: Camilla Palm, Birgitta Essén & Sara Johnsdotter (2019) Sexual healthcounselling targeting girls and young women with female genital cutting in Sweden: mind–bodydualism affecting social and health care professionals’ perspectives, Sexual and Reproductive
Health Matters, 27:1, 1615364
To link to this article: https://doi.org/10.1080/26410397.2019.1615364© 2019 The Author(s). Published by Informa
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RESEARCH ARTICLE

Sexual health counselling targeting girls and young women withfemale genital cutting in Sweden: mind–body dualism affecting
social and health care professionals’ perspectives
Camilla Palm,a Birgitta Essén,b Sara Johnsdotterca PhD Candidate, Faculty of Health and Society, Centre for Sexology and Sexuality Studies, Malmö University, Malmö, Sweden;
Department of Women’s and Children’s Health (IMCH), Uppsala University, Uppsala, Sweden. Correspondence: camilla.
palm@mau.seb Professor, Department of Women’s and Children’s Health (IMCH), Uppsala University, Uppsala, Swedenc Professor, Faculty of Health and Society, Centre for Sexology and Sexuality Studies, Malmö University, Malmö, Sweden

Abstract: Female genital mutilation (FGM), also referred to as female genital cutting (FGC), has become thesubject of an intense debate exposing tensions between varying cultural values about bodies and sexuality.
These issues are brought to the fore in settings where professionals provide sexual counselling to young
circumcised women and girls in Western, multicultural societies. This article is based on interviews and focus
group discussions with professionals in social and healthcare services. The aim of this study was to examine
how professionals reﬂect upon and talk about sexuality and the promotion of sexual wellbeing in young
circumcised women and girls. Policy documents guide their obligations, yet they are also inﬂuenced byculture-speciﬁc notions about bodies and sexuality and what can be called “the FGM standard tale”. The study
found that professionals showed great commitment to helping the girls and young women in the best possible
way. Their basic starting point, however, was characterised by a reductionist focus on the genitalia’s role insexuality, thus neglecting other important dimensions in lived sexuality. In some cases, such an attitude may
negatively affect an individual’s body image and sexual self-esteem. Future policy making in the ﬁeld of sexual
health among girls and young women with FGC would beneﬁt from taking a broader holistic approach tosexuality. Professionals need to ﬁnd ways of working that promote sexual wellbeing in girls, and must avoid
messages that evoke body shame or feelings of loss of sexual capacity among those affected by FGC. DOI:
10.1080/26410397.2019.1615364
Keywords: female genital cutting, female genital mutilation, sexual health counselling, discourses,
migration, youth, Sweden, sexuality, body

Introduction
Female genital mutilation (FGM), also referred to as
female genital cutting (FGC), has become the subject of intense debate, exposing tensions between
varying cultural values about bodies and sexuality.
On the one hand, FGC is cherished as a meaningfulintervention among women in many groups
upholding the practice,1–3 yet it is perceived as
unacceptable and unlawful in Western countries
receiving immigrants from regions where FGC iscustomary. This poses speciﬁc challenges for professionals in these countries providing care andcounselling to girls with FGC. Studies have shownthat being confronted with stigmatising attitudes

towards one’s body may impair body image inwomen and girls with FGC.1,4 Increased attention
is being placed on how professionals can provide
empirically grounded, sensitive, and holistic careand support for girls and women with FGC without
contributing to stigmatisation and impaired selfesteem.5,6
Sexual health counselling is an arena in which
norms and values about sexuality, body, andhealth are communicated and negotiated, andwhere both the provider and the recipient enter
the conversation with their own speciﬁc set ofideas, experiences, and assumptions.7 The purposeof this study was to examine how professionals in© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.
org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.

1

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

social and healthcare services reﬂect upon and talkabout sexuality and the promotion of sexual wellbeing in young circumcised women and girls. Our
key question was “How are dominant ideas about
FGC and sexuality played out in practice, andhow do professionals handle potential tensions
from conﬂicting conceptualisations of bodies,sexuality, and FGC in encounters with girls andyoung women with FGC?”.
In this paper we will demonstrate that professionals we interviewed tend to employ a genitally
focused approach in their efforts to promote sexual
wellbeing in girls and young women with FGC, often
leading them to conclude that FGC erases or at least
reduces sexual and bodily functionality. Thisapproach adheres to a particular, Western, image ofwhat constitutes a functional body and sexuality.
We argue that strategies for promoting sexual wellbeing within a Western cultural paradigm might beeffective if a girl shares the same cultural understanding. In encounters with girls and young women that
do not share these ideas, however, such an approach,
if employed exclusively and not in a holistic manner,might work counterproductively and risk imposing
feelings of incompleteness and dysfunction.

The context
In investigations of beliefs, values, and motivationsof people across the world by the World Values Survey (WVS), Sweden stands out as an extreme
example of individualism, secularism, and genderequality, not least when it comes to issues related
to sexuality.8 The WVS makes explicit that values
are culture-speciﬁc: that is, people’s notions ofwhat is “good” and “bad” regarding sexuality andbodies are affected by cultural norm systems situated in a certain time and place.9
Since the early 1990s, the Swedish governmentand ofﬁcial bodies have run programmes aimed
at ending FGC, including adoption of guidelines
and action plans, as well as media campaigns
and awareness-raising efforts targeting immigrants
and professionals in childcare, schools, healthcare,and social services.10–12 These reﬂect international
political consensus that the traditional practices of
FGC constitute a violation of human rights andimply serious physiological, psychological, and sexual health threats to girls and women.13,14 Currently, professionals are required to provide bothprevention and support in relation to girls andwomen with FGC.12 Support may include counselling in matters related to health and sexuality, or2

identifying medical conditions and ﬁnding appropriate treatment, or referring the girl or woman to a
specialist.12,15 Preventive measures, stressed in theaction plan,12 focus on attitude change, information
about the legal prohibition of FGC, and identifying
girls potentially at risk and reporting suspectedchild abuse. Professionals need to navigate thesemanifold undertakings, ﬁnding a balance between
working to promote wellbeing among those whohave already gone through the procedure without
condoning the practice.
In a wider context, campaigns, national policies,
and public media embed culture-speciﬁc ideas
about sexuality, body and health, including powerful messages labelling women with FGC as sexuallyand bodily imperfect.12,13,15,16 The notion ofdestroyed sexuality is common in depictions of
FGC in newspapers, journals and best-selling novels.
Such descriptions of FGC have variously been discussed as the “FGM fantasy”17 or “the standard
tale” about FGC.18,19 A prime example is Dirie & Miller’s bestseller Desert Flower, which has been inﬂuential in shaping narratives about FGC and its possible
impact on sexuality. In Dirie and Miller, it is asserted
that “the most minimal damage is cutting away thehood of the clitoris, which will prohibit the girl fromenjoying sex for the rest of her life” (p. 218).20
Statements about destroyed sexuality, as found in“the FGM standard tale”, are not supported in academic literature. Most research on sexuality after
FGC shows that even though some women needcare for negative consequences from FGC, womenwith FGC have sustained capacity to feel sexual pleasure and sexual wellbeing.5,6,21–23 Further, in the
countries of origin, notions of FGC as disﬁguring
the body or damaging sexuality are not common.
Instead, genital modiﬁcations are typically associated with values such as enhanced femininity, adherence to aesthetic ideals, and improved status as awoman.1,3,18,23,24 Research shows that psychologicalexpectations play a determinant role for sexual wellbeing: anxiety over one’s body or the outcome of sexual activity are major inﬂuences on sexual
inhibition.25,26 This has important implications for
professionals’ encounters, especially with sexuallyinexperienced women, as they are in a state of developing their own sexual self-image; young womenwith FGC who are resident in Western countries live
in a society that is openly opposed to the practiceand tells them that they are “mutilated” anddeprived of their ability to ever enjoy sex. Such messages may thus negatively affect body image and sexual self-esteem.

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

Theoretical framework: a holistic
approach to sexuality
This article adopts a social constructionist theoretical approach to sexuality,27 which emphasises that
notions of sexuality are inﬂuenced by cultural
norms, discourses, and social and political practices speciﬁc to their sociocultural setting.9,27,28
Accordingly, conceptualisations of sexuality cannot
be separated from their sociocultural context. Thisapproach allows us to recognise that both providers and recipients carry with them beliefs about
what is “natural”, healthy, good or bad, acceptableor repugnant, and that these beliefs are shaped by
the cultural repertoires available to them.
The dominant Western understanding of sexuality
has been informed by the pioneering model of Masters and Johnson, The Human Sexual Response
Cycle.29 This model identiﬁes four critical events inhuman sexual response: desire, arousal, orgasm,
and resolution, and it has been used as a framework
for understanding and measuring sexual dysfunctions in men and women (e.g., in the ﬁfth and current version of Diagnostic and Statistical Manual of
Mental Disorders [DSM-5]).30 It describes several
physiological responses occurring during sexual excitation such as swelling of genital tissue and changes
in heart rate.29 This understanding of sexual sensations as a genital event relies on a biomedical
understanding of sexuality, giving priority to physiological processes for experiences of desire and sexualpleasure.28 Accordingly, processes that interfere with
one of the stages have been interpreted in terms of“dysfunction”. The model has been criticised for placing too much emphasis on physiological aspects,
and for not taking into consideration the importanceof psychological, sociocultural, or relational aspectsof human sexuality,31 and for not acknowledging
the several pathways to female orgasm.32 Despite
these theoretical and empirical shortcomings, thebiomedically oriented approach holds a prominent
position when it comes to deﬁning sexual problems
in the West.33,34
In this article, our analysis is informed by a holistic approach to sexuality, one which does notignore the biomedical perspective, while also considering sexual self-concept/self-esteem, body
image, sexual self-schema, and sexual relations asimportant aspects at the core of lived sexuality.35

Methods
The empirical data in this article are based on
three focus group discussions (FGDs) and 12

individual semi-structured interviews with a totalof 20 professionals. Included were school physicians, school nurses, and nurses in primary careand residential childcare, welfare staff in schooland social services, as well as health educators.
All had experience with providing sexual healthcounselling, including FGC information aimed at
girls and young women.
Participants were approached either by email
sent to professionals in institutions that worked
with immigrants, such as schools with newly
arrived young people, through personal encounters at FGC-related seminars or lectures, or throughprevious contacts. Among the participants, one
nurse had taken a university course in sexual
health care and one nurse held a master’s degreein public health; others had no special training
in sexual health issues. All were women, aged
26–63 years; none had a background in a region
where FGC is customary. Three participants
described themselves as non-Western. Participants
had been in their profession for 3–20 years, andsome had limited experience with counselling in
relation to FGC while others had more. Professionals worked with girls in secondary andupper secondary school, aged 13–21 years. A few
worked only with minors whereas most worked
with both minors and women over 18 years ofage. The word “girls” will hereafter be used torefer to the young people the professionals worked
with, even though this does not exclude girls over
18 and thus adults by deﬁnition.
Interviews were conducted by the ﬁrst author
from 2016 to 2018. FGDs comprised three individuals each and lasted 1.5–2 h. Individual interviews
lasted one hour on average except one that wasinterrupted after 20 min due to unforeseen circumstances. Many participants were interviewed
on several occasions, often both in person at the
professionals’ workplace and by telephone, whichallowed for further elaboration of themes fromthe previous interviews. One professional participated in both an FGD and an individual interview.
A basic interview guide was used and focused on
strategies used in encounters in relation to FGC in
general and in relation to sexual health matters. It
also included questions about the participants’views of situations they thought had worked welland situations they had found challenging in providing care or support to girls.
The interviews were digitally recorded and transcribed together with notes from interviews conducted in informal contexts. Interviews were3

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

conducted in Swedish and the quotes have beentranslated by the authors. Drawing on qualitative
analysis techniques, we searched for sub-themes
and overarching themes36 in relation to sexuality
and strategies for promotion of sexual wellbeing.
The empirical data were interpreted in light ofquestions that arose from the social constructionist
framework emphasising how people talk about,negotiate, and construct meaning on the sexual
body and its capacity.27 In the interpretative process, a particularly strong overarching principle
was identiﬁed, around which all other categories
relating to sexual health promoting strategies
seemed to be organised, namely a body-oriented
approach to sexuality. We considered this particular aspect would add important perspectives toexisting research on sexual health counsellingand FGC, and thus we paid extra attention to thistheme in re-readings of the transcripts.
Informed consent was obtained from all participants. Interviewees are referred to by numbers andinformation about profession, which provides
some context while safeguarding conﬁdentiality.
This study has no formal decision on ethics
approval. According to the Swedish Ethical Review
Act the study does not require ethical vetting froman ethics review board (personal communication
with a member of the board, 9 Nov 2017).

Findings
The (cut) genitals as the site for sexualsensation, dysfunction, and intervention
From the interviews with professionals, it was evident that staff were committed to do their best in
helping girls with FGC. Professionals were attentive
to identifying FGC-related health problems, andprovided information about possible complications they thought were of relevance in relation
to the procedure and about available paths forhelp and support. Upon individuals’ requests, professionals helped arrange appointments for deinﬁbulation, and many also reported accompanying
girls to the hospital. Some, cautious about linking
health problems to FGC, tried to refer the girl toa doctor or gynaecologist to obtain a proper medical assessment for genital or related concerns. Professionals also showed devotion to promoting
sexual wellbeing in girls with FGC.
A salient feature in the interviews was that strategies promoted and ways of understanding girls’
situations were anchored in a biomedical modelof health and sexuality, where priority is given to4bodily functions, more precisely the genitals.
These tendencies are discussed below, in relation
to how professionals talk about and reﬂect upon
sexuality in girls with FGC. First, we relate the professionals’ narratives to the discussion about “theFGM standard tale” before focusing on how theseconceptions are played out in practice in sexual
healthcare counselling with girls with FGC.

FGC as interfering with sexual pleasure?
The idea that women have impaired sexual function after all types of FGC, as purported in the“standard tale”, was salient in our study. Many professionals were convinced that girls had lost theirability to enjoy sex as a result of FGC. Some did
not relate loss of sexual capacity to a particular
type of cutting, as expressed by one school welfare-ofﬁcer (1):“[with cutting] you take away all sexual pleasure forthe woman.”
Others attributed loss of sexual sensation to procedures involving the clitoris, as asserted by ahealth educator (2):“[if] they have done pricking on the girl’s clitoris,
then you still might have destroyed parts of thenerves, because that’s what can happen.”*
These accounts testify to a Western tendency toview sexual sensation in circumcised women as
something that could either be damaged or
removed solely through cutting of the genitals,
hence situating sexual desire and pleasure, orloss thereof, in the genitals. Yet, several school
nurses stressed that they place emphasis on thesize and extent of the clitoris to encourage girls
about their ability to feel sexual pleasure, emphasising the inner genital structures that have beenleft intact after FGC. Here a nurse (3) at a residential
home for children in state custody, who reported
that she had extensive discussions about sexuality
with all the girls she met:
“I usually tell them: you know, this thing about cutting in women, those who made that up were stupid.
They thought that we only have a little tiny thing,
but look how big it really is [referring to a 3D-clitoris]! So, we [women] can feel desire, that’s just a*Pricking refers to the practice where a sharp object is used on
the clitoris to induce a drop of blood, sometimes also referred
to as “symbolic circumcision”.

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

matter of being inventive, to try out and explore foryourself”.
Professionals stressed the importance of the clitoris for sexual sensation in line with the dominantdiscourse discussed above. Some of them, however, accentuated possibilities for sexual pleasure
by focusing on the clitoral tissue that remains
inside the body after FGC rather than seeing sexuality as irrevocably impaired by FGC.
Some participants had concerns about how
sexual activities could be carried out in a pleasurable way if a girl had had her genitals altered,especially in the case of suturing. Lack of available positive examples of sex and FGC seemed
to create insecurity about how to address the
topic of sex when providing information or counselling to young women with FGC. Here, the professional’s available cultural framework did notprovide sufﬁcient guidance, as illustrated by aschool nurse (4):she described herself as being in a state of re-evaluating previous understandings of FGC and its
impact on sexuality, not fully knowing “what tobelieve anymore”. Whether or not the professionals had positive or negative notions about
the possibilities for women with FGC to enjoy sex,
these notions were focused on bodily aspects.
How these ideas were played out in practice will
be discussed below.

“[I wonder] how they [girls with FGC] think sex will
be carried out. I think that’s really difﬁcult when I
have sex ed class and talk about how we look[down there], and I hand out pictures [of the genitals], and then I think ‘well, this is not how [intercourse] will be for you, you poor thing’ [said withsorrow in her voice] … Sometimes I think to myself,that I don’t even know how they can have sex [sohow would they know]. You know I don’t really
get it sometimes. How do you get through what
has been sewn closed?”

Problems and solutions in the body
While a biomedical approach often led professionals to conclude that FGC without exception
negatively interferes with sexuality and health, it
was also within a biomedical discourse that solutions and strategies to promote girls’ sexual wellbeing were sought. While professionals weresometimes hesitant to communicate about sexuality, for fear of dampening girls’ expectations
regarding their future sexuality, many reported
engaging in discussions about sexuality with girls
they encountered. Professionals balanced thedual tasks of not condoning a practice they
thought of as harmful, unnecessary, or otherwise
wrong, while at the same time trying to be sensitiveand careful not to stigmatise girls who havealready undergone FGC. Much of the support andcare described by the professionals seemed towork well, as in this example recounted by a school
nurse (6):The limitations of the current discourse as a point ofreference for the professionals was evident in thefollowing situation, in which a school nurse wasconfronted with new ideas: she had held a sex education class in which girls with FGC expressed worries about their future sexual life. The female
Somali-speaking interpreter who assisted in theclass offered to comment upon their worries, andshe assured the girls that she herself as marriedand circumcised had a satisfying sexual life, andthat she felt sexual desire and pleasure. The school
nurse (5) commented upon the situation:

School nurse in FGD: I remember a girl … she was so
relieved because she was, when we talked about what
the body looks like, biologically, and the clitoris, how
it is embedded inside, because she thought it was all
over, the sexuality, that she would never be able [tofeel pleasure] … so she was relieved when she got
information about the body … and at the sametime, this girl I met, she had probably never fully
approached her body but kept a certain distance toher [circumcision], that it [the circumcision] was nogood and that she distanced herself and had neverreally [shows with her body language]…

“I must admit I was totally convinced that it was
impossible to feel pleasure after female circumcision. But now with [the interpreter] saying that it’s
possible … [pause] I guess I have to think differently
about it”. (From notes)

Interviewer: Touched and looked?

When confronted with a narrative that challenged
her previous understanding of sexuality and FGC,

School nurse in FGD: Yes. And there I think it would
have been good to know if there was anywhere she
could get [information about sexuality], dependingon what type [of circumcision] she had, because
the outcome may vary [depending on type]. ThereI felt a bit insufﬁcient.
5

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

And while much of the support and care describedby the professionals seemed to work well, thestrong body-focused approach sometimes stoodout as problematic. On some occasions, professionals seemed to transfer their own ideas
about body and sexuality in counselling, without
exploring the girls’ own conceptualisations. This
often was reported in relation to promotion of
deinﬁbulation surgery or in providing sex education, as in this example from a school nurse (7)recalling individual encounters she had had withgirls:“I showed [the girls] what the female genitals look likein the normal female body, and then after different
types of circumcision. Then I told them that theycut off a bit of the clitoris and what the risks of thatare, with the sexual feeling and everything.”
In a similar vein, many professionals took on thetask of educating girls about what they thought
could be negative sexual and reproductive healthconsequences resulting from FGC. Information
about supposed problems appeared to be given
regardless of how girls had presented their situation, which form of FGC they had described, orwhether they had expressed having troubles inrelation to FGC. Scenarios were often describedalong this line, here with examples from two
school nurses (8 and 4):“[I have asked] if they have problems … somatic
problems, and then they usually say yes or no.
Then I generally go on telling [them] that, well,later you might want to have sexual relations …
then it can be that it’s a bit of a problem with sensation and that it might be difﬁcult feeling pleasure
and all.”“What I said [to her] was that I have thought a lot
about your problems with constipation and I thinkthat it could be a symptom … when in fact you
are circumcised and sewn closed. … But then if
she insists that she’s not [circumcised], then it falls
ﬂat, you see? Then I can’t follow through with that.”
In other instances, girls more evidently rejected theprofessionals’ proposed solutions to their situation,for example regarding deinﬁbulation. Many professionals had tried without succeeding to encourage girls to undergo premarital deinﬁbulation.
Professionals reasoned from a medical perspective
when they argued that deinﬁbulation could help
girls escape sexual or reproductive health problems. They argued that such surgery would
6

prevent painful vaginal intercourse, severe menstrual pain, stagnation of menstrual blood, or
blood accumulating in the vaginal cavity. Even
though some reported having met girls who
expressed relief when they received information
about deinﬁbulation, many shared the experiencethat girls often rejected this opportunity, did notturn up at a doctor’s appointment even thougharranged in agreement with the girl, or that girls
were reluctant to listen to the information given.
One school nurse (7) explained:“No one has wanted it [deinﬁbulation], actually. To
operate it, remove it [the FGC]. And they have been
comfortable with this [FGC] since it’s a traditional,
cultural thing. So, they didn’t want to get rid of it,
and when I simply explained the disadvantages of
keeping it compared to having it removed, and theadvantages of having [the FGC] removed, they
didn’t want to listen, and they felt that they stillwanted to keep it because otherwise no men
would want them.”
Despite the professionals’ efforts to clarify theadvantages of performing deinﬁbulation, it appears
that the girls most often had their own motives for
not wanting the operation. The interviews suggestthat the girls’ own perspectives, expectations, andfeelings regarding their genital physiology were seldom explored. These examples demonstrate a tendency among professionals to highlight possible
negative outcomes of FGC as a means to help girls
recognise potential problems of FGC, or in orderto encourage girls to link health problems with
FGC, sometimes with encouragement to go throughgenital surgery in the form of deinﬁbulation. For
some, discussing possible drawbacks of FGC wasalso a way of trying to promote negative attitudes
to FGC in order to protect future daughters.
Too strong a focus on biomedical aspects, in
combination with neglect on the professionals’
part to explore the girls’ own perspectives,appeared as a possible obstacle to developing
understanding of the girls’ situation. Despite goodintentions, what is communicated to girls withsuch framing is the conceptualisation of their genital status as undesirable or problematic, and thisfrom a purely biomedical view. Consequently, theobvious risk here is that girls are coached into interpreting their sexual experiences and bodily sensations in terms of problems and displeasure,even though current research does not support
statements about lost ability to feel sexual pleasureor, for example, constipation, as results of FGC.21,37

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

Discussion
A mind–body dualism approach
Mind–body dualism is the tendency within theWestern biomedical paradigm to make a strict division between what is physical and what is mental,
a tendency evident also in Western study. Our
analysis of interviews with professionals suggests
a widespread tendency to situate sexual sensations, dysfunctions, and suggested interventions
exclusively in the (cut) genitals. In this discourse,
both cut girls’ sexual and reproductive health problems as well as suggested solutions were primarily
formulated in terms of physiological concerns;
consequently they often seemed to neglect the
girls’ own values, assumptions, and expectations
around sexuality, body, and FGC. While the biomedical discourse usually led professionals to conclude that FGC always interferes with sexuality
and body in a negative way, some used the biomedical discourse in efforts to promote girls’ sexual
wellbeing by offering help for deinﬁbulation or
encouragement regarding the capacity to experience sexual pleasure through emphasising which
genital structures had been left intact. As mentioned, and similar to what has been found in aninterview study among Swedish midwives,38 someof the professionals we interviewed assumed completely impaired sexual capacity to be a result of
FGC. Other interviewees were not convinced
about this, but instead asserted that girls still canfeel sexual pleasure with the help from internal clitoral structures. It seems a discursive change isgoing on in Sweden in which the structure of theclitoris and its importance for female sexual pleasure have been stressed. This message has been
displayed in newspapers, sex education, and publiccampaigning during the last couple of years.39
While we contend that this information is important and useful, nevertheless it situates sexual
experience and pleasure exclusively in the genitalarea and thus fails to challenge the dominant
reductionist view of sexuality.
The notion of the genitals as the primary site forfemale sexual and reproductive wellbeing constitutes
a culture-speciﬁc understanding and framing of sexuality. It builds on a “mind–body” dualism approachin which priority is given to biomedical processes
and reﬂects the age-long questions of where to situate health in relation to the “mind” or the “body”.7,40
This biomedical understanding is mainly focused on
medical information about anatomy, physiology, anddysfunctional organs, and less on hard-to-measure

psychological and sociocultural issues, which are crucial for lived sexuality.7 Given the prominent position
that the biomedical paradigm has in informing Western understandings of sexuality28 and the Westernconstrual of FGC,21,41 it is not surprising to ﬁnd thatamong professionals, priority is given to genital
physiology. A similar tendency can be seen when it
comes to health care for women with FGC, some ofwhom experience that healthcare staff put too strong
a focus on their genitals even when they seek help forother problems.42–44 The view among the professionals that FGC is a key determinant for ill healthand dysfunction is also in accordance with how theissue traditionally has been approached in the
research ﬁeld, as reviewed elsewhere.45
That the genitalia, and what has happened tothem, are given priority in care by the professionals towards girls with FGC, is not necessarily
undesirable. It is also not wrong to encourage girls
to go through deinﬁbulation. However, for thesestrategies to be empowering, they must be acceptable to girls and make sense to them in terms of
how they understand “good” and “bad” as regards
body, sexuality, and health.7 FGC in the girls’ natal
countries is traditionally seen as “good” and as away of inscribing identity (e.g. gender, religious
or ethnic identity) and “the very notion of healthis wrapped up in having FGC” (p. 53).45 Such meanings are shaped in a local cultural context and by
personal experiences that might, or might not,have new meanings in diaspora.45 For girls who
have adopted or already are holding culturalbeliefs about FGC as undesirable or harmful tohealth and sexuality, biomedical approaches that
promote deinﬁbulation or stress the importanceof the clitoris’ inner structures for sexual enjoyment, can be helpful.46 However, for girls who
do not hold these views of their bodies, there
might be drawbacks to an approach that relies
too heavily on physiological aspects.
A paradigm that systematically emphasises therole of the genitals in sexual response and arousal,
presumes that any type of FGC will interfere with
optimal functionality, so-called genital determinism.47 In such a paradigm, there is little room forbeing both cut, or “mutilated”, and functioning.48
The only possible way to enhanced sexual healthwithin such a discourse lies in medical interventions that somehow “undo” the cutting (e.g., deinﬁbulation or reconstructive surgery of the clitoris)
or focusing solely on what has been left “intact”.
Girls and women who do not share these conceptions of FGC and sexuality, or who do not7

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

wish to further modify their genitals, still have tocarry the weight of being labelled as disﬁgured,or “mutilated”, and dysfunctional.
As acknowledged in systematic reviews,21,37 biological aspects of sexuality are inseparable fromsocial aspects.40,45 This situation presents a challenge in establishing the scientiﬁc “facts” about
FGC and its impact on sexuality and health. The
current discrepancy between well-meaning information about possible negative outcomes andthe real-life experiences of girls and women with
FGC, may thus undermine the legitimacy of information efforts.49 Furthermore, there is a risk of
suboptimal care if the caregiver offers care basedon what is known about a group at a group level
instead of information solicited in the personalencounter with an individual girl.
Although overwhelmingly compelling, the biomedical paradigm has proven insufﬁcient for
describing people’s experiences of sexuality.28
While genitalia are usually central to sexual
activity, recent discussions on sexuality recognisesexuality as multifaceted, where the role of thebrain, relational aspects, sociocultural dimensions,and psychological expectations for orgasm and sexual satisfaction must be given stronger weight.26,31
Here too a genitally focused approach runs the riskof neglecting other aspects of importance to sexual
wellbeing.35 A growing body of literature on genital
self-esteem and its relation to female sexual function shows that body shame, anxiety over body
appearance and a negative attitude towards one’s
genitals undermine sexual wellbeing and the ability to enjoy sex.26,50–52 This broader approach tosexuality and sexual pleasure, in which it isacknowledged that discourses have a bearing ona person’s lived sexuality, accentuates the importance of exploring what discourses, ideas, expectations, and experiences girls are carrying
regarding sexuality and body in relation to FGC,
especially in situations of sexual counselling.
Implications for practice
The discussion in this article has implications forboth health policies and supportive interventions.
For decades, there has been a global public discourse condemning the practice of FGC, and campaigning efforts aimed at eliminating FGC often
highlight a multitude of possible adverse consequences of FGC, including assertions about erased
sexual function. Few representations exist that provide girls or professionals with positive examples of
how sex can be pleasurable also after FGC,
8although we provide an example of an exception
in Box 1. On an individual level, too strong anemphasis on genital physiology, including negative
psychosexual messages to girls that their ability toenjoy sex might have been destroyed, runs the riskof leaving girls with FGC with feelings of hopelessness regarding their own prospects of a joyful sexual life. Further, in healthcare and social careencounters, adherence to the dominant Western
discourse in which sexuality is primarily describedin terms of physiological concerns is likely to leave
professionals with an inadequate understanding of
an individual girl’s sexual health. Such an
approach risks neglecting other aspects that arevital for sexual pleasure, in line with a more holistic view of sex. Although it is critical to educatethese girls and young women, like all girls andyoung women, about genital anatomy, physicalsexual response, and biomedical signs of genital
health and ill health, it appears to be equallyimportant to raise discussions about broader
issues such as self-conﬁdence, wellbeing, and quality of life.52
Box 1. Example of sex education for womenwith FGCThe Swedish Association for Sex Education (RFSU), a civilsociety organisation with great political inﬂuence inSweden, has recently changed their information about
FGC on their website after years of only publishingcondemning text about FGC. RFSU now provides a
positive example of how sex can be pleasurable also after
FGC. Under the heading “Can you have sex as genitally
mutilated?”, the information now reads: “It is possible toboth masturbate and have sex with others. It is not truethat the genitals lose all sensation after a genital
mutilation, or that the ability to feel desire and pleasurehas disappeared. The whole vulva is full of nerve endings
and it can be pleasurable to stimulate it in different ways.
If the tip of the clitoris, that is, the visible part, has been
cut off and there is only scar tissue there, you can try tostimulate the surrounding area with ﬁngers or with avibrator to be able to reach the parts of the clitoris thatremain inside of the body. In order to reach the clitoris
inner parts, it can be good to use a more powerfulvibrator and a wider base on the vibrator. If the clitoralglans has been cut off, it may also be that other parts ofthe body become extra sensitive and feel especially niceto caress or kiss – such as lips, throat, nipples or thighs.”(The Swedish Association for Sex Education, 10 April2019) [our translation from Swedish].

C. Palm et al. Sexual and Reproductive Health Matters, 2019;27(1):1–11

Conclusion
In this article, we have shown that a biomedical,
genitally focused approach to sexuality and sexual
health is prioritised over other aspects of sexuality
in sexual health counselling with girls who haveundergone FGC. Professionals seemed to neglect
exploring the girls’ own experiences and perceptions of the situation, which may open up room
for professionals’ projecting their own perceptions,albeit unintentionally. They align to a framework
based in biomedicine, characterised by genital
reductionism. This narrow focus might not be problematic if the interpretation of the girl’s situationis shared between them and supportive measures
are accepted by the girl. We suggest, however,that some of the interventions might generate
unintended consequences, in that they may negatively affect the girls’ body image and sexual selfesteem. Future policy making in the ﬁeld of sexual
health among girls and young women with FGC
would beneﬁt from taking a broader holistic
approach to sexuality. Professionals need to ﬁnd

ways of working that promote sexual wellbeing ingirls, and must avoid messages that evoke body
shame or feelings of loss of sexual capacity
among the those affected by FGC.
Disclosure statement
No potential conﬂict of interest was reported by theauthors.
Funding
This work was supported by the Swedish ResearchCouncil for Health, Working Life and Welfare(FORTE) and the Swedish Research Council(Vetenskapsrådet).

ORCID
Camilla Palm
http://orcid.org/0000-0003-01265265
Birgitta Essén
http://orcid.org/0000-0002-29002849
Sara Johnsdotter
http://orcid.org/0000-00027625-5873

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Résumé
La mutilation sexuelle féminine (MSF), aussi appelée excision, est devenu un sujet de débat intensequi expose des tensions entre différentes valeurs
culturelles sur les corps et la sexualité. Ces questions sont mises en avant dans des environnements où les professionnels donnent des conseils
sexuels aux femmes et ﬁlles excisées qui vivent
dans les sociétés multiculturelles occidentales.
Cet article est fondé sur des entretiens et des discussions par groupe d’intérêt avec des agents desservices sociaux et des soins de santé. Le but decette étude était d’examiner comment ces professionnels réﬂéchissent à la sexualité et à la promotion du bien-être sexuel des jeunes femmes etﬁlles excisées et comment ils en parlent. Des documents directeurs guident leurs obligations, pourtant, ils sont aussi inﬂuencés par des notions
propres à leur culture sur les corps et la sexualitéet ce que l’on peut appeler « l’histoire type de la
MSF ». L’étude a révélé que les professionnels s’efforçaient d’aider les ﬁlles et les jeunes femmes dela meilleure façon possible. Leur point de départ
de base était néanmoins caractérisé par une
optique réductionniste sur le rôle des organes génitaux dans la sexualité, ce qui les amenait à négliger d’autres dimensions importantes dans lasexualité vécue. Dans certains cas, une telle attitude peut inﬂuer négativement sur l’image corporelle d’un individu et son estime de soi sexuelle. Il
serait bon que les futures décisions politiques
dans le domaine de la santé sexuelle des ﬁlles etdes jeunes femmes excisées adoptent une
approche holistique plus large de la sexualité.
Les professionnels doivent trouver des méthodes
de travail qui favorisent le bien-être sexuel desﬁlles, et il leur faut éviter les messages qui évoquent la honte du corps ou des sentiments deperte de capacité sexuelle chez les excisées.

Resumen
La mutilación genital femenina (MGF), también
conocida como ablación genital, es tema de unintenso debate que expone las tensiones entre
diversos valores culturales sobre el cuerpo y la sexualidad. Estos asuntos se ponen de relieve en contextos donde profesionales brindan consejería
sexual a mujeres jóvenes y niñas circuncisas ensociedades occidentales multiculturales. Este
artículo se basa en entrevistas y discusiones en
grupos focales con profesionales en servicios
sociales y sanitarios. El objetivo de este estudioera examinar cómo los profesionales reﬂexionan
y hablan sobre sexualidad y la promoción delbienestar sexual en mujeres jóvenes y niñas circuncisas. Los documentos de políticas guían sus
obligaciones; sin embargo, también inﬂuyen en
ellos nociones culturales especíﬁcas sobre elcuerpo, la sexualidad y lo que se puede denominar “el cuento estándar sobre MGF”. El estudioencontró que los profesionales mostraron un
gran compromiso para ayudar a las mujeres
jóvenes y niñas de la mejor manera posible. Sin
embargo, su punto de partida básico estaba caracterizado por un enfoque reduccionista en el rol delos genitales en la sexualidad; por lo tanto, hacía
caso omiso a otras dimensiones importantes dela sexualidad vivida. En algunos casos, esa actitud
podría afectar negativamente la imagen corporal y
autoestima sexual de una persona. Para formularfuturas políticas en el campo de salud sexual demujeres jóvenes y niñas con MGF, sería útil aplicar
una estrategia holística general con relación a lasexualidad. Los profesionales deben encontrar
maneras de trabajar que promuevan el bienestar
sexual de las niñas, y deben evitar transmitir mensajes que evoquen humillación corporal o sentimientos de pérdida de capacidad sexual entre
las personas afectadas por MGF.
11

II

Sexuality & Culture
https://doi.org/10.1007/s12119-021-09895-w
ORIGINAL PAPER

Adolescent Sexual and Reproductive Health Counsellingin Relation to Female Genital Cutting: Swedish
Professionals’ Approach to Menstrual Pain as an Empirical
ExampleCamilla Palm1,2Birgitta Essén2· Sara Johnsdotter1 · Eva Elmerstig1 · Charlotta Holmström1 ·Accepted: 3 July 2021
© The Author(s) 2021

Abstract
In Sweden, as well as in an international context, professionals are urged to acquire
knowledge about possible health effects of female genital cutting (FGC) in order totackle prevention and care in relation to the practice. While professionals are guided
by policies and interventions focusing on medical effects of FGC, some scholars
have cautioned that many popular beliefs about health risks rest on inconclusive evidence. The way professionals understand and respond to health information about
FGC has in this context largely been left unexamined. This article aims to provide
a qualitative exploration of how professionals in Sweden approach adolescent sexual and reproductive healthcare encounters in relation to acquired knowledge about
FGC, using menstrual pain as an empirical example. The analysis shows that there
was a tendency in counselling to differentiate young migrant women’s menstrualcomplaints from ordinary menstrual pain, with professionals understanding pain
complaints either in terms of FGC or as culturally influenced. The study shows how
professionals navigated their various sources of knowledge where FGC awarenessworked as a lens through which young women’s health complaints were understood.
Biomedical knowledge and culture-specific expectations and assumptions regarding
menstrual pain also informed counselling. Finally, the article discusses how FGC
awareness about health risks was used constructively as a tool to establish rapport
and take a history on both menstrual pain and FGC. The analysis also recognises
potential pitfalls of the approaches used, if not based in well-informed policies andinterventions in the first place.
Keywords Female genital cutting · Sexual and reproductive health counselling ·Menstrual pain · Migration · Youth · Sweden* Camilla Palm
camilla.palm@mau.se
Extended author information available on the last page of the article

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Vol.:(0123456789)

C. Palm et al.

Introduction
Female genital cutting (FGC), also referred to as female genital mutilation (FGM),1
involves a range of genital alteration procedures performed on girls for non-medical
reasons. Procedures are categorised by the World Health Organization (WHO) into
four main types: excision of the glans clitoris and/or clitoral hood (type I), excisionof the labia (type II), narrowing of the vaginal opening after cutting and suturing
the labia minora, sometimes combined with clitoridectomy (infibulation, type III),and type IV (unclassified) including pricking, nicking, scraping and cauterisation(WHO, 2018). It occurs primarily in some groups in Sub-Saharan Africa and inparts of Middle East and Southeast Asia, and circumstances under which the operation is performed vary widely. Also motives vary with locality and may include
social acceptance, preparation for adulthood and marriage, marking of ethnic/religious/gender identity, preservation of cleanliness and modesty, and aesthetical preference (Ahmadu, 2000; Jirovsky, 2014; Leonard, 2000; Powel et al. 2020).
In policy and guidelines for professionals, in Sweden and globally, addressing
possible medical sequelae of FGC has continuously been emphasised as a means toprevent the practices from being perpetuated and to optimise care and support forgirls and women with FGC (e.g. Ministry of Health & Social Affairs, 2018; WHO,
2008; WHO, 2016; Östergötland County Administrative Board, 2015).
Meanwhile, several scholars have noted that research on health risks possibly
related to FGC does not provide a clear picture (e.g. Obermeyer, 2005; PPAN 2012).
In many cases, evidence of sexual and reproductive health outcomes is inconsistent (see reviews by Berg & Denison, 2012; Johnsdotter, 2018; Obermeyer, 2005).
Whereas many studies highlight increased health risks and, for example, have founda higher likelihood of reportings of genital pain (Lurie et al., 2020) or less sexual
satisfaction (Berg & Denison, 2012), other studies on sexuality document frequent
reports of orgasm, desire and satisfaction (Abdulcadir et al., 2016; Catania et al.,2007; Obermeyer, 2005) and no statistically significant differences on genital pain
between women with or without FGC (Alsibiani & Rouzi, 2010). This great variation underscores the challenges in conducting research on sexual health outcomes
related to FGC. These challenges are both methodological and conceptual. As highlighted by Obermeyer (2005) in her review, many of the existent studies suffer frommethodological shortcomings such as small research samples and lack of appropriate control groups. Many descriptions of presumed health effects also fail to discriminate between different forms of procedures or how they are performed e.g. in a
medicalised setting, by a medically trained person at a hospital or at home, or underless sterile conditions (Obermeyer, 2005; Earp & Johnsdotter, 2021; PPAN 2012).2
1

What to call the non-western forms of genital alteration procedures is debated. While WHO uses
‘mutilation’, it is conceded that such a term may be stigmatising, not least in a clinical context (WHO2018). In this article, the term ‘FGC’ will be used to refer to all practices included in the WHO typology.
Other descriptive terms will also be used.
2
Some also contend that representations of health risks are culturally biased, as they focus solely on
non-western forms of FGC although there are forms of FGCs that in a strict clinical and anatomical
sense are comparable to medically unnecessary surgeries on children generally accepted in the West; i.e.,

13Adolescent Sexual and Reproductive Health Counselling in…

Another challenge is the lack of appropriate theoretical concepts to properly capture
subjective feelings of pain or pleasure, when such experiences are highly embedded
in cultural meanings, values and ideals (see e.g. Dopico, 2007 or Jirovsky, 2014 forempirical examples). Consequently, these factors limit the generalisability of medical claims commonly presented in policy and public-health research on FGC, andmake it difficult to establish the actual medical effects of FGC on sexual and reproductive health (Shell-Duncan, 2008).
Against this background, a central question is how professionals navigate andmanage sexual and reproductive health in care-encounters with girls and womenwith FGC, when they are positioned between FGC policy and interventions on the
one hand, and uncertain research evidence on the other. Previous research amongprofessionals in western countries has focused primarily on care providers’ knowledge, attitudes and practices (KAP). Reviews show professionals lack confidence
and experience in caring for women with FGC, reporting a variation in FGC training
among care providers (see reviews by National Board of Health & Welfare, 2020;
Reig-Alcaraz et al., 2016). To date, the way professionals understand and respondto knowledge gained from FGC training, campaigning and information, including
awareness of potential health risks, has not been studied. This article aims to explore
how professionals in schools, healthcare and social services approach sexual andreproductive healthcare encounters in relation to acquired knowledge about FGC.
Using menstrual pain as an empirical example, the article demonstrates how professionals navigate their different sources of knowledge in counselling with young
women potentially affected by FGC. Ultimately, the study also serves as an exampleof the impact of FGC policy and interventions on work practices, a question which
merits further critical examination.

Painful Menstruation in Relation to Female Genital Cutting: Where
Does the Evidence Stand?
Pain associated with menstruation, known as dysmenorrhoea, is commonly separated into pain occurring with menstruation in the absence of pelvic pathology(primary dysmenorrhoea), or pain occurring with menstruation caused by other
underlying pelvic conditions such as endometriosis or pelvic inflammatory disease(secondary dysmenorrhoea) (Iacovides et al., 2015). In primary dysmenorrhoea,
studies have found pain to derive from several factors, particularly: excessive uterine contractions under the influence of prostaglandins (Fajrin et al., 2020), contractions of uterine blood vessels with decrease in uterine blood flow (ischaemia) andreduced oxygen to the uterus (hypoxia), and the stimulation of pain neurones (Iacovides et al., 2015). In severe dysmenorrhoea, an association with high levels of prostaglandins has been reported, and prostaglandins are implicated also in secondary

Footnote 2 (continued)
circumcision of boys, genital cosmetic surgeries on minors, and ‘normalising’ intersex surgeries on children (Brussels Collaboration on Bodily Integrity 2019).

13

C. Palm et al.

dysmenorrhoea (Harel, 2012; Iacovides et al., 2015). Medical treatments recommended in research and guidelines for professionals include analgesics or hormonal
contraceptives to reduce prostaglandins, while treatment of secondary dysmenorrhoea can include treatment with medication or other treatment of the underlying
condition (ACOG, 2021; Harel, 2012).
In policy papers and research on FGC citing potential health risks, it is often
claimed that FGC causes menstrual pain (e.g. Alsibiani & Rouzi, 2010; Nour, 2008;
WHO, 2016, 2020, 2021), though few studies have examined this alleged association or its causes in detail. The rationale for the stated outcome is seldom clarified,although two hypotheses dominate in the literature: that a narrow vaginal opening(FGC type III) may lead to obstruction of menstrual flow and haematocolpos andhaematometra (i.e. accumulation of blood within the vagina and uterus) or that FGC
may give rise to infections which ascend to the internal genitalia resulting in inflammatory disease and scarring and subsequent painful menstruation (Abdulcadir et al.,2011; Elnashar & Abdelhady, 2007; Iavazzo et al., 2013; Nour, 2008; WHO, 2018).
The hypothesised causality has not yet been verified through empirical studies.
Among the few studies that have examined pelvic infections in relation to FGC, none
has found an association between the two (see reviews by Iavazzo et al., 2013; Obermeyer, 2005). The hypothesis about an accumulation of blood seems to be deduced
from the condition ‘imperforate hymen’ (a total closure of the vagina) where bloodis accumulated in the internal genitals. Whether this condition can be extrapolated toindividuals with FGC type III, infibulation (where there is still a vaginal opening),
has not been confirmed through empirical studies or clinical observation, i.e. ultrasound or clinical findings of retained menstrual fluid at defibulation surgeries.
On closer examination, a review of the literature shows that sources supporting
specific claims about menstrual pain do not always provide evidence in favour ofthe claim, and no apparent original research forming the basis of the claim can befound. One example illustrating this tendency is the systematic review by Iavazzoand colleagues (2013), cited in the WHO guidelines for professionals (WHO, 2016).
With referral to four reviews, the authors claim that FGC causes painful menstruation ‘due to obstructed blood flow’ (Iavazzo et al., 2013, 1146). However, an assessment of the sources cited shows that one review does not address menstrual pain
at all (i.e. Momoh, 2004), or that sources cited in the reviews, respectively, either
contradict the claim such as the Gambian study (Morison et al., 2001 in Obermeyer,2005) that found higher frequencies of menstrual pain among women not exposed to
FGC compared to women with FGC, or refer to empirical studies or advocacy literature that has not studied menstrual pain (such as many of the sources cited in Nour,
2004, 2008).
Where does this leave the evidence on menstrual pain and FGC? Empiricalstudies on health outcomes after FGC show that the evidence on the potential link
between various forms of FGC and menstrual pain is inconclusive. Setting aside thelimitations in the academic publications discussed above, existing research shows
disparate results. For example, some studies conducted among groups where FGC
type I-II are common have found statistically significant higher frequencies of painful menstruation among women with FGC compared to the control group of women
without FGC (El-Defrawi et al., 2001; Elnashar & Abdelhady, 2007; Kaplan et al.,13Adolescent Sexual and Reproductive Health Counselling in…

2013; Mahmoud, 2016; Shiferaw et al., 2014), whereas other studies found no suchdifference between the groups (Andro et al., 2014; Arafa et al., 2018; Morison et al.,2001). Likewise, a recent systematic review and meta-analysis of painful gynaecological complications summarises that ‘there was insufficient evidence to conclude
that FGM/C3 is associated with dysmenorrhea’ (Lurie et al., 2020, 3). In studies
among women with FGC type III (Catania et al., 2007; Chalmers & Hashi, 2000;
Momoh et al., 2001), documented frequencies of menstrual pain range from 44%(Catania et al., 2007) to 74% (Chalmers & Hashi, 2000). Severity of pain is seldom reported. The figures can be compared with occurrences reported in the general
population, varying from 33 to 93% across age groups (see global reviews by De
Sanctis et al., 2016; Latthe et al., 2006) and 89% in a sample of young Swedish
women (Söderman et al., 2019). About 15% of adolescents report severe dysmenorrhoea leading to absenteeism from work/school and social activities (De Sanctis
et al., 2015; Söderman et al., 2019). Differences in estimates may be due to how
pain is defined and different ways of measuring pain (De Sanctis et al., 2016). Differences may also be attributed to contextual factors such as the varying culturalvalues or meanings ascribed to menstruation, suffering and pain by respondents indifferent settings (see e.g. Bobel, et al., 2020), although such factors are seldom discussed. Nonetheless, the overall impression is that dysmenorrhoea is a very common
condition in populations with or without any type of FGC.
Taken together, the previous research on FGC does not provide support for theassumption that FGC is evidently related to menstrual pain, let alone causing menstrual pain. Yet, qualitative studies with infibulated women (Abdi, 2012; Thierfelder
et al., 2005; Villani et al., 2016) and with providers caring for women with FGC
type I-III (Carven et al., 2016; Thierfelder et al., 2005) have documented menstrual
pain as a common problem reported in relation to FGC. Whether this is a result ofdysmenorrhoea being a very common condition among all menstruating persons,or if there is an actual causal link to FGC (which would possibly require a different
treatment of menstrual pain) has not been established and calls for further studies.

Health Claims in FGC initiatives in Sweden
Since the 1980s, families have migrated to Sweden from the Horn of Africa, where
the practice of FGC types II and III have been almost universal (UNICEF, 2013). A
number of initiatives have since been mediated through Swedish government programmes aimed at expanding knowledge of FGC, including guidelines, handbooks,
a national helpline, awareness-raising activities targeting affected communities, professionals and the general public, and national support for local initiatives in thework against FGC (Östergötland County Administrative Board, 2016). For example, the Swedish government has commissioned the agencies responsible for thenational work on FGC to disseminate guidelines and knowledge produced within
the ongoing FGC programme (Östergötland County Administrative Board, 2016).
3

FGM/C is an abbreviation for female genital mutilation/cutting, our note.

13C. Palm et al.

In 2015 alone, over 5,000 professionals in welfare and civil society organisations
were reached through this specific FGC education, and there has been an ongoinginterest in these activities from welfare organisations ever since (Ministry of Health& Social Affairs, 2018; Östergötland County Administrative Board, 2016). The education covers recommended ways to broach the topic in clinical encounters, ways towork preventively, as well as background information on FGC including descriptions of different types of FGC, where cutting is prevalent, various motives, enumeration of consequences, and information on legislation (Östergötland County
Administrative Board, 2015, 2016). Reference material on FGC, produced within
the national program, is also available online in the form of presentations, information material, fact sheets and e-learning on official platforms.
A core feature of awareness-raising and education for professionals has been
to address potential harmful effects of FGC. The intention, as stated in policy andguidelines, is to enable professionals to identify and treat complications and to discourage the practices by providing information about the potential harm of FGC(Ministry of Health & Social Affairs, 2018; National Board of Health & Welfare,2016; Östergötland County Administrative Board, 2015). In the Swedish context,
menstrual pain and school absenteeism due to severe menstrual pain, have beenhighlighted in reference materials and education materials, as well as by government
appointed experts in news media4 as one of many symptoms for professionals to bewatchful for (Essén & Johnsdotter, 2017). Likewise, Swedish nursing and medical
school literature suggests that FGC ‘should be expected’ if a young woman from an
FGC-practising country presents with menstrual pain (Almroth, 2008, 100). In thesedescriptions, the rationale is not always explained, although haematocolpos, genital
scarring or pelvic infections are sometimes mentioned (National Board of Health &Welfare, 2016; Östergötland County Administrative Board, 2015). However, thesehypotheses have not been tested empirically. Awareness-raising initiatives have thus
contributed to diffusing quite a uniform but empirically unsupported representationof menstrual pain in girls and women with FGC.
Sweden has a long history of FGC-related work. Hence, professionals in Sweden
have long been subjected to extensive information and awareness-raising activities
of FGC—information which highlights sometimes uncertain medical consequences,such as menstrual pain. This context makes an interesting empirical example forstudying professional practices in relation to awareness-raising interventions andacquired knowledge about FGC.

4
Government-appointed experts working in the programmes have been cited in various news media mirroring features of their guidelines on FGC: ‘They [girls] particularly call [the helpline] during the winterwhen their pain is at its worst. When it’s cold, the menses clot and are difficult to expel if the girl is sewn
closed’ [Expert cited in large Swedish newspapers, SVT; TT 9 June 2016]. Needless to say, a process
such as this – that menstrual fluid inside the body would be affected by outdoor temperature – is not aphysiological possibility.

13Adolescent Sexual and Reproductive Health Counselling in…
Table 1  Composition of participants according to profession and workplace (n)SchoolSocial services

Healthcare

12

1

3

Social worker

1

5

Health educator*

1

Medical providers (nurse/
midwife/physician)

Total

County level

Total
16
6

1

2
24

*

Health educator refers here to people who coordinate intervention programmes [utbildningssamordnare], including FGC education targeting migrant groups and professionals at either local or county
level

Methods
Participants and Recruitment
The present study emerged from a broader qualitative project5 on sexual healthcounselling and sexual health among women with FGC living in Sweden, with aparticular focus on young women and professionals providing care and support forthis group.
Twenty-four professionals were included in the study. They worked as nurses,
physicians, midwives, health educators [utbildningssamordnare] and social workers
in different settings such as schools, primary care, youth clinics, residential homes
for children or social services across the country. The majority were healthcare providers in clinical practice. A description of participants according to profession andworkplace is provided in Table 1. Professionals worked with young people aged
13–23 years, a few only with minors whereas most encountered both young women
who are minors and women over 18, and thus adult by definition. ‘Young women’
will hereafter be used to refer to the young people the professionals worked with,even though this does not exclude girls under 18. All participants included in the
study were women. None had a background in a region where FGC is customary.
While consultation on sexual and reproductive health matters for adolescents in
Sweden is mainly offered by youth clinics or within school healthcare, the national
strategy on FGC is not limited to medically trained professionals, but includes abroad spectrum of personnel such as school staff and medical and social care providers. In this setting, a number of professions can be expected to be involved intargeted interventions on sexual and reproductive health for girls and women with
FGC. Eligible to participate in the study were professionals who gave their informed
consent and who had experience providing sexual and reproductive health counselling for young women with FGC.

5This study is part of a Ph.D. project titled Sexual health among Somali women with female genital cutting living in Sweden.

13

C. Palm et al.

To recruit participants, the project was advertised in various settings including
two interdisciplinary networks addressing sexual and reproductive health and rights
issues (SRHR), and through one of Malmö University’s recurring open seminars on
SRHR for interdisciplinary groups of professionals. Emails were also sent to professionals in residential areas or institutions with significant migrant youth populations: i.e. youth clinics, preparatory school programmes and health-related reception
services for newly arrived young people.6 Participants were also recruited throughsubsequent snowballing. With only two exceptions, all participants had taken part in
FGC education activities and reference materials on FGC. This probably reflects therecruitment strategy, which particularly targeted professionals who felt that they had
experience to contribute. It probably also reflects the Swedish context, where professionals working with migrants are likely to have been offered FGC education.
Procedure and Analysis
This article draws on an analysis of sixteen individual qualitative interviews andthree focus group discussions (FGDs) conducted by the first author from 2016 to
2020. Interviews were semi-structured with open-ended questions, and focused on
sexual and reproductive health encounters with young people in relation to FGC.
Individual interviews ranged from 60 to 80 min. FGDs comprised three participants
each and lasted from 90 to 120 min. One professional who participated in an FGD
was also interviewed individually. Interviews took place at the professionals’ workplaces, or by telephone if preferred by the interviewee. One interview was conducted
at a café. All were audio-recorded, except one individual interview during whichnotes were taken. All recorded interviews were transcribed verbatim.
The analysis followed what Braun and Clarke (2006) call an inductive thematic
analysis approach. The analysis began with open coding where salient themes andrecurring phenomena were identified through repeated reading of the transcripts.
Through this process, approaches to menstrual pain was identified as a prominent
theme in the material, which could add empirical insights to existing knowledge inthe research field. Instances in the material that were deemed of relevance to thistheme were tentatively coded, and subsequent themes and sub-themes were developed. Additional interviews were conducted to explore aspects of interest in more
depth. During the analytical process, themes and sub-themes were then reviewed
and refined during the process of writing.

6
It is important to note that many young women from groups where FGC is prevalent have undergone
FGC prior migration to Sweden, and research supports that there is a general abandonment of FGC after
migration (Johnsdotter 2019). Thus, professionals in Sweden who have encountered FGC in their work
have likely worked with immigrated girls and young women.

13Adolescent Sexual and Reproductive Health Counselling in…

Results
Three themes were identified in the thematic analysis in terms of professionals’
approaches and strategies in relation to menstrual pain in young women with FGC:
(1) ‘Female genital cutting as a presumed cause of menstrual pain: medical explanatory frameworks’; (2) ‘A constructivist approach to menstrual pain’ (3); ‘Menstrual
pain as a working tool in clinical practice’.

Female Genital Cutting as a Presumed Cause of Menstrual Pain: Medical
Explanatory Frameworks
Most professionals presented menstrual pain as a common health consequence ofFGC. Participants without a medical background referred to information obtained
from FGC education, while medical professionals additionally supported their arguments with reference to medical explanatory frameworks in terms of their clinicalknowledge of menstrual characteristics. Medical professionals described typicalmenstrual pain as originating from uterus activity, either as cramps from uterine
contraction when the mucosal tissue discharges, or as lack of oxygen to the uterus.
Menstrual pain in relation to FGC was discussed in terms of disturbances from these
physiological processes.
A main idea was that FGC causes menstrual pain due to obstructed outflow.
Interviewees expressed this as menstruation ‘accumulating’ in the body, saying it‘doesn’t come out’, or ‘is left in the abdomen’. A health educator commented:
It’s the classic thing, you know: stomach aches and blood accumulating … butthen the question is what is left there from before? After all, not everything
will come out. … I guess you’ve seen, you’ve read about this, haven’t you?
How they can get large accumulations of blood in the abdomen, that it basically can be the size of a child’s head.
Some explicitly referred to FGC information from awareness-raising activities assources of their understanding. One social worker, for example, commented that she
particularly valued information about signs of FGC to look out for, including ‘blood
accumulating, and that they get clots [of blood] in the abdomen and those kinds ofcomplications that you might not have thought of in the first place’. These descriptions of ‘clots of blood’, or ‘blood accumulating’ in the body, reflect how menstrual
pain has been framed in public-health information on FGC in Sweden (see also
WHO, 2018). In expressing these ideas, professionals implicitly equated ‘FGC’ witha narrow vaginal opening. Many, however, noted that it turned out young women
seldom had infibulation, but often reported other variations of FGC equal to type
I-II or sometimes ‘pricking’. This is in line with research in Somalia, showing trends
towards lesser operations among the Somali group (Powell et al., 2020) which is
the largest migrant group in Sweden from a community where FGC is customary.
The Somali group was also the group repeatedly referred to in the professionals’
accounts.

13

C. Palm et al.

Although participants asserted that obstructed menstrual flow could cause pain,
their reasoning showed that it was not clear how this association was to be understood. When asked to clarify, medical professionals drew on their clinical knowledgeof dysmenorrhoea, suggesting a number of different possibilities. Some attributed
pain to disruption in and prolonging of uterus activity associated with primary dysmenorrhoea. One example of this was expressed by a midwife working as a school
nurse:The uterus has to work hard to get rid of the blood, cramping, contracting
more in order to discharge it … and it becomes like a clot that won’t come out… it will come out eventually, but this of course makes it much more painful.
Likewise, another midwife and school nurse described menstrual pain as linked
to how fast the mucosal tissue could discharge. Being partially sewn closed could
cause clots, which in turn prolonged the painful process, she reasoned. Others
described the pain as a result of blood accumulating in the uterus, cervix and/or
vagina, causing ‘pressure and aching’ in the genital area. Yet some gave no further
explanation, or said they were uncertain how to explain the association. In thesemanners, medical explanatory frameworks about ‘normal’ or ‘disrupted’ menstrual
processes were used to explain menstrual pain in relation to FGC.
Although many participants held a primary assumption compelling them to connect young women’s menstrual pain to infibulation, some medical professionals
reflected upon clinical experience that suggested menstrual pain was not evidently
linked to FGC but was a common complaint in all young women, with or without
FGC. For example, one school nurse stated that she thought FGC could cause pain
during menstruation, but was nevertheless ambivalent about whether or not there
really was any difference between young women with or without FGC:
I don’t have any statistics or anything, but my feeling is that young women
have severe [menstrual] problems regardless. My experience is that Swedish
young women I talk to also have a lot of problems during menstruation, menstrual pain that is.
Others stated that menstrual pain was a ‘very common complaint’ in all young
women they had encountered, that they ‘wouldn’t be able to tell the difference’between young women with or without FGC, or that ‘it is hard to distinguish fromordinary menstrual pain’. Such comments can be interpreted as partly contradicting
the preunderstanding of FGC as the cause of menstrual pain in young women, as
articulated by the professionals. However, these experiences seemed not to be given
much explanatory power in the professionals’ accounts.
A Constructivist Approach to Menstrual Pain
Given a clinical context where professionals had a preunderstanding that FGC
causes menstrual pain, there was a tendency to initially connect menstrual pain
reported by young women to infibulation. Accordingly, in menstruation counselling,
medical professionals explained how they tried to assess whether dysmenorrhea

13Adolescent Sexual and Reproductive Health Counselling in…

was primary or secondary and, if secondary, whether pain was secondary to FGC orother conditions. In management of young women’s pain, they were leaning on general medical training, particularly insight into the physiological processes associatedwith dysmenorrhoea, as well as knowledge gained from education specifically on
FGC. However, professionals also used knowledge based on cultural expectations on
adequate responses to menstrual pain and their clinical knowledge about how best to
manage it.
In discussing menstrual pain in young women with presumed FGC, some clinical professionals described how they had observed that young women responded
to pain in ways dismissed by the professionals as inadequate. When they discussed
these experiences, they spoke more broadly about young women with a migrantbackground, often taking Somali young women as an example. Responses to menstrual pain, explained by the interviewees, included lying still and resting, drinking
hot tea, missing school and having excessive difficulties continuing life as usual. In
these descriptions, there was a tendency to talk about the young women’s responses
as culturally influenced. Some expressed they believed ‘cultural taboos’, ‘stigma’or ideas about ‘uncleanliness’ make young women stay home from school, or that
cultural expectations to ‘suffer in silence’ could be an answer to a young woman’s
unwillingness to use painkillers. Young women’s responses were also discussed bysome as health ‘illiteracy’ or ‘knowledge deficiency’ regarding how to interpret bodily processes or appropriate ways to respond to them. A midwife and school nurse
expressed it thus:
They think that it’s a sign of disease. And of course, if you lack knowledge
about menstruation, and how it works and what you can do about it, then itgets difficult [for you]. Then you’ll think you’re ill when you have your period,
and you stay out of school. And then they have mothers who … don’t have theknowledge either, who also think they’re ill.
In this respect, the professionals’ accounts illustrated a more constructivist
approach to the young women’s pain. They suggested that sociocultural factors suchas the way health, bodily processes, and menstruation are understood, play a rolein young women’s experiences of and responses to menstrual pain. Here, excessive
menstrual pain was not primarily portrayed as the result of FGC but was describedas physiologically the same in all young women, albeit as something that could be
handled in more or less efficient ways.
In contrast to the young women’s strategies to cope with pain, medical professionals emphasised the importance of physical activity and continuing to go to school, in
addition to the option of medication i.e. ‘painkillers’ or ‘hormonal contraceptives’ intreating menstrual pain. Framed in terms of their clinical knowledge and experienceof efficient ways of responding to pain, common comments were along the lines:‘I tell them that, to feel better, it’s important they stay physically active so that the
bleeding can start’, as put by a school nurse. Also, a school nurse and midwife proposed, ‘You shouldn’t be in such pain that you can’t go to school. That’s not okay’.
In these accounts, Sweden was implicitly presented as a country with highacceptance and limited stigma attached to menstruation and menstrual pain. A midwife and school nurse commented on what she considered ‘the Swedish’ normative13

C. Palm et al.

stance on menstrual pain: ‘We are the opposite here, it’s like “bite the bullet” and“this is how it is”, or “yes, so what?, everybody has it”. It has almost become theopposite [here].’ ‘Crying out’ in pain, ‘hiding’ or feeling ‘ashamed’ during menstruation were positioned as odd. Instead, the examples illustrate that menstrual
pain is not expected to be particularly troublesome or to hinder women in their daily
lives, i.e. menstruating women are expected to be able to continue life as normal.
Accordingly, many reasoned that pain which does hinder daily life is pathologicaland merits medical attention. Professionals described how they, for example, suggested defibulation (in case of infibulation) or further clinical assessment to rule out
other potential causes to pain such as endometriosis, if a young woman presented
with excessive pain.
A former school nurse, working in primary care at the time of the interview, however, gave a contrasting account. She commented on expressions of menstrual pain
among young women with FGC:
It’s possible they don’t really accept it, don’t know what to do and ‘don’t want
to go to gym class’ and [think] it’s embarrassing [having a period]. And I think
many Swedish girls also experience this, that it’s difficult and they don’t wantto say that they have their period.
This participant focused more on similarities in expressing painful menstruation,suggesting that young women might face challenges in going on with life as normal
or might be affected by cultural stigma regardless of cultural background.
In terms of menstruation counselling, professionals navigated different explanatory frameworks in their efforts to make sense of and respond to the young women’s
pain complaints, whether pain was thought to result from FGC and/or be an expression of an unfamiliar cultural coping strategy, or just ordinary (primary) dysmenorrhoea. Thus, on the one hand, participants described and dismissed young women’sculturally different responses to menstrual pain, stressing the importance of continuing life as normal during menstruation or else seeking medical care. On the other
hand, they sympathised with the young women’s strategies during menstruation,
acknowledging that all young women might experience stigma and challenges incontinuing life as usual during menstruation.

Menstrual Pain as a Working Tool in Clinical PracticeParticipants strived to acknowledge their awareness of presumed harms of FGC, andargued that FGC was an important issue to address. All had made efforts to initiate conversations about FGC in professional encounters with young women possibly
affected by FGC. Efforts were made both in relation to their specific work context as
well as the legal context.
For medical professionals, menstrual pain was described as a useful working
tool in clinical practice, in one of two ways. First, given a clinical context where
FGC was expected to lead to painful menstruation, menstrual pain seemed tofunction as a flexible working hypothesis alerting professionals to the possibility

13Adolescent Sexual and Reproductive Health Counselling in…

that the person before them might be infibulated. An example of this approach
was expressed by a midwife at a youth clinic:[In taking down a menstruation history] we get information about whether
they have a really hard time with their period, whether they need to stayhome from school, if they’re helped by painkillers … then you have thatwith you in the back of your mind … and already have a plan worked out sothat you can steer the conversation towards those questions [about FGC] as
well.
Also in relation to social work practice, menstrual pain as a ‘working hypothesis on FGC’ was brought up by one social worker. She commented that after
receiving education about FGC, she was more attuned to menstrual pain asa symptom that suggested a girl or a woman may have been exposed to FGC,
although she had not yet applied this information in her work. Starting fromthis working hypothesis, some professionals explained how they tried to assess
whether the young woman might have been infibulated and, if this was the case,whether she had other health issues related to the FGC. Many described how theywould first recommend or offer information about defibulation in case the young
woman is infibulated. In addition, professionals explained how they follow theirstandard protocol, communicating the option of medication i.e. ‘painkillers’ or‘[hormonal] contraceptives’, or provide information about other ways to treat
menstrual pain such as with ‘heat’ and ‘physical activity’. Others described how
they make an assessment in conjunction with providing brief information about
possible harms of FGC and available options for help, including the alternativeof defibulation, in the event the young woman needed it, then or forthwith. This
was the case without, sometimes, knowing whether or not the young women had
undergone FGC.
Second, another trend permeating the material was that many professionals inclinical practice described how they used menstrual pain as a starting point for
conversations about FGC. Participants argued that the question ‘fits there’, or is‘a useful way in’. A typical scenario in the interviews was expressed by a school
nurse in an FGD with other participants making supportive comments:
I actually start by asking about menstruation because I think it’s a usefulway in. ‘How is it when you have your period? Are you in a lot of pain?’ …
and then I continue, ‘Could it be that you are circumcised?’ And yes, that’s
often the case. Some have trouble, some don’t, and those who don’t [wellthen] it’s not a problem and then they don’t want help either.
The strategy for initiating conversation was influenced both by the professional
and the legal context. Mindful that young women might be aware that FGC is
not a universal norm and that the practice is indictable and morally condemnedin Sweden, many expected FGC to be a sensitive topic to discuss. All professionals thus described efforts to raise the question in a way that would not alienate, offend or frighten the young woman. Strategies described included signallingawareness of FGC, stressing they had no intention of reporting the (previously

13

C. Palm et al.

performed) FGC to authorities, avoiding talking about FGC in terms of ‘rightand wrong’, not using the word ‘mutilation’, and ‘not being hasty’ in encouraging
young women to disclose their genital status, but ‘letting things take their time’.
While some medical professionals had implemented organisational protocols fortaking FGC history during routine health check-ups [hälsosamtal] (for example toask directly about FGC or ask all young people in health encounters if they had
had genital surgery), this was not the case for most professionals in this study.
Instead, those who emphasised menstrual pain as a useful way to initiate discussions about FGC often commented that they lacked other ways to raise the issue.
For one school nurse, targeting FGC indirectly starting with a medical symptom,
had helped her to ‘have the courage to raise the question’ already ‘being in thatarea of the female body’. Yet others emphasised that an approach focused on possible symptoms (experienced or not) helps to invite a non-intimidating conversation as it signals the mere interest to offer help. A school nurse encapsulated thislatter perspective:
I don’t ask directly about circumcision, because I won’t get a good answer.
Instead, I ask if they have any trouble in their genital area … problems withpeeing, pain or painful menstruation. ‘If so, I can help you’ and ‘you can getthese kinds of problem if you have been circumcised, for example’. So I try to
use this as a way into the conversation, and then I feel it’s easier to reach them.
In these manners, (1) menstrual pain as a flexible working hypothesis and/or (2)menstrual pain as a tool for initiating conversations, were presented by many ofthe medical professionals as useful tools in clinical encounters with young womenpotentially exposed to FGC. Among the non-medically trained professionals, menstrual pain worked as an alert on FGC for the social worker who had been informed
about such an association in FGC-specific education. For another social worker, who
had no prior FGC education, no such association was made. Instead, she commented
that she lacked the tools to initiate conversations. In encounters with young womenthat she knew had undergone FGC, she had asked generally about health problems
but had not specifically targeted FGC.
As suggested by these examples, menstrual pain itself was not necessarily the
primary concern, but was used as a tool to steer the conversation towards aspects
which were considered important. These aspects varied. While many articulated
that they wished the practice would end, describing it as ‘oppressive’, ‘harmful’ or‘unnecessary’, the interviews indicated that the main goal of initiating conversations
about FGC was to start communication in order to provide help and support and topave the way for harm reduction work in the long term. Professionals reported thatconversations could be about assessing whether a young woman was suffering as aresult of FGC, or about providing information on health risks or potential future sexual and reproductive health problems they associated with FGC and provide information on pathways for help i.e. gynaecological assessment and defibulation then orat a later stage. A few noted that they also aimed to work preventively by providing
information on legislation and potential sexual and other health risks or asked about
attitudes towards FGC in order to protect future generations. This was, for example,
the case with the professional working as a health educator on a strategic level, but

13Adolescent Sexual and Reproductive Health Counselling in…

also among other professionals, although prevention did not appear to be their mainconcern. Another, more general motive stated was to pave the way for open communication about FGC.
In sum, medical professionals used an assumed association between menstrual
pain and FGC as a way of initiating conversations about FGC. The ambition, it
seemed, was to build rapport by offering a friendly environment for conversations
so as to be able to offer support, then or forthwith. Conversations were initiated firstand foremost to pave the way for long-term harm-reduction work, and secondly, fora few, to facilitate conversations aimed at long-term prevention and protection of
future generations. This strategy was employed in relation to the professional, sociopolitical and legal contexts.

Discussion
This study provided a qualitative exploration of how professionals in schools,
healthcare and social services approach sexual and reproductive healthcare encounters in relation to awareness about FGC. In a context where professionals are urged
to acquire knowledge about possible health effects of FGC as a way to tackle prevention and care in relation to the practices, the way professionals understand andrespond to knowledge gained through campaigns and training is pertinent to explore.
This study provides a novel contribution. Departing from menstruation counselling, the study shows how professionals navigate their various sources of knowledge
including awareness of FGC in encounters with young women who may have been
exposed to FGC. The analysis shows that there was a tendency in counselling to differentiate young migrant women’s menstrual complaints from ordinary menstrual
pain, with professionals understanding pain complaints either in terms of FGC or asculturally influenced. FGC awareness worked as a lens through which young women’s health complaints were understood. Biomedical knowledge and culture-specificexpectations and assumptions regarding menstrual pain also informed counselling.
In encounters with young women potentially affected by FGC, menstrual pain waspresented as a particularly valuable tool in clinical practice.
With a few exceptions, participants had taken part of FGC education and reference materials on FGC. Similar to how menstrual pain has been discussed in Swedish FGC education, policy materials and guidelines (Almroth, 2008; National Boardof Health & Welfare, 2016; Östergötland County Administrative Board, 2015), thestudy found that professionals with training on FGC had a preunderstanding that
FGC causes menstrual pain. For these participants, menstrual pain worked as analert and flexible working hypothesis about FGC among young women from highprevalence countries. In this respect, FGC awareness and especially the linkage
made between FGC and menstrual pain, functioned as an ‘interpretive resource’(Loseke, 2001) and lens through which young women’s health complaints initiallywere understood as potentially caused by FGC.
The study shows that participants strived to acknowledge awareness of FGC in
encounters with young women potentially affected by FGC, having all made efforts
to raise the issue. Efforts were made both in relation to the professional and legal

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C. Palm et al.

context. In a context where FGC is unlawful and stigmatised, participants expected
FGC to be a sensitive topic to discuss, and navigated ways to use the knowledge in asensitive, non-judgemental and non-intimidating way. The study found that, against
this background, professionals used the presumed association between menstrual
pain and FGC as an indirect intake to conversations about FGC. Previous literature
has linked professionals’ unease to broach the topic of FGC to having more to dowith the professionals’ assumptions about the practices (Leonard, 2020) or ‘outsiders’ own moral and emotional difficulties’ with FGC, than with actual experiencesin professional practice (Johansen, 2006, 523). In this study, professionals formulated their concerns in terms of finding their way to initiate a discussion in waysthat would not alienate, offend or frighten the young woman. Professionals are welladvised in their caution not to use stigmatising language and attitudes, as this might
contribute to distrust in service providers (Khaja et al., 2010) and influence willingness to seek care (Michlig et al., 2021), as well as contributing to women feeling ‘abnormal’ (Villani, 2020), ‘traumatised’ or ‘stigmatised’ (Karlsen et al., 2019).
Starting conversations about health problems (experienced or not) that were believed
to resonate with the real-life experience of living with FGC, was seen as a tool forbuilding rapport and establishing a neutral, less intimidating environment. The strategy can be seen as an effort to give ‘permission to talk’ as termed in sexual healthcounselling (Annon, 1976) and pave way for open communication about FGC. For
professionals who had implemented guidelines for raising the issue directly, theapproach of targeting FGC indirectly was not used but should be viewed in relation
to the professional context. The strategy was also related to the professionals’ individual agenda. While participants to some extent intended to work preventively byproviding information about legislation or potential harms of FGC, the main goal, as
it appeared, was to build trust and pave the way for better care provision in the longterm. Starting conversations about medical symptoms was seen as a way to signal anintention to help. With regard to the impact of policy and interventions, the findings
contrast with what was reported in a recent study of British-Somali women that suggests healthcare professionals used FGC awareness to extract information for safeguarding reasons ‘over and above [the women’s] health needs’ (Karlsen et al., 2019,7). In the UK, healthcare professionals have an absolute duty to report any FGC
identified in underaged young women. This is not the case in Sweden, even though
the national organ responsible for FGC education in Sweden has encouraged reporting FGC in all minors to authorities.7 From a policy and intervention perspective,
the results call for further consideration of the role of the professional, socio-political and legal context in which professional practices take place.
Menstrual Pain as Physiology and Culture
While the present study found menstrual pain was used as a tool in clinical practice, the study shows that professionals struggled to make sense of menstrual pain
7
Official website of the organ responsible for the national work on FGC in Sweden, hedersfortryck.se/hedersrelaterat-vald-och-fortryck/konsstympning.

13Adolescent Sexual and Reproductive Health Counselling in…

in young women that may have been exposed to FGC. On the one hand, a main idea
was that a narrow vaginal opening (infibulation) causes an obstruction of menstrual
flow, subsequently disturbing menstruation processes and causing pain in various
ways. This finding aligns with how menstrual pain in relation to FGC has been
framed in Swedish information and training on FGC (e.g. Almroth, 2008; National
Board of Health & Welfare, 2016; Östergötland County Administrative Board,2015). The finding suggests that professionals had adopted messages from FGC
training even though research on menstrual pain and FGC has not been able to provethe correlation (e.g. Lurie et al. 2020; Obermeyer, 2005). Medical professionals also
supported their understanding on knowledge based in medical training on physiological processes associated with primary and secondary dysmenorrhoea. On the other
hand, concurrently, professionals employed a constructivist approach to pain, andtended to refer to young migrant women’s responses to menstrual pain as an expression of culture (e.g. shame, stigma, or taboo) or health illiteracy, in a sense positioning them as based in a traditional, as opposed to a modern, biomedical knowledge
system. The way of understanding young women’s menstrual pain in terms of either
FGC and disturbed physiological processes, or as a culturally influenced expression,suggests a differentiation of young migrant women’s expressions of menstrual painfrom ordinary menstrual pain. The framing of young migrant women’s responses topain (i.e. staying home from school, having excessive difficulties continuing life as
usual) as excessive and deviant, as opposed to normal, suggests a tendency to culturalise the young women’s expressions of pain. At the same time, the differentiation ofyoung migrant women’s menstrual pain from ‘normal’ menstrual pain, was brought
into question when professionals drew on their clinical observations and alluded to
menstrual pain as a common complaint in all young women, also conceding thatall young women may struggle with stigma or shame in relation to menstrual pain.
These experiences, however, did not appear to be given explanatory power in theprofessionals’ efforts to make sense of the young women’s menstrual pain. In thecontext of existing studies on adolescents’ coping strategies for menstrual pain demonstrating that staying home from school and resting are strategies common across
many ethnic groups (De Sanctis et al., 2016), the professionals’ approach, suggesting that menstruating women can and should take part in activities as usual, can beseen as participants giving voice to a Swedish cultural ‘script’ on menstrual pain.
According to Simon and Gagnon (1986), cultural scripts inform individuals about
cultural codes concerning how to enact and interpret their experiences and lives.
The sentiments in the interviews reveal prevailing assumptions that menstrual pain
is not expected to disrupt women’s daily lives, or else the pain is pathologised.
Recent campaigning from menstrual activists and governmental public-health initiatives further suggests that this is an established idea, and script, in Sweden. For
example, in the campaign ‘severe menstrual pain is not OK!’ by the National Boardof Health and Welfare, the main message is that menstrual pain that leads to absenteeism requires medical assessment and treatment (National Board of Health & Welfare, 2019). In contrast, menstrual activists in Sweden are making efforts to change

13

C. Palm et al.

current framing of menstrual pain, claiming it is not to be taken lightly and that it
justifies sick-leave or adapting workload.8
Counselling on menstrual pain was thus based not only on professionals’ awarenessof FGC and their medical training on dysmenorrhoea, but also on their culture-specificexpectations about adequate ways to express and respond to menstrual pain. In light ofscripts (Simon & Gagnon, 1986), it can be interpreted as professionals navigating different cultural scripts and norm systems in menstruation counselling with young womenfrom a cultural background different from their own. In doing this work, they leaned on
information picked up in FGC training, their medical training and also on cultural norms
specific to menstrual pain. On a normative level, the inclination to repudiate young
migrant women’s coping strategies, or scripts, as ‘inadequate’ or health ‘illiteral’, suggests
professionals’ own knowledge system and frames of understanding were given a superior position. Yet, on an individual level, in menstruation counselling, participants sympathised with young women’s pain, and employed a variety of explanatory frameworks tomake sense of and respond to young women’s lived experiences of menstrual pain.

Implications for Practice
Awareness of FGC and the linkage made between FGC and possible health effects,
especially menstrual pain, encouraged professionals to be attentive to the possibilityof FGC among young women from high-prevalence countries presenting with healthcomplaints. A central question then is, to what extent is the FGC awareness of helpin efforts to establish better communication and rapport in service encounters?
In a wider context, the linkage made between menstrual pain and FGC can beviewed in light of a long-term engagement in FGC-intervention that has been taken
on by different actors worldwide (e.g. WHO et al., 2008). In this apparatus, a standardised way to frame FGC has appeared, a ‘formula story’ (Loseke, 2001), or a grandnarrative that includes a familiar narrative about the four types of FGC operations,what they entail, why the practice exists and its possible consequences for healthand sexuality (Leonard, 2000, 2020). Such descriptions have been referred to as ‘thestandard tale’ of FGC as they are often represented in a repetitive manner (Leonard,
2000). Among critical scholars, however, there is a growing consensus that many
popular beliefs about FGC are misguided and rest on weak empirical assumptions(Earp & Johnsdotter, 2021; Obermeyer, 2005; PPAN 2012; Shell-Duncan, 2008).
Many have also noted that there is a tendency to relate to the most extensive type(infibulation) in descriptions about FGC, which might contribute to misconceptions
about FGC in contexts where lesser forms are prevailing (e.g. Johansen, 2006). Thisis relevant not least in the Swedish context where FGC type III used to be a common type of FGC among immigrants, but now is a practice in decline (Powell et al.,2020), which is also suggested by the observations made by professionals in this8
www.​mensen.​se, project ‘menstruation-certified workplaces’, [menscertifiering av arbetsplatser]
launched in 2019, information extracted 1 July 2020.

13

Adolescent Sexual and Reproductive Health Counselling in…

study. Moreover, recent studies suggest that it is not necessarily the extent of theprocedure that determines how harmful it is perceived by the individual to be (ifexperiencing harm at all), but the experience of the procedure itself (Michlig et al.,2021; see also Sharif Mohamed et al., 2020).
What problems may arise if such a ’standard tale’, based on sometimes uncertain empirical assumptions, is used in professional practice? Insofar as the knowledge contributes to establishing trust or better care and communication about FGC,
it appears to be a valuable tool. The results show that awareness about possible
health risks was used constructively as a way to build rapport and establishing a
dialogue about FGC, and for many the strategy seemed to work fine. In addition,
an unintended consequence seems to be that complaints about menstrual pain wereacknowledged to a great(er) extent. There are, however, possible pitfalls with thisapproach, some of which will be discussed below.
First, with a lack of compelling alternatives, the strategy among some professionals to target FGC indirectly through menstrual pain, suggests that young women are
given unequal opportunity to talk about FGC-related issues, when such conversations are made dependent on the event of particular health complaints. This is notnecessarily a problem. Some might argue that if the primary focus is on care andsupport, raising the issue would only be relevant if the young woman has concernsor health issues that could be related to the FGC. On the other hand, from the perspective of safeguarding, or harm reduction in the long term, an opportunity to discuss FGC might get lost with such an approach.
Secondly, as has been argued elsewhere (Earp, 2020; Palm et al., 2019; Sharif
Mohamed et al., 2020), while it is essential to acknowledge potential risks of FGC,
a reductionist focus on the (cut) genitals, or jumping to the conclusion that healthcomplaints must be related to the FGC, might lead to underdiagnosis or undertreatment of other conditions that may be related to the woman’s complaints. Such a
reductionist gaze, directed too narrowly on the stigmatised or non-normative identity
or experience, is not limited to healthcare encounters with women with FGC (e.g.
Bergström et al., 2013; Khaja et al., 2010) but has been identified in several sexuality
related fields. For example, in a Swedish context such an approach has been reported
in relation to LBGT groups (Björkman & Malterud, 2009), persons with experienceof selling sex (Holmström, 2015; Larsdotter et al., 2011), and people with polyamorous lifestyles (Carlström & Andersson, 2019). Ultimately it may lead to suboptimal
outcomes of the health encounter. A contrasting approach in the clinical encounter,as suggested by some interviewees in this study, is to start with an unbiased clinical assessment before giving recommendations, bearing in mind that FGC can, butdoes not necessarily have to, play a part in the person’s illness (Johnsdotter & Essén,2020). This is pertinent not the least in the context of uncertain evidence as regards
menstrual pain and FGC (Lurie et al., 2020; Obermeyer, 2005). In such a context, theintention to proceed from young women’s real-life experiences of FGC, seems misplaced. Counter to the intention, an overemphasis on FGC as the cause of complaints
could possibly diminish trust and dialogue and willingness to seek help, if the young
woman feels singled out or perceives counselling as based on misconceptions about
FGC or her situation (Bergström et al., 2013; Karlsen et al., 2019; Khaja et al., 2010).
Thus, for all that is good with increased awareness of FGC, to counter the event that13

C. Palm et al.

professional practice is based on stereotypes or misguided assumptions about FGC
and the people affected by it, the results in this study stress the importance of wellinformed interventions and, thus, rigorous research and quality-checking in the firstplace (see also Essén & Mosselmans, 2021).
Third, a downside of introducing FGC as a probable cause for discomfort is therisk of iatrogenic pathology (Michlig et al., 2021) in that it might prompt young
women to interpret their bodies in terms of deficiencies related to FGC (and, assuch, a chronic condition), when this does not correspond to their own experiences,or when menstrual pain might just be ordinary dysmenorrhoea (thus temporary).
Ultimately, through expectancy effect, this could lead to maladaptive responses orinternalisation of genital pain (see Earp, 2020 for a theoretical discussion). Reading one’s body in terms of ‘mutilation’, deficiency or pain, is not common in local
contexts where FGC is the norm. Although people often are aware of the risk ofserious health consequences (Shell-Duncan, 2008), genital modifications are typically associated with beautification, morality, or sometimes seen as a preparation forthe ordeals of life (Jirovsky, 2014; Malmström, 2013). In western migration settings,
however, studies have shown that internalising new ideas about FGC has come toshape women’s perceptions, not only about the practices, but also in terms of body
image, sexual self-image and perceptions of genital pain (Johansen, 2007; Lienand Schultz 2013; Villani, 2020). Professionals in this study were well aware andcognisant of these risks and used strategies to destigmatise young women’s experiences of FGC. Again, though, if not based in well-informed policies and interventions, there is a risk that professionals’ strategies fall short, however carefully chosen
and well-intended they are. Some might argue, from this perspective, that current‘awareness’ might serve as a hinderance for optimal care and prospects for establishing trust.
Methodological Considerations and Implications for Future ResearchParticipants included professionals who had experience of encounters related to
FGC, and the vast majority had taken part in FGC education. Participants’ accounts
could therefore result from a vested interest in these issues and could perhaps reflect
perspectives grounded in professional experience to a greater extent than would be
the case among individuals who did not participate.
This study, which includes personnel with varied professional backgrounds,
underscores the importance of considering the particular contexts of professionals in understanding how they understand and make use of acquired knowledge
about FGC. These findings are important, not least in a context such as Sweden,
where non-medically trained staff are urged to be attentive to medical conditions
such as menstrual pain in order to identify girls and young women with FGC, either
as a safeguarding or preventive measure, or in order to provide care and support(National Board of Health & Welfare, 2016; Östergötland County Administrative
Board, 2015).
Future studies should explore the role of professionals’ experiences of clinicalencounters, in relation to how FGC policy and interventions are interpreted and13Adolescent Sexual and Reproductive Health Counselling in…

implemented in practice. A hypothesis based on the findings of this article is that
where professionals have less experience of clinical encounters, policy and interventions will play a greater role in clinical practice. Given the inconsistent evidence
on sexual and reproductive health effects of FGC (Andro et al., 2014; Obermeyer,2005), the study also raises questions about what knowledge professionals should
acquire, and what work professionals do with the knowledge gained. These questions merit further critical scrutiny. Another area for future research is to explore,in more depth, how sociocultural ways of framing the circumcised body, pain, andclaimed consequences for sexual health affect how girls and women with FGC
reflect on their bodies post-migration to the West.
Acknowledgements This work was supported by the Swedish Research Council for Health, Working
Life and Welfare (FORTE) under Grant 2015-00771; the Swedish Research Council (Vetenskapsrådet)under Grant 2015-03546, and Malmö University.
Author Contributions B.E. and S.J. obtained funding and administered the project. C.P., B.E. and S.J.
designed the research and C.P. collected and analysed the qualitative data. C.P. wrote the manuscript
which was supervised, revised, and edited by E.E. and C.H. C.P., E.E. and C.H. contributed to the conceptualisation of the analysis. All authors read and approved the final manuscript.
Funding Open access funding provided by Malmö University.
Data Availability All relevant data are included in the article.
Declarations
Conflict of interest No potential conflict of interest was reported by the authors.
Informed Consent Informed consent was obtained from all individual participants included in the study.
Ethical Standards The research was conducted in accordance with the ethical standards of the National
Research Committee, and with the 1964 Helsinki Declaration and its later amendments or comparable
ethical standards.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​
ses/​by/4.​0/.

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Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Authors and Affiliations
Camilla Palm1,2Birgitta Essén2· Sara Johnsdotter1 · Eva Elmerstig1 · Charlotta Holmström1 ·1

Department of Social Work, Faculty of Health and Society, Centre for Sexology and Sexuality
Studies, Malmö University, 205 06 Malmö, Sweden

2

Department of Women’s and Children’s Health (IMCH), Uppsala University, 751 85 Uppsala,Sweden13

III

TYPE Original Research
PUBLISHED 11 July 2023
DOI 10.3389/fsoc.2023.1188097

OPEN ACCESSEDITED BY

Ragnhild Elise Brinchmann Johansen,
Norwegian Centre for Violence and TraumaticStress Studies, Norway
REVIEWED BY

Ngambouk Vitalis Pemunta,
Linnaeus University, Sweden
Beth Maina Ahlberg,
Uppsala University, Sweden*CORRESPONDENCE

Camilla Palm
camilla.palm@mau.se
RECEIVED 16 March 2023
ACCEPTED 19 June 2023
PUBLISHED 11 July 2023

The relationship between
dominant Western discourse andpersonal narratives of female
genital cutting: exploringstorytelling among
Swedish-Somali girls and women
Camilla Palm1,2*, Eva Elmerstig1 , Charlotta Holmström1 andBirgitta Essén2
1

CITATION

Palm C, Elmerstig E, Holmström C and Essén B(2023) The relationship between dominantWestern discourse and personal narratives offemale genital cutting: exploring storytelling
among Swedish-Somali girls and women.
Front. Sociol. 8:1188097.
doi: 10.3389/fsoc.2023.1188097
COPYRIGHT© 2023 Palm, Elmerstig, Holmström and Essén.
This is an open-access article distributed under
the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or
reproduction in other forums is permitted,
provided the original author(s) and the
copyright owner(s) are credited and that theoriginal publication in this journal is cited, in
accordance with accepted academic practice.
No use, distribution or reproduction ispermitted which does not comply with theseterms.

Centre for Sexology and Sexuality Studies, Department of Social Work, Malmö University, Malmö,
Sweden, 2 Department of Women’s and Children’s Health (IMHm), Uppsala University, Uppsala, Sweden

Introduction: A dominant narrative, referred to as “the standard tale,” prevails in
popular representations about female genital cutting (FGC) that often contrast
with how cut women traditionally narrate their FGC experience as meaningful
in contexts where FGC is customary. However, scholarship has increasingly
highlighted how global eradication campaigns and migration to countries where
FGC is stigmatized provide women with new frames of understanding which
may lead to a reformulation of previous experiences. This article subjects thestorytelling itself to analysis and explores how participants narrate and make senseof their FGC experience in a post-migration setting where FGC is stigmatized.
Methods: Semi-structured focus groups (9) and individual interviews (12) with
Swedish-Somali girls and women (53) were conducted.
Results: The article highlights how the participants navigate their storying in
relation to "the standard tale" of FGC in their efforts to make sense of theirexperiences. Navigation was conducted both at an intrapersonal level throughcontinuous identity work, and in relation to the social context in interpersonalencounters, i.e., with service providers and others, among whom the standard tale
has become a truth.
Discussion: The article places the analysis within broader discussions aboutanti-FGC work and considers the implications in relation to efforts to end FGC.
KEYWORDS

female genital cutting, female genital mutilation, anti-FGM discourse, migration,
storytelling, qualitative research

1. Introduction
Through decades of global efforts aimed to counter female genital cutting (FGC),
a uniform portrayal of the practices has taken form within an international discourseof opposition that frames FGC as gender-based violence that victimizes girls andwomen due to its presumed negative consequences to women’s wellbeing (Leonard,
2000; Shweder, 2005). This common framing of FGC, however, contrasts withhow cut women traditionally narrate their experiences as meaningful according toconcepts of proper identity related to gender, ethnicity, culture, and/or religion inregions where FGC is customary (Abusharaf, 2001; Njambi, 2004, 2007; Jirovsky,
2014; Powell et al., 2020). While anti-FGC messages—through global eradication

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campaigns and migration processes—have contributed topromoting negative attitudes toward FGC among once-practicing
groups (Hodžić, 2017; Wahlberg et al., 2017; Powell and Yussuf,
2018), studies have increasingly highlighted that exposure toadverse messages about FGC may negatively impact girls’ andwomen’s self-understanding (see review by O’Neill and Pallitto,2021). Drawing on these recent concerns, this study explores
how girls and women of Somali background narrate their
FGC experience post-migration to Sweden—a country with acondemnatory discourse on FGC. More specifically, the study
highlights how interviewees relate to dominant Western discourses
and related representations about FGC when storying and trying
to make sense of their own FGC experience.
In the article, “discourse” is used to denote knowledge, i.e.,a particular set of ideas, assumptions, conceptualizations, andframings of a phenomenon that are collectively shared and takenfor-granted as truths (Foucault, 1981). The terms “narrative,”“story,” or “account” are used interchangeably to refer to explicit
ways of framing experiences or a phenomenon in terms of lengthy
textual or speech representations such as interviewees’ accounts or
media reporting. This article will engage in a particular narrativethat has variously been referred to as “the standard tale” of FGC(Leonard, 2000, 2020), “standard story” (Njambi, 2007), or “FGM
fantasy” (Rogers, 2009). Although not identical in their meanings,
the concepts all refer to popular representations and truth claims
connected to dominant condemnatory discourse on FGC.

to as “female genital mutilation” (FGM), as a manifestation ofmen’s domination over women, typically, cut women are narrated
as victims of gender-based violence. Parts of the narrative are
epitomized in the Somali supermodel Waris Dirie’s bestsellingnovel Desert Flower (Dirie and Miller, 1998):
The operations are usually performed in primitive
circumstances by a midwife or village woman. They use noanesthetic. They’ll cut the girl using whatever instruments they
can lay their hands on: razor blades, knives, scissors, broken
glass, sharp stones—and in some regions—their teeth. The
process ranges in severity by geographic location and cultural
practice. The most minimal damage is cutting away the hoodof the clitoris, which will prohibit the girl from enjoying sex forthe rest of her life. (Dirie and Miller, 1998; p. 218)
In Njambi’s (2004) article targeting the anti-FGC campaign andthe discourse it has produced, she poses a critique of what she terms“sensational stories” about FGC. As regards a publication from theAmerican Medical Association (AMA) in 1995 where teeth are
mentioned, Njambi critically notes “while not a single group is
identified which employs such crude instruments, such statements
are presented as a matter of ‘fact’ from one text to another in almost
identical language” (Njambi, 2004; p. 284). Images of unsanitaryconditions, rusty razor blades, coercion, and violence from theones you love, such as in Dirie’s story, are common features in
FGC representations (Gruenbaum, 2005; Rogers, 2009). So are
medical and sexual health consequences (PPAN, 2012). It is notable,
however, that the question about health outcomes related to FGC
is not as intuitive as it might seem from the “standard tale” (see,e.g., Essén, 2023). Systematic reviews on health outcomes show that
FGC is associated with some health consequences, with type III
cutting being associated with more health and sexual complications
than type I and II cuttings (Berg et al., 2014; Lurie et al., 2020;
Sylla et al., 2020; Johnson-Agbakwu et al., 2023). Nevertheless, formany health conditions, no statistically significant associations canbe found (Berg et al., 2014; Lurie et al., 2020; Sylla et al., 2020). Thisis probably not a result of all FGC being free of harm but reflects thechallenges in conducting methodologically and conceptually soundresearch on the matter (e.g., representative sampling, adequate
control group, accounting for the diversity of FGC practices, using
tools that account for local meanings of FGC and capture thecomplex interplay among culture, health, and sexuality). Despite
these reservations regarding existing studies, assertions about longterm health consequences are often presented as “facts” in thestandard tale (Essén and Mosselmans, 2021; Essén, 2023).
This way of describing FGC is part of a larger discourse of
opposition toward FGC that has its legacy in early Western radical
feminist writings about the practices, sometimes referred to as
the “anti-FGM discourse” (Njambi, 2001). FGC became an issue
of global interest when radical feminists started in the 1970’s
portraying the practices to rally support for its abandonment.
Particularly important was the work of Fran Hosken who coined
the term “female genital mutilation” (Hosken, 1993). Theoreticallyanchored in patriarchal theory, first-hand accounts of FGC wereanalyzed as a manifestation of men’s oppression over women,
often emphasizing the potential harms of the practices, especiallytargeting sexual health. Within this framework, practices were

2. Narratives about female genital
cutting2.1. A dominant Western narrative about
FGC: “the standard tale”“FGC” (or female genital mutilation or female circumcision) is
an overarching term for a variety of genital alteration procedures
performed on girls for non-medical purposes. It is practiced
among different groups, for different reasons, and under varied
circumstances (Box 1). Despite its diversity, FGC has come to be
portrayed in a now familiar way, commonplace in anti-FGC work,
policy papers, media reporting, and introductory sections in FGC
literature (Leonard, 2000; Gruenbaum, 2005; Njambi, 2007; Rogers,
2009; Wade, 2009; PPAN, 2012; Malmström, 2016). The Americansociologist Lori Leonard has argued that this narrative has becomeso standardized in its form, she has termed it “the standard tale” ofFGC (Leonard, 2000, 2020). In her article, “We did it for pleasureonly”: hearing alternative tales of female circumcision’, Leonard
identifies some common features of the standard tale:
What is cut, how much is cut, at what age it’s cut, with what
implement, and by whom [. . . ] So is the litany of consequences:hemorrhage, shock, infection, infertility, sexual dysfunction,
problems in childbirth, death, and so on. (Leonard, 2000;
p. 213)In the standard tale, the practices are typically described
as ancient and deeply rooted (Leonard, 2000, 2020; Njambi,
2007). Based on an understanding of FGC, more often referred

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and political awareness (Gruenbaum, 2005), such accounts areby necessity simplistic in their nature—not aimed to capture
nuances or diversity of voices (Obiora, 1997; Nnaemeka, 2001;
Gruenbaum, 2005). Rather, as “formula stories,” they provide animage stripped of much of its context (Loseke, 2011). Meanwhile,
empirical accounts among women in social science research
have offered accounts displaying diverse meanings and contextual
understandings of the practices, including variations in cutting
procedures, motives, and functions among the varied groups
that practice it or have once practiced it (Box 1). For example,
some women may say that reasons for practicing FGC include
beautification and modernization (Leonard, 2000, 2020), or that
it is about health and fertility (Ahmadu, 2007; Jirovsky, 2014).
Other women might emphasize sexual morals or the importanceof FGC in developing a proper gender identity, religious identity,or cultural or national identity (Abusharaf, 2001; Njambi, 2004,
2007; Malmström, 2016; Powell et al., 2020), or a combination of
the above. There are also women in FGC-practicing contexts—
activists and others—who long have discarded the alleged benefitsof the practices and strived for its abandonment (Abusharaf, 2000).
Moreover, how women relate to their experience of FGC may vary
greatly, from feelings of strength, pride, honor, and empowerment,
to feelings of sorrow, grief, betrayal, and regret (Abdulcadir, 2019).
On an individual level, various factors may influence how one
makes sense of the FGC experience. Such factors may include
the presence of long-term health consequences or other healthconditions (Catania et al., 2007; Abdulcadir, 2019; Essén andMosselmans, 2021), how well the girl was prepared for the event,degree of cultural acceptance in the context it was performed(Schultz and Lien, 2013, 2014), and use of anesthesia and othercircumstances around the cutting event (Abdulcadir, 2019). In
other words, research shows a great variation in how women havenarrated their FGC experience: as victims of violence, coercion,and betrayal, or in terms of empowerment, enhancement, andfemale emancipation. What stories are narrated in a particular
context depends both on individual circumstances and biographiesand on structural and sociocultural conditions shaping experiences(Plummer, 1995; Gubrium and Holstein, 2009).

BOX 1 WHO typology of “female genital mutilation” and Somali
categorizations and terminology.
‘Female genital cutting’ refers to a broad range of procedures whichhave been practiced in varied ways, for varied reasons, under different
circumstances among some groups within some African, Asian and Arabcountries (such as Sudan, Somalia, the Gambia, Egypt, Malaysia, Senegal,
Kenya, Eritrea, and Ethiopia). Practices are diverse but are generally divided
into four categories according to the World Health Organization typology(WHO, 2018): infibulation where the labias are trimmed and sutured together
with or without cutting involving the clitoral gland (type III cutting); excisionof the labia minora/majora with/without cutting parts of the clitoris (type II),or excision of the clitoral hood and/or the tip of the clitoris (type I). Type IV
includes all other procedures that injures the outer genitalia for non-medical
purposes such as pricking (inducing a drop of blood with a sharp object on
the clitoral gland), piercing, incising, cauterization, burning (WHO, 2018).
In Somalia, FGC [gudnin in Somali] has traditionally been categorized into
two broader types: infibulation (or pharaonic cutting) or sunna cutting, that
may include all other forms of cuttings other than type III. In practice, sunna
cutting may entail an essential closure of the vaginal orifice, anatomicallyequal to pharaonic cutting (WHO, 2018).

seen as inherently abusive and something women cannot truly
consent to (Thiam, 1978; Daly, 1979; Hosken, 1993). Personal
narratives that challenged these ideas were dismissed as inauthentic(e.g., Thiam, 1978; Hosken, 1993), and female proponents of thepractices were described as “mentally castrated” (Daly, 1979; p.
164). In her discourse analysis on feminist contributions to the
FGC issue, the American sociologist Lisa Wade notes that thework of Hosken and her contemporaries has largely come toshape current international efforts to end FGC, and likewise thepublic debate of today (Wade, 2009, 2012, see also Earp andJohnsdotter, 2021). In the Swedish context, the anti-FGM discourse
is hegemonic. The perspectives in this dominant discourse havebeen influential in informing political policy and law (SFS, 1982;
The Swedish Government, 2016; Ministry of Health and Social
Affairs, 2018; p. 316) and the representations of the standard tale—
as a manifestation of this discourse—prevail in Swedish educational
materials on FGC, official reports, and statements by Swedish
authorities (e.g., National Board of Health and Welfare, 2002;
National Board of Health Welfare, 2005; Östergötland County
Administrative Board, 2015)1 . The standard narrative has also
influenced societal responses, public awareness, and professional
practice, insofar as professionals expect the standard tale from
affected groups during professional encounters (Johnsdotter, 2019;
Palm et al., 2019, 2020, 2021).

2.3. Reformulation of experiences inmigration
While research thus has documented endorsing accounts of
cutting practices in settings where FGC is a social norm, studies
suggest that a migration context with a condemning discourse
on FGC offers a powerful potential site for the renegotiation ofprevious values. Several studies now exist that have investigatedaffected groups’ attitudes toward FGC in Western migratory
settings, reporting processes of abandonment (e.g., Gele et al., 2012;
Koukoui et al., 2017; Wahlberg et al., 2017; Johansen, 2022). A
related question that has gained increased attention among scholars
is to what extent normative discourses on FGC and anti-FGC
politics also can have a negative impact on girls’ and women’s
self-understanding (Ahmadu, 2007; PPAN, 2012; Johnsdotter andEssén, 2016; O’Neill and Pallitto, 2021). Research in migratory
settings where FGC is stigmatized indicates that women may

2.2. Personal narratives about FGC
experiences in research
While the “standard tale” has informed popular beliefs
about FGC and proven effective to mobilize action for change1“Så ska vi stoppa könsstympningarna” [This is how we will stop thegenital mutilations], debate post [debattinlägg] in the Swedish newspaper
Expressen, by Maria Arnholm, Minister of Gender Equality at that time, about
the Governments work on gender equality, in Expressen 8 September 2013.

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internalize new understandings of their experiences. For example,
in studies about sexuality, cut women have reported how exposure
to new cultural scripts on FGC and body appearance had madethem start questioning their normalcy, leaving them feeling bad
about themselves (Johnsdotter and Essén, 2004; Ahmadu, 2007;
Catania et al., 2007; Lien and Schultz, 2013; Villani, 2017).
Through global eradication campaigns, similar tendencies havebeen reported among women in Ghana, Egypt, and Burkina Faso
(Jirovsky, 2014; Malmström, 2016; Hodžić, 2017).
While previous research has suggested that exposure toanti-FGC discourse may result in women internalizing an
understanding of themselves as maimed, this study contributes tofurther understanding of girls’ and women’s agency in constructing
and telling stories about FGC in a social setting with a stigmatizing
discourse on FGC.

at facilities used by Somali community organizations, schools,
libraries, or at participants’ workplaces, as preferred by theinterviewees. Interviews were held in Swedish, English, and Somali.
In FGDs, discussions in Somali were immediately summarized into
Swedish by the Somali-speaking women helping with recruitment
and cross-checked with other Swedish-speaking participants. At
one point, a professional interpreter was used. Two individualinterviews were held mainly in Somali and were interpreted byan acquaintance chosen by the interviewee. Individual interviews
lasted on average 60 min and FGDs lasted 1.5–3 h. Often but notalways groups were held with young (often unmarried) womenand adult women separately. With consent from participants,
interviews were audio-recorded. In some cases, notes were taken,
and interviews were summarized immediately after the interview.
The current study is part of a PhD project that initially focusedon young women (Ethical clearance Dnr 2014/620). The project
was gradually extended to also include older women. Ethicalapproval was provided by the Swedish Ethical Review Authority(Dnr 2020-00724). The present article is based on interviews
conducted in two sets between 2014 and 2022, with the bulk of data
being collected in 2020–2022. Participants gave verbal informed
consent at the beginning of the interview, which was documented
by audio recording. Participants were provided with an information
sheet about the purpose and procedure of the study which wasread together and discussed before the interview. The information
included the right to withdraw the participation at any time without
further explanation, information that participation is voluntary,and that participants may choose not to answer questions, would
they wish so. All interviewees have been given pseudonyms anddetails have sometimes been changed in the presentation of thefindings to maintain confidentiality of the participants. For a few
participants, more than one pseudonym was assigned.
The study approached the analysis assuming that stories are
co-produced and socially constructed (Plummer, 1995; Gubriumand Holstein, 2009). Departing from this assumption, analyticalattention was paid both to what people say, and to how people sayit, i.e., the meanings conveyed by the strategies employed whenconstructing stories (Gubrium and Holstein, 2009), and also to
the interactional processes involved in the telling (Plummer, 1995).
Given that FGC is banned, morally condemned, and a stigmatizedexperience in Sweden, participants could be expected to assume
that the interviewer holds expectations on a particular story about
FGC to be brought forward during interviews. Acknowledging thatthe interview situation is affected both by the social context andthe teller’s expectations of the listener (Plummer, 1995), careful
efforts were made to make room for a variety of experiences to bevoiced. For instance, questions were posed in a way meant to signal
space for various stories, such as “I know that some.. while others. . .
What do you think?” Nevertheless, the issue of self-representationis always present in research. As will be shown and discussed
in the Results section, stories are always created, negotiated, andexchanged in relation to the social context and to the receiver of thestory (Linde, 1993; Plummer, 1995).
Guided by these approaches to storytelling, an inductive
analysis was conducted. Transcripts were read and coded, checking
for recurring themes related to the study topic. In the first stepof the analysis, the attention moved back and forth between thewhats and the hows, and refining codes and themes, what has been

3. Method
Nine focus group discussions (FGDs) with 2–17 participants
each and 12 individual interviews with Swedish-Somali girls andwomen (16–65 years old) were conducted for a total of 53
participants. Most participants interviewed individually had also
participated in an FGD. Some had lived in Sweden for many
years whereas some had migrated to Sweden more recently.
Most of the younger women attended or had recently completed
upper secondary school. Some had full or part-time jobs or were
unemployed, and a few studied at the University. Among the older
women, a few had full-time employment and some had part-time
employment, while others were unemployed or were enrolled in
educational programs. The composition of participants reflects thesituation in Sweden, where older Somali women have faced barriers
entering the Swedish labor market (Carlson et al., 2012). In thearticle, participants between 16 and 25 years of age, often but notalways unmarried, will roughly be referred to as “young women.”
Other participants will be referred to as “older women.” Whilemost of the older participants reported they had pharaonic cutting(type III), generally, younger participants had sunna cuttings orwere uncut.
Participants were recruited from across the country. To
include people with a variety of experiences, participants wereapproached through different vantage points. Most were invited
to participate through the help of female representatives at threeorganizations frequented by Somali women, of which one was ayouth organization specifically working with FGC (i.e., awarenessraising and support for girls with FGC). The representatives
advertised the project, approaching members of the organizations,friends, acquaintances, neighbors, and other women they knew.
Younger participants were also invited through school nurses
working with young migrants and through a specially trained
female Swedish-Somali research assistant using her network fromher work as a Somali health-communicator in Sweden. Yet, others
were recruited through previous contacts.
Interviews were semi-structured with open-ended questions
covering queries about previous knowledge and information about
FGC, views on how FGC relates to health and sexuality, and thebenefits and disadvantages of the practices. All interviews wereconducted face-to-face by the first author and were conducted

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called “analytic bracketing” (Gubrium and Holstein, 2009). The
Results section was structured through the themes identified during
this process of analysis. Themes were thereafter refined during theprocess of writing, developing subsequent themes and sub-themes.
In the second step of the analysis, the focus was on how the accounts
related to dominant Western discourses on FGC, including the“standard tale” of FGC. To analyze how dominant discourses wererelated to the interviewees, bell hooks’ (1989) concept of talking
through and talking back was used. It suggests that dominantdiscourses may be used (talked through) or refused and resisted(talked back to) and may help illuminate the constructive elements
people use when making sense of and constructing stories of theirlife experiences.

seldom through news media. Maano (18–23 years, unmarried) saidin an FGD:
When I came to Sweden, I was 14, I was invited toa meeting after class. They talked about the law, that it isforbidden, of everything that can happen and the risks andeverything—then I was informed about it. Because I knew
nothing about it [before].
Similarly, Aalihya (18–23 years, unmarried) explained in an
individual interview:
Interviewer: What kind of information do you receive
about this in school? What have you learned about gudnin[FGC] in Sweden?

4. Results“Before I came here, I didn’t think that this would affect mylife in any way. I was 13 years old and hadn’t heard anything
about gudnin, because it was something no one talked about. . . So when I came here, I learned quite a lot: that you canhave difficulties during sex . . . that it affects our ability to feelpleasure during sex, that it’s not endorsed by the religion, which
has been a major reason for FGC.”

The analysis is structured under the following themes
addressing how participants navigated dominant Western
discourses on FGC: (1) Positioning own experiences to an imageof the infibulated woman; (2) Narrating the FGC event as acommonplace story; and (3) Stigma.

In addition, interviewees reported how they were influenced
by discursive changes in the Somali group in the diaspora andin Somalia in which pharaonic cutting increasingly has beencondemned, e.g., by imams, or in campaigns. Based on thesesources, an image of the “cut woman” was constructed. In
terms of harm, personal experiences of FGC were positioned
against and made sense of in relation to this imagined other(infibulated) woman.
Implicit in these narratives was that “FGC,” if not specified,generally was associated with pharaonic cutting. This was madevisible, for example, in how health consequences were discussed as
an obstruction due to a vaginal closure characteristic of pharaonic
cutting. Common comments were that sunna cutting was “lessharmful,” “nothing,” or “just a nick.” The exception was someyounger uncut participants who tended to collapse all genital
cutting under the umbrella “FGC,” or others who explicitly included
sunna cutting, often in the context of stating opposition against
all forms of genital cutting. In terms of their own experiences,discourses on health and sexuality were negotiated in relation topersonal experiences of not necessarily feeling harmed themselves.
When participants narrated their experiences, the presence of a seal
was particularly central and personal experience was often related
to how they imagined it to be for (other) infibulated women. The
positioning varied primarily depending on the participant’s own
experiences of FGC.
Young women with sunna cutting made sense of theirexperiences of FGC by positioning it against pharaonic cutting(and not, for example, uncut women). Sometimes the positioning
was explicit. This was most evident in Yasmiin’s narrative. Yasmiin(18–23 years, unmarried) was interviewed together with a friend
from a non-practicing ethnic group. During the interview, she wascareful to distance her experience of sunna cutting from pharaonic
cutting and what she assumed were societal expectations of FGC.
She described pharaonic cutting as something causing menstrual

4.1. Positioning own experiences to an
image of the inﬁbulated woman
When talking about FGC practices, participants of all agescommonly used the Somali terms gudnin, and “sunna” and“pharaonic,” respectively, to denote the various practices included
under the overarching term “FGC.” Few participants used “FGM,”“mutilation,” or the Swedish equivalent [könsstympning]. It did
occur among those who had been engaged in anti-FGC work. Whenkönsstympning was used, it was described as “the Swedish term.” To
reflect the tone of the interviewee, the terms used by the individualinterviewee will be used in the presentation of the empirical data,e.g., “sunna,” “sunni,” “pharaonic,” “mutilation,” “circumcision,” etc.
A salient theme in the interviews was that participants
negotiated notions of FGC as harmful to health and sexuality.
Framed within a medical and religious narrative, interviewees
condemned FGC, referring to it as “dangerous,” “traditional,” and“cultural” (as opposed to “modern” and “religious”). Many citedhealth risks associated with FGC, asserting, for example, that it“comes with a lot of problems,” “causes ‘pain’,” and a “lack ofsexual feeling.” Their position was attributed to a conviction that
it is a harmful and unreligious practice, not least in relation
to Islamic notions of “doing no harm.” Participants explained
how notions of harm were based on personal experiences—theirown, or heard from significant others, or through circulating
stories about women with FGC in their local context, when in
Somalia and/or in Sweden. Sometimes, these stories were framedin the form of “horror stories” of death, “lifelong suffering,” severe
complications, painful wedding nights, “sexual death,” and broken
marriages due to problems associated with FGC. The participants’position was also informed by anti-FGC discourses in Sweden,
e.g., through campaigns, targeted sessions about FGC in schools,
or anti-FGC initiatives targeting the Somali community, or more

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pain and sexual problems and simultaneously dissociated from an
idea of herself as having been harmed—framing her sunna cutting
as a harmless form of FGC:

Many of the young interviewees used the term “them” asopposed to an implicit “us” or “me,” when they narrated what
FGC meant to them. Common comments were about feeling“fortunate” or “being grateful” that their parents had avoided
pharaonic cutting and chosen sunna cutting for them instead. In
contrast, pharaonic cutting was described with pity and sorrow.
Young women expressed worry and sympathy for mothers, friends,
and others with infibulation. Some imagined that infibulation
would invoke shame or be a too-sensitive topic to discuss forinfibulated women, as they imagined it to affect women’s everyday
lives, creating a “life-long suffering” or a “sexual death,” as describedby one interviewee. In these examples, the young women withsunna cutting talked through dominant discourses of FGC as aharmful practice in the long term. The way participants related
it exclusively to pharaonic cutting while excluding sunna cutting
suggests that they were influenced by the discursive change frompharaonic to sunna cutting in Somalia, more so than by Western
dominant discourse that also tends to emphasize harm imposed byinterventions on the clitoris. Through this construction, it could
be interpreted that the stigma of anti-FGC discourse was placed
elsewhere—onto pharaonic cutting, which provided a yardstickagainst which their own experiences were storied. Yet, others
expressed reluctance to divide experiences into sunna or pharaonic
cutting, claiming the practices are the same in terms of anatomicalchange, stating that some so-called sunna cuttings still involve
partial or essential closure of the vaginal orifice. This was even more
so among the older women with sunna cutting, who often statedthat there were only small differences between their sunna cutting
and pharaonic by the time they were cut.
Few of the younger participants with sunna cutting thus
narrated their experiences in terms of feeling harmed. Morecommon was expressing doubts and worries about whether the
FGC might affect them in future. These concerns were related
to marriage and child-birth, and often related to being partiallysewn closed. Yet, a few also worried about how sunna cutting
would affect sexual desire and pleasure. In terms of health andwellbeing, when young participants with sunna cutting positioned
their experience against pharaonic cutting, sunna cutting was
simultaneously constructed as undramatic or unproblematic. The
narration of one’s own sunna experience as something that had notaffected their health and wellbeing in any essential way did not,however, mean that participants necessarily stated support for its
continuation. With only one exception, young participants withsunna cutting stated opposition against all forms of FGC, but notbased on notions of long-term harm. Instead, opposition toward
sunna cutting was expressed as the procedure being a painful ordeal
in the short-term that no longer had any tangible meaning, as
social pressure had eased with migration and religious teachings
had made participants reassess the practice on a religious basis.

Yasmiin: well my [FGC], it’s much better, or you know, it’s
not sewn all together. It’s just like with the boys.’ They just cut
a bit and then they didn’t touch anything.
Friend: But do you feel anything (sexually)?
Yasmiin: Yes, of course! You know, I’m like anyone else.
Only that they touched a bit, but they didn’t sew.
With statements such as “this sunni, they just cut a tiny bit,so you mustn’t feel sorry for me,” and “I don’t think it can becompared with those who are sewn,” she distinctly “talked back”
to discourses about cut women, stressing that it is not a monolithic
experience. She further refused a categorization of herself as “other,”instead emphasizing sameness and similarities between her anduncut women. She said, “I don’t feel any different, I don’t feeldifferent down there.” By these remarks, Yasmiin resisted the ideaof herself as victimized, harmed, or sexually maimed.
While not all young or older women with sunna cutting
explicitly positioned their experiences against pharaonic cutting inthis manner, the positioning was often made indirectly throughrelating their own experiences to that of an imagined, otherinfibulated woman. Most young and older women with sunna
cutting dis-identified with “FGC,” sensing that the topic was not
related to their own experiences. For example, Aalihya (18–23 years
old, unmarried) who first canceled the interview, explained:
At first, I thought of not coming so I canceled [theinterview], because I thought I might not have anything tocontribute. As I’m not pharaonic, I cannot speak [for womenwith FGC] and don’t want to speak for someone else who hasreal problems.
While many young women voiced how “FGC must end,”
cataloging potential health problems, most participants
simultaneously discounted their own experiences of sunna
cutting as a form of FGC that had caused them long-term harm.
Instead, what they had learned about the long-term health effectsof FGC was spontaneously related to pharaonic cutting, and in
this way also seen as unrelated to their own experiences of sunna
cutting. Hani (16–18 years, unmarried) expressed it thus:[With gudnin] there are so many bad things that canhappen to your body. It can impact your body, it can affectyour health, it can affect how you pee, it can affect your period,
everything. . . and I think the worst thing is the first night when
you get married, that’s the worst thing.
Interviewer: Are you yourself worried about this?

4.1.1. “It gets better after the ﬁrst child”
The presence of a seal was central also in the narrativesof infibulated girls and women. Many mentioned healthcomplications they associated with being partially or essentially

Hani: Me? No, I’m not worried, but I’m thinking about
how it is for the others.

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sewn closed, e.g., genital pain, pain and difficulties during
menstruation and first sexual intercourse, childbirth, and/or
urination. Others mentioned associated impacts on sexual desire
and pleasure, relating to a socially ideal gendered norm of womenwith infibulation as sexually modest and passive, although many
refuted this idea, stating other experiences. Once the seal was
opened, however, many stated “everything will be alright.” Fawsia(40–45 years, married) who reported having been partially sewn
closed during “sunna” cutting, said: “After I married, it’s all
good now. Now it’s ok.” Anissa (16–18 years, unmarried) who
associated infibulation with difficulties during sexual intercourseand childbirth, looked forward to her planned defibulation surgery.
She stated:

Woman C: We’re all different, some are still in pain you
know, others are not. So there you are different as individuals,
you know. We’re not all the same.
Woman D: If you’re healthy, some are healthy, they
don’t feel any pain. [Interpreter summarizes:] “Thatwoman says that she is still in pain from time to time.
‘Sometime it’s there, sometimes it’s gone.’ But it is different fordifferent women.”

Yet, others compared their experiences with uncut women,
pondering about genital pain, menstrual pain, or sexual arousal
among those who have not undergone FGC:

You will be in pain [during sex] and have no sexual
feelings. But they’ll [the feelings] come back if you open [theinfibulation]. I believe that.

Woman, older: We’re all in the same boat, we’ve been
through circumcision, but we want to know what it’s like forwomen without circumcision.

Interviewer: So as long as you open [the infibulation], thenthere’s no problem?

This group of girls and women expressed uncertainty about
whether to interpret the presence of discomfort to FGC or not.

Anissa: Yes.
Anissa echoed narratives among the older women withpharaonic cutting, many of whom expressed great concern overhaving been sewn closed; however, making remarks that difficulties
were resolved after defibulation.
While many described experiences of harm, others dissociatedfrom such experiences. In addition to these narratives, personal
experiences were related to the presence of a seal (and not, forexample, the excision of labia or the clitoral gland). Farhiya (30–35 years, married), for example, made sense of her absence of pain
or troubles by narrating it as an effect probably due to the factthat some stitches had opened up after her surgery as she was out
playing and running after the operation. Refuting the idea of herself
as harmed, she still talked through Swedish and Somali narratives
that associate infibulation with inevitable long-term harm.
In terms of health problems, the meanings of FGC were
contested among participants. Sometimes, they claimed ordeals
of infibulation to be a collectively shared experience, Asha (50–55 years, married) expressed it thus in an FGD: “we’re allin the same boat, we have been through this circumcision,”’suggesting she expected others to share similar experiences. In
this sense, Asha talked through a dominant, supposedly known
narrative. At other times, women such as Zahra (40–45 years,
married) resisted generalizations, expressing in-group variations
and FGC as a heterogenous experience. This was evident in
FGDs among older women when some participants claimed to
speak the “truth” about FGC—either it was stated as unavoidably
carrying health problems or people emphasized FGC as aheterogenous experience:

4.2. Narrating the FGC event as acommonplace story
Many participants, young and older, told stories about
the moment of the cutting event in their own lives. Whennarrating their experiences, participants negotiated theirpersonal experiences and also navigated storytelling in relation
to assumptions about the listener’s expectations and to dominantWestern narratives about FGC and FGC experiences. In interviews,
the FGC event was recurrently described as an expected andordinary part of life, what can be called a commonplace story. For
example, Jawahiir (45–50 years old, married) expressed it thus:
When I had this gudnin, when I was a kid, that was ok forme to have gudnin because it’s religion and all the other girls
also had it.
Although many, such as Jawahiir, expressed that FGC was apainful ordeal, emphasis in the accounts was, with only a few
exceptions, placed on the naturalization and anticipated-ness ofthe event. When participants were asked about their previous
knowledge of FGC, a common comment was that FGC wassomething “everyone went through,” conveying a sense that life was
expected to go on. Manoo (18–23 years, unmarried) commented:
Before I came to Sweden, this was something I neverthought about. It was just something everyone had done. I
didn’t think that it would affect my body in any kind of way,or affect anything, it was just something that happened toall [girls].

Woman A: It hurts very much the first time you have sex.
Woman B: But it doesn’t continue after that, it’s after a
few months, [changes her mind] only the first time, then it
disappears, that pain.

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Through contextualization, participants rationalized theirposition by sharing an understanding of the cultural context
in which FGC was a social norm. About the radically different

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discourses on FGC in Somalia and in Sweden, Aalihya (18–23 years,
unmarried) said:

When I had this gudnin, when I was a kid, that was ok forme to have gudnin because it’s religion and all the other girls
also had it. But when I grew up and got married, I thought
this was wrong. That you shouldn’t cut. So when I had my firstdaughter and my mother told me I must have her cut, I told her
you shouldn’t cut. But she said “no, it’s religion, it’s important,”
so I’m like “ok”.

I don’t feel like I’m proud that I have [FGC] but I thinkthat this was their way, where I lived. And people are like that,that they can’t do everything right all the time, so I can’t saythat I’m proud, or that I have had something that is beautiful or
anything. That’s not how I think. But at the same time, I thinkits like, I’m not the person who thinks that “Oh my God, I havebeen through some horrible stuff!” I accept [it] because I thinkthat they didn’t know any better.

Through their storytelling, many participants refused victim
status and emphasized agency, yet also described the position in
relation to structural conditions such as cross-generational power
relations and social pressures that constrained their power toprevent the event from happening. Countering ideas of themselves
as passive victims, participants constructed their stories as having
both agency and being determined by social norms and powerrelations that required them to undergo FGC, describing having alack of choice or feeling forced to undergo it.
In storying the FGC-event, participants made sense of andconceptualized their experience in light of dominant Western
discourses and presumed hegemonic ideas about girls and womenwith FGC as victims of a violent event. Some talked froma victimized position, others talked back to such a position.
Common to all participants was that they each engaged invarying kinds of contextualizing and talking back to assumed
shared ideas about FGC in their new social setting. The examples
are illustrative reminders that the storytelling context prompts
participants to tell a certain kind of story in a certain way.
Some stories seem not intelligible to tell, given the culturalcontext, but need to be rationalized and contextualized forparticipants to think of them as plausible to voice in the interview
situation.

Through unprompted statements such as that of Aalihya or
Maano, it seemed like participants commented on an expected
grander narrative about how girls and women would relate totheir FGC in childhood. In constructing the stories in this way,participants seem to speak to and negotiate what they assume to beshared ideas of FGC as the opposite (e.g., as a disruptive, violent,
and malicious event)—prompting them to make the clarifying
remark implicitly stating, “it wasn’t like that.”
Many participants engaged in similar talking back toimaginations of FGC as unavoidably associated with feelingsof victimization. Others, such as Khadra (50–55 years old,
married), were one of the few who clearly emphasized a victimized
perspective. She participated in interviews on more than one
occasion. During the first individual interview she was crying,saying “What I was exposed to was indeed very terrible, they took
away everything.” Khadra stated that memories keep coming back.
Throughout the interview, she emphasized the harm and sorrow
she felt over FGC, such as health and sexual problems, and therecollection of the loss of close ones after FGC.
Another recurrent theme stressed was how participants
had looked forward to the day of FGC, given the context.
Many emphasized their self-determination and desire in
relation to having FGC performed. Haaweyo (16–18 years
old, unmarried) remarked:

4.2.1. Change talk: narrating from the position ofa “now better-knowing” self
Condemnation through the eyes of the current context
was another recurring theme permeating the material—andparticipants commonly engaged in various forms of “changetalk”—accentuating how they now were thinking of FGC as aredundant event:

You know, it was we [sisters] who asked [our mom], she
didn’t force us to do this. We were the ones who thought weshould do this, because everyone in the neighborhood would
bully us if we hadn’t done it.

It should not continue, it should end, stop. As we have
now gained more knowledge, the people have received more
information, so this [FGC]—no one does it anymore, even in
Somalia, it has been stopped. (woman in FGD)

Many described the moment of FGC as a painful event
they regret, yet like in Haaweyo’s account, the FGC event was
primarily made sense of by stressing that it was something
they felt happy about, anticipated, begged for, and were looking
forward to, challenging the idea of themselves as a passive victim
of violence.
While many participants underlined their agency in relation
to the cutting event, they simultaneously made sense of it assomething out of their control, something “overdetermined,” thatthey had tried to resist in various kinds of ways. A desire to be likeeveryone else coupled with peer pressure and fear of stigmatization
were some elements brought forward when participants described
their desire to undergo FGC. Mothers who opposed having
their daughters go through cutting also often explained how
grandmothers decided on FGC against their will while living in
Somalia. Jawahiir (45–50, married) explained:

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Previous practices of FGC were made sense of in terms of being“backwards,” having a “traditional mindset,” and having a “lack ofknowledge” as regards medical or religious aspects of the practices.
Participants, young and older, positioned themselves against theseimageries of the less known, by declaring how they or Somali
people “now know better” and are opposed to FGC. Aalihya (18–23,
unmarried) clarified:
Back then [in Somalia], you thought that [pharaonic] was
required by religion, so we thought that what they say must be
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Sweden], and you became older, you have talked a lot about sex
and stuff in class, and you have studied more religion and seenthat it’s not permitted.

their daughters, you know,” the women told me. “You feelsuspected and haunted in a way, even though you’re notapproving of genital mutilation yourself.”

From the position of a “now better-knowing” self, participants
described themselves, parents, or the wider Somali community, as
having acted according to what they thought was in the best interestof the child and/or in accordance with religious teachings. Rukhaya(24–28, unmarried) said:

Sometimes, as in the above example, accounts of stigma wererelated to safeguarding measures; however, such examples wererare. More often, experiences of stigmatization in relation to FGC
were related to social aspects. The two sisters Maryam (16–18 years,
unmarried) and Bilan (20–23 years, unmarried) came from a homewhere their parents had decided not to have any of their fourdaughters undergo any type of FGC. They related in an FGD:

Now when we know it’s not allowed in the religion, we[sisters] say to our mom “look what you have done” . . . but she’s
not so knowledgeable about religion so that she can tell exactly
what is right. . . . she’s not that educated that she knew what wasright and what was wrong, so that’s why we can’t say to her “youdidn’t do good.”

One time when I was in the store, a woman approachedme... and she asked “why are you doing this [FGC]?” We said
“it’s a rule in our culture.” [She said:] “No, you must stop it, youmust shout out to your country that this is no good” . . . and we
didn’t recognize the term [she used], but she showed us [cutswith her hands] so then we knew. [laughs]

As Rukhaya drew on personal experiences, she also talked
back to dominant Western narratives including the character ofthe evil villain or the uncivilized in a barbaric-civilized binary.
Instead, the emphasis in her and others’ accounts was on FGC
as an act of care by loved ones. Drawing on discourses on what
constitutes good parenthood and good religious practice, FGC
was made sense of as rational given previous cultural scripts.
Accordingly, participants staked out moral positions of being agood parent, having good intentions, or being a good Muslim actingin accordance with moral discourse. This could be interpreted as away to accommodate both previous cultural scripts that required
FGC, positioning it as desired and a social norm, and to the newposition of opposition toward the practice and as something that isundesired and should end.

The older women’s and the young sisters’ accounts illustrate
how they managed ideas from outsiders about them being secret
upholders or proponents of FGC.
Sometimes stigma was associated with the experience of having
been exposed to FGC. When younger women talked about thestigma of carrying FGC, it was related to the prospects of getting
married or having a partner. Yasmiin (16–18 years, unmarried)
accounted for how she navigated what she assumed to be SwedishSomali boys’ expectations in relation to marriage:
When he asks if you are sunni or [pharaonic] and you’re
not sunni, he won’t be happy . . . because this woman can’t
make you happy.
Yasmiin based her reasoning on discourses about pharaonic
cutting and diminished sexual pleasure learned in Somalia.
Among older women, stigma in relation to having been exposed
to FGC was particularly salient in relation to gynecologicalexaminations. Women recurrently told how they at some point
had felt different and alienated by healthcare staff during
gynecological examinations. Older women expressed how they
prepared for healthcare providers’ preconceptions about FGC orstrong emotional reactions. Here is an excerpt from an FGD:

4.3. Stigma
Few participants spoke explicitly about stigma; however, theaccounts showed how they navigated and related their experiencesin different ways in relation to FGC being a stigmatized experiencein Sweden. Few claimed to have taken part in FGC information
through Swedish news media, TV, or newspapers; and only afew participants explicitly referred to “the media” as a source ofstigmatizing messages about FGC. Instead, most related to anindirect, subtle, and internalized experience of stigmatization, giventhat FGC is not a social norm in Sweden.
Some shared experiences of feeling stigmatized in relation to
the criminalization of FGC. In an FGD with older women, they
continuously referred to an anecdote about a Somali family in theirhometown. The story went, as told by a woman in her 50’s.:

Luul: When they examine you, they cry.
Khadiija: Saying, ‘I’m sorry this happened to you.’
Luul: The nurses look [at you] and get all shocked.
Khadija: You can tell they get sad.

The daughter in primary school had told her teacher theywould visit her family in Somalia during the summer. Suddenly
the family was called in by the school nurse who had reported tothe social authorities for fear of future genital mutilation. Social
services told the mother they were not allowed to mutilate theirdaughter and they had to sign a paper to confirm they hadreceived the information. “Not all Somalis want to circumcise

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Luul: I’m afraid they will react like that.
Interviewer: Afraid of their reaction?
Khadija translates for Luul: Afraid that they will look, say
stuff, the questions they ask, how much pain you feel.

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stigmatized and sterotypified by service providers and others when“the first thing she [the nurse] asks when she looks at me: ‘Are you
genitally mutilated?” as stated by Filhan.

Participants repeatedly stressed that they sensed that FGC
stigma was associated with the Somali group. A scenario oftencited was how young women—themselves, friends, or daughters—
had been targeted by school nurses when seeking help for
menstrual pain. Batuulo (18–23, unmarried), who worked in ayouth organization with anti-FGC advocacy and support in relation
to FGC, related:

5. Concluding discussion
This study highlights how Swedish-Somali girls and womenconstruct their stories about FGC in relation to dominantcondemnatory discourses about “female genital mutilation” in theirefforts to make sense of personal experiences. Personal experienceswere narrated in relation to what participants assumed to be societal
ideas about FGC, in particular in relation to notions of harm,
agency/force, and victimization.
That participants had to actively navigate and negotiate
dominant condemnatory discourses on FGC was visible in relation
to the social context—in the interview situation with the researcher
and other participants in FGDs—and in relation to stories aboutnavigating outsiders’ expectations. Participants engaged in various
narrative strategies for talking through and talking back (hooks,
1989) to dominant condemnatory discourses. This became clear
through the absence of clarification and abridged comments
implying “we all know—no need to clarify” (talking through),or stressing in-group variation, offering contextualization, andengaging in the un-doing of stereotypes (talking back). These
strategies can be understood as an example of how they storied theirexperiences in relation to a grander narrative that was supposedly
shared and known—a “standard tale” (Leonard, 2000, 2020).
In relation to the wider society, participants navigated societal
expectations of them being in favor of FGC. The experiences
resonate with a public discourse in Sweden that insists on FGC
being a widespread yet hidden activity. Such claims are common
in Swedish news media, despite plenty of research suggestingthat there is generally a fast abandonment of the practice after
the migration (the situation has been described in Johnsdotter,2019). Being afraid to raise authorities’ suspicions in relation to thecriminalization of FGC was an example of how the participants had
to navigate societal expectations regarding their attitudes toward
FGC. More commonly, however, participants had internalized
stigma related to FGC. As reported in the previous literature(O’Neill and Pallitto, 2021), girls and women in the current study
explained how they prepared for strong emotional reactions or
preconceptions about FGC from healthcare staff—what Jacobson
et al. (2022) identified as women conducting “emotional healthwork.” The present study shows that this work was conducted also
outside the healthcare context, and regardless of actual experiencesof genital cutting, i.e., also the young uncut participants had tonegotiate an ascribed FGC label, for example, when seeking help for
menstrual pain. This situation is also described in a previous article
where Swedish healthcare staff explain how concerns about FGC
were directed at Somali girls (Palm et al., 2021). The association
made by others between Somalis and FGC was described as an
attributed category that stuck to their bodies only by appearance.
It was an association that invoked strong images and emotional
responses in the other, what can be understood as a “sticky
association,” to use Sara Ahmed’s concept (Ahmed, 2014; p. 11,98). The findings suggest that FGC as a sticky association with
Somali ethnicity, risks having stigmatizing and stereotyping effects.

I particularly encounter young women who tell me thatthey are treated in a [certain] way in the Swedish healthcare
system, like “ah, maybe you’ll have trouble giving birth because
you’re mutilated.” They say that without knowing, without
having examined me, or just because I’m from this place[Somalia]—then they call me mutilated, just because I havemenstrual pain, they’ll bring this up [genital mutilation]. . . . soit’s very dramatic.
Many experienced that healthcare staff jumped to theconclusion that their symptoms were caused by FGC, regardless ofwhether having undergone any type of FGC or not. Most illustrativeof this situation was probably the story of Filhan (16–18 years,
unmarried). She explained:
I had appendectomy some years ago, but when I complain
about still having aches, they sent me to the gynecologist toensure it’s not female circumcision. And I have already told
[them]: I’m not [circumcised]! But they’re like: “with these
symptoms, it could be this [FGC]” . . . I have noticed among myfriends from other countries, that they don’t get these questions“are you genitally mutilated” . . . And [at the doctors] I’m like“no,” and they’re like: “are you sure? Do you remember when
you were a kid” and blablabla.
In the case of Filhan, her story was not deemed trustworthy
by the healthcare providers she encountered, as they kept insistingthat her symptoms fitted their picture of FGC. What the girls’
and women’s stories also show is how they navigated outsiders’ideas about FGC where FGC stigma was attached to the women’sbodies and Somali appearance, regardless of actual FGC experience.
Batuulo related a situation in school where the teacher had targeted
her in a general discussion about FGC:
We had a teacher, and you could tell he wanted me totalk about it. “What do you think about this female genital
mutilation?” I can see why he asked . . . but he singled me out . . .
I told him it’s not okay because I have noticed it only happens
to Somalis, or Somali girls.
A common comment about this situation was that “wecannot hide” from peoples’ anticipations, referring to Somalia asa high-prevalent country of FGC. This association was endorsed
and sympathized with by some and resisted by others. The
advantage, some argued, is that FGC becomes acknowledged asa potential concern affecting the Somali group. Others talked
back to representations associating Swedish-Somalis with FGC,
for instance, by trying to detach FGC from Somali ethnicity byengaging in change talk (see previous section) or stating that it is
not exclusively a Somali phenomenon. Yet, others expressed feeling

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As has been reported in previous studies among Somalis in Canada
and the UK (Khaja et al., 2010; Karlsen et al., 2020; Parikh et al.,2020), the findings in the present study point to a tendency ofovergeneralization where girls and women of Somali backgroundare singled out, misjudged, or are having their situation reduced
to a matter of alleged FGC. Ultimately, such an approach has
been shown to lead to suboptimal healthcare and diminished trust
in service providers and prevention efforts (Essén et al., 2002a;
Khaja et al., 2010; Karlsen et al., 2020). This adds to poorer healthoutcomes and barriers to accessing proper care and support asalready faced by Somali women in Sweden and in other diaspora
settings (Essén et al., 2002b; Esscher et al., 2014; Karlsen et al.,2020).
Previous literature on FGC has shown the impact of migrationon the reformulation of previous experiences of FGC (Catania et al.,2007; O’Neill and Pallitto, 2021). The present study further displays
how both condemnatory discourses in Sweden and Somalia, on
national, community, and relational levels, have informed how
participants make sense of FGC. Confirming previous studies, theSwedish-Somali girls and women in this study had internalized an
ideology of FGC as bad, wrong, and undesired (c.f. Gele et al.,2012; Wahlberg et al., 2017; Johansen, 2022). They were affectedby discourses framing FGC as harmful to health and sexuality,
as well as un-Islamic (Wahlberg et al., 2019; c.f. Johansen, 2022).
“FGC” was in most cases synonymous with infibulation (Powell
and Yussuf, 2018; c.f. Johansen, 2022), at least in relation to
health aspects. Participants explained how they had developed
negative attitudes toward FGC as a result of religious convictions orexperiences of harm—their own experiences or those heard of fromsignificant others. Notions of harm were also based on hearsay andanecdotes within the Somali community in Sweden and Somalia.
Circulating stories about the “sexually ‘dead”’ infibulated woman
was an example of this. As has been described in previous research,negative attitudes toward FGC were also informed by dominantcondemnatory discourse in the Swedish migration context, whichemphasizes FGC as a violent and harmful practice (Gele et al.,2015; Wahlberg et al., 2019; Ziyada et al., 2020). This pictureof FGC as related to by the participants concurrently resonateswith discourse in Somalia, where FGC is increasingly condemnedon a similar basis, partly due to decades of global efforts to end
FGC (Powell et al., 2020). Based on these sources, an image of
the “cut woman” was constructed. In terms of harm, personal
experiences of FGC were positioned against and made sense ofin relation to this imagined other (infibulated) woman, associatedwith victimization, lifelong suffering, and sexual problems. Whileparticipants were affected by anti-FGC discourse, especially theemphasis on the negative health and sexual effects, the constructionof a binary between sunna and pharaonic cutting, where the stigma
of anti-FGC discourse was related to pharaonic cutting, seemed tooffer discursive space for identity construction and position that
accommodated to both the condemnatory setting in migration,
discursive changes on FGC in Somalia, and personal experiences
and beliefs. Similar conclusions are presented in a recent study
among Sudanese and Somalis in Norway, but rather among theolder generation (Johansen, 2022). The way participants related
notions of long-term harm to infibulation while generally excluding
clitoridectomy could be interpreted as their statements being more

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influenced by the discursive change from infibulation to sunna
cutting in Somalia, than of Western dominant discourses on harm
which include all types of FGC. Another plausible explanation
could be that anti-FGC messages in Sweden tend to emphasize
the health effects of infibulation without discriminating between
specific types of cutting (e.g., Östergötland County Administrative
Board, 2015). This could have the effect that all other kinds ofprocedures are detached from the FGC category.
In terms of prevention efforts and treatment, the participants’conceptualization of sunna versus pharaonic cutting has at least two
implications. First, young women with sunna cutting positioned
themselves through a negative definition of pharaonic cutting—as something they were not. This might be a consequence of thestigma related to FGC, and signals that no alternative (positive)
identification seems available that can combine having undergone
FGC with not necessarily feeling harmed. The exception was
the young woman, Yasmiin. Drawing on discourses about health,religion, and modernity, the separation of pharaonic and sunna
cutting seemed, for her, to provide a progressive, modern, and“whole” self-identity. On the contrary, for women with infibulation,
there seems to be a repertoire of language and labels for selfcategorization within the survivor or victim paradigm. Yet, the“mutilation” discourse—as implied by the very term mutilation—offers few other (positive) options for self-categorization other thanmaimed. Second, in efforts to end FGC, there has been a tendency toemphasize “worst case scenarios” (Obiora, 1997; p. 53) of possible
health, mental, and sexual outcomes of the FGC event. These
are often based on alleged consequences of infibulation, without
differentiation between specific types of cutting and their potential
related risks (Obiora, 1997; Gruenbaum, 2005). The present study
further underscores what has previously been argued, namely thevalue of discerning between various kinds of cutting and their
specific potential health risks. Otherwise, some girls or womenmight, as suggested by Earp and Johnsdotter (2021), expect “theworst” from their cutting, irrespective of their own experiencesfrom FGC, or, as suggested by the present study, some may
discard FGC messages altogether, seeing them as unrelated to theirown experiences.
So what kind of story is this? In social science research on
storytelling, it has been recognized that publicly circulating stories
have a great impact on social life (e.g., Plummer, 1995; Loseke,2011). In his seminal book, Telling Sexual Stories, sociologist Ken
Plummer (1995) illustrates how what he called “sexual stories,”
e.g., “coming out stories” or “rape stories,” when becoming public,
create space for others to draw upon when narrating their own
experiences. In this way, it can be argued that stories may become
interactive. At an individual level, people use stories to organize,
understand, and interpret their experiences. Scholarship on FGC
has increasingly cautioned that a drawback from an anti-FGC
discourse that categorizes cut girls and women as “mutilated” may
negatively impact their body image, self-esteem, and sexual selfimage, insofar as girls and women start defining themselves interms of their “mutilation” (Johnsdotter and Essén, 2016; Earp,
2021). There is now a myriad of studies supporting this notion(Johnsdotter and Essén, 2004; Ahmadu, 2007; Malmström, 2016;
Villani, 2017; Ziyada et al., 2020), reporting how some women haveincorporated the standard narrative of themselves as “mutilated”

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10.3389/fsoc.2023.1188097(Villani, 2017; Ziyada et al., 2020), disfigured (Jordal et al., 2022), or
victimized (Vloeberghs et al., 2011). Similarly, a recent systematic
review of qualitative research on psycho-social wellbeing after
FGC synthesizes how some women with FGC report feelingsof shame, stigma, inferiority, or of being different in migration
settings (O’Neill and Pallitto, 2021). In contrast to these findings,
the present study found that such a narrative did not seem toprovide a meaningful language or a sufficient frame to make senseof one’s own experiences. In contrast to the standardized story
about FGC, this study indicates that there is no one uniform
story among the interviewees. The study found that the Somali
girls and women had internalized an ideology of FGC as bad,wrong, harmful, and undesired, yet, on a personal level, navigatedexperiences of not necessarily themselves feeling harmed, wronged,
or violated. Simultaneously, participants negotiated previous
cultural scripts that constructed FGC as religious, morally good,and desired. Participants used various narrative strategies suchas contextualization and engaging in change talk, or positioning
against an imagined cut woman to make sense of these experiencesin the new Swedish context. This can be seen as an example of
how stories are created, negotiated, and exchanged in relation to thesocial context and the receiver of the story (Plummer, 1995). Where
previous studies have contributed to an understanding of how newlabels, categorizations, and possible social identities such as “themutilated”—offered through prevention strategies (e.g, campaigns
and awareness raising efforts)—may affect girls and women already
exposed to FGC, the present study furthers the understandingof girls’ and women’s agency in constructing and telling stories
about FGC in a migration setting that condemns FGC. Overall,
the study showed that participants did not carry a single “grandnarrative” about FGC, but still had to navigate and negotiate such anarrative. Common to most was that they engaged in various kindsof counter-storying in their efforts to make sense of their uniqueexperience. Navigation was conducted both at an intrapersonallevel through continuous identity work, and also in relation to
the social context in interpersonal encounters, i.e., with service
providers and others, among which the standard tale has becomea truth.
Some discourses and stories, in a given time and place, attain
more cultural currency than others (Foucault, 1981; Plummer,
1995). In Sweden, “the standard tale” of FGC is an official story
about FGC that has gained greater cultural currency than others.
Overall, the study shows how participants, when trying to makesense of their own experiences, had to negotiate a dominantstory about FGC including ascribed identities, experiences, labels,
and terms that were not necessarily developed from their own
realities. One possible implication of the dominance of the standard
tale is that stories that counter the listener’s expectations are
silenced or not deemed trustworthy, such as in the example
of Filhan. If a stereotyped story, like the “standard tale,”informs the professional encounter rather than the personal
experience, it might have stigmatizing and silencing effects and may
distort communication. Brian Earp, the bioethicist and notorious
defender of all children’s right to avoid non-consensual genitalmodifications, sympathetically suggests that rather than forcing
victim status on an individual, “an alternative approach would
be to acknowledge the diversity of outcomes, meanings, andinterpretations surrounding distinctive types of genital cutting

Frontiers in Sociology

across societies, both positive and negative, and allow affectedindividuals to decide for themselves whether they wish to be treatedor seen as victims of ‘mutilation”’ (2021; p. 1880).

Data availability statement
The datasets presented in this article are not readily available
because all relevant data is presented in the article. Requests toaccess the datasets should be directed to camilla.palm@mau.se.

Ethics statement
The studies involving human participants were reviewed andapproved by the Swedish Ethics Board (Dnr 2014/620; Dnr
2020-00724). Written informed consent for participation was not
required from the participants in accordance with the national
legislation and the institutional requirements. Participants gave
verbal informed consent at the beginning of their interviews, which
was documented by audio recording.

Author contributions
BE funded, administered, designed the project, and edited
and revised the manuscript for intellectual content. EE and CH
supervised the manuscript, contributed to the conceptualizationof the analysis, and edited and revised the manuscript for
intellectual content. CP designed the research, conducted andanalyzed the qualitative data, and wrote original draft and edited
and reviewed the manuscript. All authors have read and approved
the final manuscript.

Funding
This study was supported by the Swedish Research Council(Vetenskapsrådet) under grant VR 2015-03546 and 2018-03365,
Malmö University, and Uppsala University.

Acknowledgments
This study stems from the broader project Changing attitudes
toward female genital cutting among Somalis in Sweden headedby BE, professor of International Maternal and Reproductive
Health, Uppsala University, and Sara Johnsdotter, professor of
Medical Anthropology, Malmö University. We are grateful to
Zahra Abdi for research assistance and to other people involved in
the recruitment process.

Conﬂict of interest
The authors declare that the research was conducted in theabsence of any commercial or financial relationships that could beconstrued as a potential conflict of interest.
The reviewer BA declared a shared affiliation with the authors
CP and BE to the handling editor at the time of review.

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Publisher’s noteorganizations, or those of the publisher, the editors and thereviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
endorsed by the publisher.

All claims expressed in this article are solely those of theauthors and do not necessarily represent those of their affiliatedReferences
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IV

SEXUALITY CONSTRUCTIONS IN
RELATION TO FEMALE GENITAL
CUTTING:
Young and older Swedish-Somali women on sexual
responsiveness
Camilla Palm1

Abstract
Through focus groups (9) and individual interviews (12), this study explores
subjective experiences of sexual responsiveness in relation to female genital
cutting (FGC) among Somali women and youths living in Sweden. FGC in
Somalia is traditionally associated with the creation of a restrained sexuality inaccordance with gendered sexual norms. In efforts to end the practice, however,
it is continuously stressed that FGC aims at depriving women of their sexual
capacity. Specifically, this study seeks to examine how contradictory sexuality
constructions are navigated and negotiated among women of different
generations post-migration to Sweden. In contrast to what has been suggested informer literature, younger women seemed less influenced by condemnatory
discourses in terms of their sexual self-understanding while the opposite was thecase among the older women. The article discusses how this can be understoodand possible implications.
Keywords: female genital cutting, female genital mutilation, discourse,
sexuality, qualitative research

Introduction
Sweden is often depicted as one of the most sexually liberal and gender-equalcountries in the world (Inglehart et al., 2017). The image of Sweden is associatedwith individualism, women’s sexual agency, and independence (Lennerhed,2014). Since the entry of a radical feminist analysis of women’s situation,
1 Faculty of Health and Society, Department of Social Work, Centre for Sexology and Sexuality

Studies, Malmö University, Malmö, Sweden

1prominent in western countries during the 1970s (Rubin, 1984), this perspective
has marked Swedish public discourse, legislation, and policy approaches tofemale genital cutting (FGC), more commonly known as ‘female genital
mutilation’ (FGM) (SFS, 1982:316; Teigen and Wängnerud, 2009). To improve
women’s situation, the Swedish government has continually funded gendermainstreaming efforts, including work to prevent violence against women and
FGC (Östergötland County Administrative Board 2016). In Swedish policy andpublic discourse, immigrant women presenting with FGC have in this context
been interpreted as victims of a particularly gruesome expression of men’s
domination over women, ultimately designed to deprive women of their sexualautonomy and fulfillment (e.g. Halldén 1979, p.30 in Johnsdotter and Essén,
2004; Östergötland County Administrative Board 2015). In contrast, being
almost universally practiced in Somalia (Powell and Yussuf, 2018; UNICEF,
2013), scholars evidence a complexity of subjective experiences of a practice that
may entail pain yet also intricately associated with pride, normalcy, marking of
womanhood, religious identity, and an alleged instilling of sexual morals inwomen (Powell and Yussuf, 2018). As shown by the American anthropologist
Gayle Rubin (1984), what is considered ‘natural’ and ‘unnatural’, ‘healthy’ and‘unhealthy’ as regards sexuality is by no means fixed or identical across social
contexts. To move from one social context to another sometimes means a radical
change of norms regarding ideal (gendered) sexuality. What happens in thisdisplacement of bodies and social norms?
‘Female genital cutting’ refers to non-therapeutic procedures involving
removal of the external female genitalia by cutting the clitoris and/or labia(clitoridectomy/excision, so called type I-II in the widely used World HealthOrganization’s typology), or narrowing the vaginal orifice, also called
infibulation or type III cutting (WHO 2023). In migratory settings, research has
primarily focused on attitude change and sexual and reproductive health needs
and interventions. A small but growing literature addresses psychosexual wellbeing, sexual norms, and the construction and reconstruction of sexual identities
in relation to FGC (e.g. Ahmadu, 2007; Lunde et al., 2021; O’Neill and Pallitto,
2021; Villani, 2019; Ziyada et al., 2020). In particular, this research highlights
possible impacts of condemnatory discourses, including associated messages
about sexual dysfunction. This discourse has produced a powerful image of the
subjugated ‘mutilated woman’ as a victim of barbarism and male violence(Mohanty, 1988; PPAN, 2012), affecting how women with FGC are perceived
and perceive themselves (Lunde et al., 2021; Palm et al., 2023). A pressing
question is what effects prevention efforts have on the populations they ultimately
intend to help, and how girls can be safeguarded from a medically non-necessary
procedure without stigmatizing and victimizing this same group by reinforcing
racialized stereotypes or undermining body image and sexual self-esteem (Earp,
2021; Palm et al., 2019; Villani, 2023). Informed by qualitative interviews and2

focus groups with Swedish-Somali women of different generations, this article
aims to examine how women negotiate and navigate different sociocultural
constructions of sexual responsiveness after migration and exposure to Western
discourses of the FGC. Having included women of different generations, thestudy also seeks to further understanding of how differences of age, point ofimmigration, and marital status (used as a proxy for sexual experience), may
generate diverse experiences from the viewpoint of the research question.

Sexual pleasure and well-being after female
genital cutting
For generations of Western observers of the practices, the notion that capacity forsexual pleasure and desire is erased after FGC has been an almost undisputable
fact (Hosken, 1979/1993; PPAN, 2012; Parker, 1995). According to the SierraLeonean American anthropologist Fuambai Ahmadu ‘there is an automatic, often
unconscious, equation of female genital cutting with sexual dysfunction’(Ahmadu, 2007:, p.278). In the Swedish context, depictions of sexual impairment
after FGC are common features in policy papers, news media, and best-sellingnovels, also affecting public opinion (Palm et al., 2019). Holders of thisperspective can now draw on a large body of research on the negative impacts of
FGC on health and sexuality (Berg and Denison, 2012; Lurie et al., 2020; O’Neilland Pallitto, 2021; Sylla et al., 2020). Thus far, however, most academic literatureshows that while some women suffer from sexual problems from FGC, thecompiled body of research does not support popular beliefs about erased sexual
capacity (Berg and Denison, 2012; Esho and Kumar, 2023).
Studies comparing groups of women with and without various forms of FGC
display divergent results. Some studies among women with FGC type I-III reportlower sexual function in some domains compared to uncut women e.g., pain,
lubrication, desire, and satisfaction (Berg and Denison, 2012; Lurie et al., 2020).
Some demonstrate higher sexual function among cut women in some domains,others have found small or no differences between the groups of women(Abdulcadir et al., 2016; Berg and Denison, 2012; Catania et al., 2007). Various
factors may explain why research has not been able to establish greater
differences in orgasm and sexual satisfaction between these groups. The
significance of the internal clitoral structure and the clitoral gland whichsometimes remains intact beneath an infibulation scar, have sometimes beenhighlighted (Abdulcadir and Catania, 2021). Einstein’s study (2008) on
neurobiological responses to FGC demonstrated a reorganization of neuralnetworks involved in orgasm, also potentially explaining the varied reports ofsexual pleasure among cut women. The many roads to orgasm, for example
through the stimulation of breasts or vagina, may also explain the varied results3

(Ahmadu, 2007; Okonofua et al., 2002; Towne, 2019). Moreover, the fact that
subjective sexual experience is contingent of various intersecting factors (e.g.,physiological, emotional, relational, socio-cultural etc.) can probably be one clue
to the mixed results. For example, expectancy effect, gender norms andpsychological expectations play an important role in sexual responsiveness andsexual excitation (Janssen and Bancroft, 2023; Laan et al., 2021).
In tandem with a general shift in scientific studies of sexuality (Parker, 2009),
work on FGC has increasingly focused on sexual experience as sociallyembedded and learned (Connor et al., 2023; Malmström, 2016; Villani, 2019).
The focus on sexuality as a process of socialization has resulted in increased
attention to how globalization processes and the diffusion of Westernunderstandings of FGC impact girls’ and women’s notions of their bodies andsexuality. These studies indicate that some girls and women may develop anegative sexual self-image through internalization of Western discourses on FGC
and sexuality conceptualizing the cut body as maimed or mutilated (see review
by O’Neill and Pallitto, 2021). In migratory settings, factors such asacculturation, having a western sexual partner, peers questioning FGC,
information in news media, identification with egalitarian gender equality andsexuality norms, and embracing of a clitoris-centered sexuality-discourse havebeen reported to play a role (Gele et al., 2015; Johnsdotter and Essén, 2004; Jordal
et al., 2022; Ziyada et al., 2020). It is generally assumed that with the uptake ofnegative sexual health messages about FGC, girls and women will come to define
their bodies and sexual function as imperfect. Growing evidence supports thishypothesis, with younger women potentially being at greater risk of developing
a negative sexual self-image than older women (Catania et al., 2007; Malmström,
2013; Ziyada et al., 2020). Yet studies among young women are still few. The
present study provides a contribution to fill this gap.

Rubin’s sex hierarchy and respectability
The analysis is informed by theories in gender and sexuality studies. In 1984,
Gayle Rubin presented the now widely used concept the charmed circle, which
discusses how some types of sexual behaviors are characterized as ‘good, normal,
natural, blessed’ and others as ‘bad’ and unaccepted (Rubin, 1984, p. 153). Rubinsuggests that in the middle of the charmed circle is sex that is heterosexual,
reproductive, within marriage, vaginal intercourse, without elements ofcommercialism or kink. According to Rubin, those aligning with the inner circleof accepted sexual behavior are awarded with social approval in accordance withthe sex hierarchy. On the other hand, behaviors that fall on the outskirts ofmorally accepted behavior in a given context risk negative social sanctions and4stigma (Rubin, 1984). Sexual norms are highly gendered. Following Beverly
Skeggs (1997), women navigate sexual morals through the notion ofrespectability. For example, young women in general populations in Sweden and
Norway navigate complex fields of sexual norms to advance their position ofrespectability and avoid stigma of showing too much sexual interest or being
perceived as in lack of self-control (Fjær et al., 2015; Holmström et al., 2020).
This is despite living in countries described as some of the most gender-equal andsexually liberal in the world (Inglehart et al., 2017).

MethodIn total, 12 individual interviews and 9 focus group interviews with 53 SwedishSomali women of different generations were conducted between 2014 and 2022.
Focus groups lasted 1.5 to 3 hours and contained 2-7 participants each, except for
one where 17 participants unexpectedly showed up. Individual interviews lasted
around 60 minutes. Some of those interviewed individually had also participatedin focus groups. Most focus groups were conducted with younger and older
women separately. While focus groups aimed to provide knowledge about social
norms and contested opinions, individual interviews offered contextualized
understandings of participants’ subjective experiences and perceptions (Lambertand Loiselle, 2008).
The sample was diverged and consisted of women from urban and more rural
areas, within and outside the labor market, with various levels of education andyears of residency in Sweden. Most had lived in Sweden for 2-8 years. About athird were between 15-25 years old, often but not always unmarried. They are
here referred to as ‘young women’. Others are referred to as ‘older women’.
Women born in the 1980s or later often reported they had sunna cutting or were
uncut, while older generations usually had undergone infibulation (c.f. Johansen2022).
Participants were found with help from civil society organizations, school
nurses, a Swedish-Somali research assistant, and through previous contacts. To
limit selection bias that may result from the reliance on ‘gatekeepers’, recruitment
was purposely directed at different sites, using varied entry points (Bloch, 2007).
In-person interviews were conducted in Swedish, English, or Somali, in privaterooms at participants’ schools, workplaces, libraries, or at premises used by theSomali women. The Somali-speaking women helping with recruitment also
helped organize interviews and worked as interpreters when participantspreferred to speak Somali. In one focus group, a professional interpreter wasused. Participants gave verbal informed consent at the beginning of the interview.
To ensure confidentiality, names and identifying characteristics have beenchanged or withheld in transcripts and the presented data. To limit the risk of5

identification, two pseudonyms have been used for women who participated bothin groups and individually. The study was approved by the Swedish Ethics
Review Authority (Dnr 2014/620; Dnr 2020-00724; Dnr 2023-03890-02).
All but two interviews were audio-recorded. Most were transcribed verbatim,
or careful notes were taken when participants preferred not to be recorded. Allinterviews used semi-structured, open-ended questions, themed around reasoning
on FGC, marriage, sexuality, and related norms in the new context. With young
participants, vignettes covering the research themes were also used to facilitate
discussions on the topics. Vignettes, which encourage reasoning from a thirdperson perspective, have been reported to be suitable to discussion on topics whenparticipants might not have first-hand experiences or have experiences that are
sensitive to disclose (Barter and Renold, 2000). The vignettes were drawn fromcases in news-paper articles and from a research article about young Somalis in
diaspora. They were piloted among young and older women and thereafterrevised. Here is an example of a vignette:
Amran, 17, lives in Sweden. She thinks her parents did wrong when they had her
circumcised. Not because she has any particular health problems--she has heard
from her friends that you can get problems, but this is not what worries her, but she
is worried about how it might be for her when she becomes sexually active.

Vignettes were introduced at the end of the interviews and allowed forparticipants to elaborate further on the study topic.
The analysis broadly followed a thematic analysis as documented by Braunand Clarke (2006). By repeated readings of the transcripts, inductive codes were
established through the process of data analysis. Codes were developed by theidentification of recurrent patterns and other themes related to the researchquestion. These clustered around gendered sexuality constructions, addressed in
the Result Section.

Results
Traditional ideals of female sexual closedness
Interviewees stressed that a primary reason for performing FGC in Somalia has
been to create a restraint female sexuality. To be ‘closed’, a term used by theinterviewees, was described as a traditional gendered norm in Somalia learned
from early childhood to decrease risk of infidelity, premarital sex and the related
risk of having a child without an officially known father (c.f. Johnsdotter, 2002).
Sexual closedness also relates to an Islamic ideal of female sexual modesty(Isotalo, 2007; Connor et al., 2023). In Somalia, interviewees explained, FGC

6was perceived as one means to produce moderate sexual emotions and assist
women in practicing chastity before, within, and outside marriage:
The reason why they do it, is that the girl should not think about sex. They want to
reduce their feelings and desire to have sex and stuff like that. That’s why. (Aisha,unmarried, in her 20s)

When interviewees talked about sexual desire and pleasure, they used theSomali term dareen or the Swedish equivalent of ‘sexual feeling’ [sexuellakänslor, känsla] or ‘to feel’ [att känna]. While Swedish vocabulary separates
emotional feelings [känslor] from sensory feelings [känsel], interviewees used‘sexual feeling’ to denote to both states of sexual desire (i.e., sexual urges, needs,
emotions, passion, arousal) and/or sexual pleasure (i.e., sensation, sexual
response, arousal), or to desire and pleasure as interrelated and as a common term
for sexual responsiveness (c.f. Connor et al., 2023).
In terms of sexuality, young and older women used a metaphor of women‘chewing gum’ to refer to the alleged effects of FGC, and infibulation inparticular:[Prompted by the other women, Bilan tells me]: [Back in Somalia] they had an
expression saying that those who don’t have [a clitoris] they will just lie down flat,they’re like when chewing gum, ‘Are you done?’ They joke, saying that [women]
are like ‘Are you done yet?’. But I don’t think it’s true, it’s not true.

The chewing-gum metaphor provides with the mental image of a woman lying
still, showing no sexual feeling, bored, waiting for the act to be over. It portrays
someone displaying disinterest in sex, who remains passionless, in line withsocial norms prescribing female sexual closedness. Although women suggested
the image is exaggerated, it can be interpreted as an embodiment of femalemodesty, in relation to which women explained their own experiences. The
presumed counterpart was in discourses of the uncut woman, magudnin[uncircumcised] or kinterley [a derogatory term connoting the clitoris is left
untouched]. Aisha again:
Others will think that they are more prone to have sex, that they will get horny andhave a lot of feelings.

Women stated that people would fear that uncut women will ‘seek out men’ tosatisfy their sexual urges, or ‘need their husband [sexually] all the time’, having
a rapid sexual response with ‘no stop’, using metaphors of the clitoris as an‘engine’ or an ‘airplane’ that holds an incredible sexual force. Women who by7

others are defined by these traits could be seen as marked as lacking respectability(Skeggs, 1997) – she is ‘not a good girl’, ‘can do whatever she wants’, or risk
being labeled a socat [someone walking the streets/street prostitute]. Thesebehaviors and feelings, described as transgressions of gender norms, resonate
with the nymphomaniac woman with insatiable, ungovernable sexual urges wholacks self-control (Groneman, 1994), and witness to an opposing ideal of female
sexual modesty.
A concurring ideal was for women to be able to enjoy sex within married life.
In a conversation about female orgasm, Canab (married, in her early 40s)
expressed disappointment over her husband’s disinterest in responding to her
sexual invites or contributing to her orgasm:
That’s also where I fight with my husband. His shahwada [orgasm] comes quickly.
After that he says “I’m tired” [showing how he’s leaning back]. I ask “why are you
tired?! Go away if you’re tired!” You must think of your wife. Me also, I also must
think of my husband, we both need to think of each other […] If you only think ofyourself, you will always have [orgasm] quickly. The other person – what can I
do? I don’t want to have sex if it’s going to be that way, that’s no fun … [He] doesnothing [after orgasm]. It’s disgusting. You must educate yourself! […] Not saying‘me, me’ and then come quickly. One time – two minutes! I think.. no it’s not good[…] If you don’t want [to have sex] – go! Go away, and I will marry another man.
If you’re tired.

Many emphasized women’s right to sexual pleasure as prescribed by Islam, even
if some placed more emphasis on their personal right to sexual pleasure. Those
who claimed sexual enjoyment as a right in Islam also claimed equal
responsibility to contribute to their partner’s sexual satisfaction or else, the wifeor husband, is entitled to divorce and seeking another partner (c.f. Malmström,2016).
Here the professed restraining impact of FGC on sexual responsiveness was
generally not described as inhibiting sexual desire and pleasure within marriage:

Woman A: It’s kinitr [the clitoris] that makes women sexual, and now [withcutting], those thoughts have been taken away.
Interviewer: I’ve heard about “chewing gum”; can you tell me about that? [Women
burst out laughing and vivid discussions ensue.]
The interpreter tries to keep up with the discussions, translating for Woman B: The

8

feeling is still there, we’re like anyone else with [regards] to feeling, in sexuality[she pulls the veil over herself, pretending to be lying down still like a dead fish
while laughing, signaling ‘not in a million’]
Woman C: We do the same as everyone else, we have the same needs, the same as[women] in Sweden – the feeling the woman has towards her husband. (focus
group with 17 older women)

Even though women did not speak with one voice in terms of understandings ofthe relationship between sexuality and FGC, their statements signal that theimagined stereotyped behavior, personified in the chewing-gum-woman was not
an ideal women wanted to be associated with. In contrast, using humor, womenoften distanced themselves from this discourse framing cut women in terms of
too much sexual restraint, sexual disinterest, or dysfunction. FGC was describedas not negatively influencing female sexual responsiveness, but molding it tokeep female sexuality within the boundaries of a charmed circle of heterosexual,
potentially procreational, marital sexual conduct, to speak with Rubin’s terms(Rubin, 1984).

Negotiating discourses of diminished sexual responsivenessInfluenced by the normative ideal of female sexual restraint supposedly enhanced
through FGC, women repeatedly related accounts of their own experiences.
Opinions varied regarding what role FGC played in affecting female sexualfunction. For some, their opinions had changed or been reinforced with migration.
Claims of sexual agency
Young and older women alike indicated they were impacted by changing
discourses in Somalia propelled by anti-cutting campaigns and imams, especiallythe focus on negative sexual and other health consequences (see Palm et al.,2023). It was evident from the interviewees’ talk about health risks in terms of a‘seal,’ that ‘FGC’ was often equated with infibulation, although some explicitly
mentioned sunna cutting. Among the younger women who had undergone sunna
cutting, erased sexual responsiveness after infibulation was generally assumed.
In a focus group, young women discussed negative health consequences of FGC:
Faduma: And also – during intercourse, they have a lot of pain.
Gargaaro: And they don’t have pleasure.

9In such general talk of plausible negative sexual effects from FGC, it became
apparent that women were not talking about themselves. By referring toanonymous others or using ‘they’, interviewees distanced themselves from theexperiences. Haweeyo (unmarried, in her early 20s), having sunna cutting said:‘they have no [sexual] feelings. You know, they don’t feel anything. They’re likedead [lies down with her scarf over her head to illustrate].’ She continued ‘they
who don’t have sunni [but pharaonic], well it’s dead, her dareen [feeling]’, thewoman is ‘dead in her body almost’. In contrast, when interviewees related totheir own experiences, they drew on other belief structures, testifying to a moreaffirmative sexuality-discourse.
While it was generally stated that reduced libido is a rationale for FGC,
women’s understandings of this idea varied. Some contested notions of reduced
sexual responsiveness altogether, referring to responsiveness as natural, inborn,
and/or God-given, something that no FGC in the world could take away. They
dissociated from ideas about reduced libido calling it a ‘myth’ that ‘others’, or
people with an ‘old tradition’ may hold, as put by Idil (married, in her 40s):
I think you’re born with dareen [sexual feelings]. Some have more, others haveless or zero [shows with her hands]. It’s not about kintir [the clitoris] or gudnin[circumcision], no. They think so, but it’s not like that.

Idil and some others with her, instead stressed that a modest sexual appearance isa matter of upbringing and managing performance in accordance with culturaland religious codes of conduct, ‘We have dareen [feeling] but we have ourreligion that say’s “no you cannot do this until you’re married”, you see? We wait
until we marry.’
More common, however, was talk about sexual responsiveness as to someextent reduced by FGC. While infibulation was described as creating a physicalsexual restraint that would ease after defibulation at marriage or after the firstchild, clitoridectomy was presented as inhibiting excessive sexual
responsiveness. In most cases, women claimed FGC to reduce sexual
responsiveness, yet not in a way that hinders normal sexual response or precludes
sexual enjoyment:
Orgasm comes as the latest stage, but when you are [circumcised] … all the
problems are in your outer part of your vagina. Before you get to the inside you
will feel pain because you’re passing this [shows a tiny hole with her hand].
(Faduma, unmarried, in her mid 20s)

It was evident from the interviews, that ‘normal’ in this case related to sexualintercourse within marriage. Many like Faduma tended to underscore sexual

10excitement as not solely located in the outer sexual organs, but as coming from‘hormones’, ‘the brain’, ‘from the entire body’, and from vaginal stimulation atintercourse. The accounts stating no negative impact of FGC on sexual
responsiveness also testified to an understanding of the clitoris as surplus.
Haweyoo, in her 20s, explained: You know, if you’re sunni, you still havefeelings left. Like... she’ll get [feeling] as usual. She later continued:
Like me, I’m sunni. I have no feeling. Or, I mean, I have feeling, yes, but I’m notpaying attention to boys. Now when we sit here and talk, I don’t get as horny as a
guy would be, maybe. You know what I mean?

The effects of FGC were made sense of as dampening a multi-directional andunruly sexuality – the ‘engine’ that makes the sexual drive rush away
uncontrollably. Whereas such traits were attributed to male sexuality, they weretalked of as excessive and un-welcomed with regards to female sexuality. For
female sexuality, a central theme was the notion that (proper) sexual feelingcomes with love and marriage and a deflowering on the wedding night:
Dareen [feelings] will come with love. Feelings come with your husband. Take mefor example, I have much [feeling]. Much more feeling than other women have. I
have feeling 24/7 and my entire body smells [of desire], so that others will know.
And at first you feel pain, you can’t feel desire if you feel pain. But after comesdareen, if you have love for the husband that you will share your life with (Idil,
married in her 40s).

Most made sense of the dampening effect as a temporal closedness which, it wasclaimed, would not affect sexual responsiveness within marriage:
Haweeyo: After you marry and you’ve done it [intercourse], it will like pass , itwill.. then you’ll know what it is [the feeling], you have gotten used to it, after you
had intercourse.
Friend: You get more sex-drive, you mean?
Haweeyo: Yes, that’s how it is.

What Haweeyo refers to here is how women will recognize their own sexual
feelings and emotions with the awakening of the future husband. The statements
can be interpreted as interviewees talking about a spontaneous desire that isperceived to be cut away with FGC, while responsive desire is assumed to be left
intact. Within sexology literature, responsive and spontaneous desire have been

11

used to describe the experience of desire after sexual intimacy has been initiated(responsive desire), or prior to sexual intimacy having been initiated(spontaneous) (Basson, 2003). The idea that women will get access to sexualdesire and responsiveness after marriage was prominent among both older andyounger women. The deflowering on the wedding night was this way described
as opening up sexuality – both in terms of physical access to vaginal stimulationand orgasm, and also to general sexual feelings, attentiveness, and emotions interms of a relational process and change of mindset.
In terms of Gayle Rubin’s (1984) charmed circle, sexual responsiveness wasunderstood to work ‘normally’ within marriage and (potentially reproductive)
intercourse. This resonates with sociocultural norms of marriage and vaginal
intercourse as the proper context for sexual conduct. Following the interviewees,
what is potentially cut away with FGC is sexuality normatively perceived as
excessive, on the outskirts of the charmed circle; the untamed sexual desire,random or multi-directed, as opposed to the responsive, relationally directed,
ideally, toward a husband. The understandings seem also related to a sexhierarchy premiering ‘inner’ vaginal sexual responsiveness, while ‘outer’, clitoralsexual pleasure is seen as superfluous and undesired, as described in the Egyptian
study by Malmström (Malmström, 2016). Thus, all interviewees asserted sexual
agency, challenging portrayals of FGC as producing frigidity and a too passive
female sexuality as implied in discourses on FGC in both Somalia and Sweden.
Internalization of accounts of sexual inadequacy
Many shared the idea that FGC molds a sexual closedness in line with an innercharmed circle, yet the meanings women attributed to this notion varied anddepended on whether or not the woman aligned to the disposition of a restrained
sexuality intended by FGC. The married woman, Canab, for example, expressedsorrow over a lost opportunity to feel unconditioned and autonomous sexualdesire not needing to be waiting to be aroused. Haweyoo, the young unmarried
woman, on the other hand, endorsed the disposition of not feeling governed byher sex-drive. Reduced excessive desire seemed for her to advance her sense ofrespectability and moral impeccability.
While the interviewees overall rendered a picture of an affirmative sexuality
discourse, more ambivalent accounts were presented by some of the interviewees.
To a greater extent than among the older generation, young sexuallyinexperienced women expressed uncertainty about their prospects for enjoying
sex in relation to having been exposed to FGC. In contrast, young married womenwith infibulation echoed older women claiming sex within marriage will work
fine. Primarily, this seemed to relate to whether participants drew on personalsexual experiences or on those of others, or if they relied on expert knowledge
i.e. school staff or other appointed FGC-experts in Sweden. In these interviews

12the importance of sexually sensitive tissue for sexual responsiveness was a central
theme. Khadiija, unmarried, in her late teens, explained:
I don’t think it’s the same if you did circumcision, you don’t have as much desire
as without circumcision because it’s a sensitive spot and they have taken it away.

According to Khadiija, girls with genital cutting will never be able to experience
the same intensity of desire and pleasure as those who are uncut. As opposed toa discourse of the clitoris as excessive, here surfaces an understanding of its
significance for sexual pleasure and desire. Few claimed to have partaken of
media messages on FGC. Common comments were instead that they rarely
consumed Swedish news media. Messages about reduced sexual function after
FGC were primarily gleaned from professionals in Swedish school such asteachers in biology lessons, or sessions targeting FGC in school led by Somali
health educators, school staff, and other invited experts. Aisha (in her 20s) who
had sunna cutting, said:
Before I came here, I didn’t think that this would affect my life in any way … So
when I came here, I learned quite a lot: that you can have difficulties during sex
and that some have chosen to open up and that it [FGC] affects our ability to feelpleasure during sex.

Aisha and many like her had also talked to married female friends and relatives
from whom they had learned more diverse perspectives, where some had reported
they had sexual difficulties related to sunna-cutting, and some claimed nodifficulties. Leylo, an unmarried woman in her early 20s, described the shock in
her first encounter with the radically different view on FGC presented at anawareness-raising session in Swedish school. This had caused her to reflect on
FGC and made her re-evaluate previous understandings:
It’s like getting a birthmark, then no one talks about this! And maybe everyone has
it, at least that’s what you think, but then it’s something weird in other peoples’eyes, like in Swedish society … So it was like, I thought to myself: why do I havethis [FGC] and still don’t know that much about it?

Although slightly more common among the younger generations, ambivalent
understandings of sexual effects of FGC were also evident among some of theolder women with infibulation. This appeared to be a process that began alreadyin Somalia. Bilan, a married woman in her mid 40s, explained:13

We have feeling, we’re not saying we don’t have feeling, there is [feeling]. But wehave something, already registered in our brain, that we have lost something […]that you have reduced the feeling. We have already heard it, you know. And it’s
up here [points to her head], that you think ‘well I’m mutilated’ … we think wehave been tempered, that we’re maybe not like [them] […] that’s why you mutilate.

It was also impelled by negative depictions of infibulation in Somalia. Bilan
described the unease she felt when gradually coming to learn that infibulation
was not a desired state:
You hear people saying that this is not good, that you are sewn and that you should
only take away the clitoris and leave [the rest] […] so when you have this[pharaonic] you start getting worried; what have they done, why did they do it likethat [infibulation], and then when you get married what will happen? And I used
to ask my sister “what will happen, how was it, did it hurt, or feel [anything]?” But
they all said “no, it hurts but you’ll be fine.”

In a more general sense, interviewees adhered to a discourse about attitudechange, stating a firm conviction that pharaonic cutting is a harmful, traditional,
un-Islamic practice that belongs to the past (see Palm et al., 2023). Infibulation
was in this context portrayed in terms of victimization, sexual difficulties, andsexual pain. In this discourse, sunna cutting was often depicted as a milder
procedure associated with decreased health risks. In accounting for theirunderstandings and experiences, interviewees negotiated contradictory messages,on the one hand notions that sexuality after marriage will be a source of pleasure,and on the other hand notions of impaired sexual responsiveness after FGC.

Renegotiating notions of ‘open’ and ‘closed’ sexuality
The new context has called upon, and sometimes reinforced, processes ofrenegotiation of traditional notions of female sexual closedness. To uphold ideals
of premarital closedness was generally supported. In Somalia, FGC wasperceived as assisting women in preserving sexual closedness and keeping theirsexuality within a charmed circle of morally accepted behavior. Interviewees
talked about a shift where unmarried women growing up in Sweden, however,
could ‘stay in line’ with gendered sexual norms and advance their respectability
by social performance alone.
As seen above, women unsettled the discourse that connects FGC to lost sexual
responsiveness and related protection of sexual morals. In addition, many
declared that a girl has a hymen that can be protected without infibulation being
necessary:

14

[You think] that you should be closed [down there], you have this idea of being
closed on the outside and on the inside. But there’s no need [to close] the outside,
it is inside – it’s that that is virginity … In Sweden they don’t have gudnin[circumcision] if born here. (Ruun, a mother in her 50s)

Protection of virginity through infibulation was to inflict meaningless harm,
Ruun, and many with her, argued. They drew upon the fact that Somali girls bornin Sweden can preserve virginity despite being uncut. In contrast, they tended toemphasize management of sexual feelings by sexual self-governance and social
behavior – a responsibility they recognized was highly gendered. Instead ofphysical control via FGC, sexual impulses were something a girl could control
by acting responsible and avoiding risks, many stated. Leylo and Sahra(unmarried, in their 20s), reasoned in a pair interview:
Leylo: It [desire] is natural and it should be allowed to exist as it is, so in myopinion, why should it be something to prevent? Rather, I think you should raise
your daughters and teach them, you know, the right way.
Sahra: Yes, that’s true!

Young women stressed that girls should be taught sexual morals and to be careful
to avoid sexual risks and unwanted pregnancy, for example, through their
upbringing, religious teachings, and through education.
On an individual level, the women navigated expectations on respectability
through balancing notions of what they termed ‘open’ and ‘closed’ female
behavior. Covering one’s body and hair, behaving modestly, not laughing out
loud, refraining from having male friends, and premarital abstinence were
examples of being ‘closed’. To be ‘open’ was described as the opposite: exposing
the neck and/or hair, revealing body contours, being talkative in the presence ofboys, display sexual interest or curiosity (for example in Sex Education class), or
engaging in premarital sex. The metaphors of open and closed can be interpreted
as marking the moral the positions of a ‘good’ or ‘bad’ girl.
Navigation of gendered expectations on sexual behavior was the most salient
among young unmarried women and related to virginity ideals. In different ways,
they navigated notions of open and closed to avoid negative social consequences
associated with being considered a ‘bad’ or unrespectable, girl. This navigation
was pursued regardless of the presence of a physical closure of FGC or of actual
sexual experience (c.f. Cinthio, 2015). Fear of gossip and a reputation as sexually15

outgoing, made some avoid markers of ‘openness’, or enhance signs of‘closedness’. Aisha (unmarried, in her early 20s) explained:
Interviewer: So there’s also that she is a virgin, she hasn’t had sex with anyone, yet
in others’ opinion she’s not a virgin?
Aisha: yes […] That’s because you’re like.. too open with everybody, having malefriends and so […] then they may get the picture that she’s not a good girl. Me, I
also had a lot of male friends before, but now I’ve changed […] because I don’t
want to be seen with them. […] Other mothers, from my country in particular, it
can be like a big thing if you’re out hanging around with boys, then you’re a whore,and so on. So I don’t want them to have anything on me, to talk about.

Young women had internalized codes of sexual openness and closedness andnavigated notions of respectability and decent social behavior in relation to theirself-representations, peers, family, and the surrounding community.
Some notions of closedness and openness had changed with migration to
Sweden, such as the role of an intact infibulation. This seemed to relate tochanging norms regarding sexual pain. Among infibulated women having had
their sexual debuts in Somalia, sexual pain at first intercourse was described as
unavoidable. In contrast, many interviewees denaturalized this notion. Young
women continuously stated they would not tolerate sexual pain, and it was
described as something they feared and that should be avoided. Likewise, manymothers praised the availability of free and easily accessible defibulation surgery
provided by the new context. Some, like Shamshi, an unmarried woman in herlate teens, stated she did not worry about being questioned regarding her sexual
morals (and virginity) after her planned defibulation surgery. She rejected theidea of infibulation as an essential mark of closedness.
Challenged notions of the role of FGC in signaling respectability were evident
in the emphasis placed on ‘love’ and ‘trust’ and a ‘plenty-of-fish-in-the-sea’
mentality, expressed by young women and mothers. Interviewees reasoned that
the Swedish context, characterized by a diversity of ‘open’ and ‘closed’ bodies
in terms of FGC, provided girls with many possibilities of finding a SwedishSomali man who would accept marrying a Somali girl who is physically open,
whether through defibulation, being uncut, or having sunna cut.
Although these examples of a more relaxed attitude to premarital defibulation
exist, others equally suggest that women fear negative social consequences forthemselves (if young) or their daughters in relation to premarital defibulation.
Many appreciated defibulation at marriage, yet expressed hesitance towardpremarital defibulation as it would jeopardize an infibulated girls’ reputation.
Waris, who had participated in a focus group, later said in an individual interview

16that she did not want to tell others that her daughter had undergone premarital
defibulation in Sweden. She had reconciled with her daughter’s decision, yetfeared gossip and negative consequences for her. Likewise, Xaawo, a woman in
her late teens, considered what her future husband would think if he is presented
with an open infibulation, as it would imply she had had sex.
Yet, a few discarded virginity requirements altogether. The young woman
Yasmiin, who struggled with being regarded as too open due to her social
appearance, questioned norms of sexual restraint completely. Convinced thatvirginity and the hymen was something ‘made up’, Yasmiin said:
I don’t believe in virginity. I’m like: I can have sex whenever I want, whenever, as
long as I don’t get pregnant. Virginity doesn’t exist. That’s what I’m saying.
Virginity doesn’t exist, that’s what I will tell my children. I won’t sit and say‘you’re a virgin, you must be a virgin’.

Discussion
This article investigated young and older Swedish-Somali women’s subjective
experiences of sexual responsiveness in relation to female genital cutting, in theface of changing sociocultural notions regarding FGC and its influence on sexual
responsiveness in a diaspora setting. Women described a common rationale for
performing FGC in Somalia being to reduce women’s sexual desire andresponsiveness to assist women to conduct their sexuality in accordance withsocially accepted and appropriately gendered behavior. Speaking in terms of
Rubin’s (1984) sex hierarchy, FGC is supposed to work as a means to keep
female sexuality within the boundaries of a charmed circle of accepted sexual
behavior. This included inculcating pre-marital abstinence and sexual closedness
through a responsiveness perceived as controllable and that does not override
presumed male sexual passion. Consistent with previous studies (Johansen, 2022;
Johnsdotter and Essén, 2004), the results suggest that the external regulation ofsexuality through FGC is replaced by increased emphasis on inner control, selfdiscipline and self-governance. Instead of physical intervention in the body,
fostering a sexuality within the charmed circle was suggested to be managed
solely by social behavior and respectability (Skeggs, 1997). Women in the study
argued that there is no need for FGC as (i) the theory about sexual inhibition isineffective anyway; (ii) a hymen protects virginity, thus outer intervention is
unnecessary; (iii) sexual closedness and respectability can be demonstrated bysocial behavior; and, sometimes, that (iv) sexual closedness and virginity are
redundant. The implicated shift to an emphasis on (only) inner self-control
confirms previous research suggesting increased reliance on trust, and17sometimes, social control, or decreased importance of preserving premaritalvirginity (Johnsdotter and Essén, 2004; Johansen, 2022; Ziyada et al., 2020).
Women were affected by notions about reduced sexual responsiveness as
portrayed in Somalia and in Western discourses on FGC and continuously
navigated and negotiated normative discourses in relation to their selfunderstanding. In their self-representation they also drew on their individual
beliefs, relational experiences, and those told by others, providing more diverse
experiences than in dominant discourses. Overall, women in the present study
conveyed positive expectations regarding sex, expressed viewing sexual desire
and pleasure as important and self-evident. Negative impacts of FGC on sexualfunction was generally associated with infibulation and the presence of a seal.
Sunna cutting and clitoridectomy was often described as having no negative
impact on sexual responsiveness. Concurrently many argued that sexual
responsiveness was more or less reduced by clitoridectomy (c.f. Johansen, 2022).
Women made sense of this in terms of clitoral responsiveness being excessive,
not paramount to sexual desire or enjoyment. Rather, clitoral-driven sexuality
was constructed as superfluous, or sometimes as promiscuous, dangerous, andundesired. It can be likened to what an interviewee in Malmström’s (2016) study
refer to as ‘having six fingers’, the underlying message being that no one needs
an extra finger to function normally. The view of the outer, clitoral sexuality as
excessive seemed to relate to a premiering of sexual interdependence,
heterosexual marriage and intercourse (c.f. Ahmadu, 2000; Malmström, 2016).
The construction resonates with Western Freudian ideals of clitoral pleasure as
immature (as opposed to the mature vaginal pleasure) (Bell, 2005) whilst placing
vaginal pleasure at the inner, divine circle, in the sex hierarchy. This contrasts tomore recent sexuality discourses in Sweden, pushed by the feminist movement,
which emphasize women’s independence and sexual autonomy, also highlighting
the significance of the clitoris for auto-erotic pleasure and orgasm found among
western women (at least on a normative level) (Herbenick et al., 2018; Leval etal., 2004; Parker, 1995). In this study, cutting was understood to affect only
spontaneous, self-directed, or multi-directed sexuality, normatively constructed
as un-welcomed, in contrast to ‘good’ and ‘normal’ sexual function relationallydirected towards a husband. In marriage, spontaneous and/or responsive desire
was claimed to thrive with love for the husband. Depending on women’s
dispositions, the alleged effects were either cherished and welcomed as producing
the women as erotic subjects (e.g. Johansen, 2022; Malmström, 2016) or grieved
and regretted, producing feelings of inadequacy and loss.
Not as evident, but nonetheless surfacing, were more ambiguous views on how
FGC might negatively have affected women’s sexual responsiveness. This
understanding was linked to perceptions of the clitoris as important for sexual
receptiveness (c.f. Johnsdotter et al., 2009; Jordal et al., 2022; Ziyada et al.,2020), and was most common among young sexually inexperienced women, and18

seemed to relate primarily to whether women drew on their own experiences ornormative discourses. These findings support what has been suggested inprevious research on health effects: that there might be a bias in how sexualfunction is described in anti-cutting campaigns and dominating Western
discourses compared to peoples’ subjective experiences or how they regard
themselves (Essen and Mosselmans, 2021; PPAN, 2012; Shell-Duncan, 2008).
Uncertainties among young women were impelled by the migration context,
especially learned from experts in school settings i.e. school staff, healtheducators and others in anti-cutting sessions. Among older generations,reconsideration of the negative impact of FGC on sexuality was attributed
religious leaders and anti-cutting campaigns in Somalia, but also to personal
doubts formed by personal experiences and those of others.
A noticeable finding was that sunna-cut young women seemed less influenced
by condemnatory discourse in terms of their sexual self-understanding than what
could be expected from former literature, while the opposite was true for older
women (Ahmadu, 2007; Catania et al., 2007; Ziyada et al., 2020; Villani, 2019).
Young sexually inexperienced sunna-cut women dissociated from the litany ofhealth consequences otherwise associated with anti-cutting messages, expecting
it in relation to infibulation but not for clitoridectomy (see also Palm et al., 2023).
Rather, young women seemed to manage to preserve a positive sexual selfidentity despite living in a setting with longstanding anti-FGC work and having
themselves been exposed to, and adopted aspects of, anti-FGC discourse. There
are many possible explanations for the divergent results.
One possible explanation might be the shift in discourse favoring sunna-cutting
over pharaonic cutting among Somalis (Johansen, 2022; Powell and Yussuf,
2018). This constructed binary is reinforced in anti-cutting campaigns in Somaliathat tend to highlight negative health effects from pharaonic cutting whileconstructing sunna-cutting as a less severe, or harmless, procedure (Powell andYussuf, 2018). A previous study among Swedish-Somali women found thatsunna cutting seemed to offer a possibility of a valued, superior position and selfidentity that accommodates both to international condemnation of FGC and to
discourses of change and modernity in Somalia (Johansen, 2022; Palm et al.,2023). In practice, Western condemnatory discourse as expressed in Sweden is
not that dissimilar. Although Swedish efforts to combat FGC include all types ofprocedures, examples in policy papers, education and handbooks are often drawn
from infibulation and ‘worst case scenarios’ (Obiora, 1997; Palm et al., 2021).
This probably facilitates dissociation from FGC-messages for sunna-cut women,
who in this study mostly feared complications of potentially having been partiallysewn closed. The fact that older, infibulated women increasingly have been
exposed to anti-FGC discourses, in Somalia and the diaspora, may also explain
why older generations in this sample expressed more negative or ambivalent

19

views on the impact of FGC on sexual responsiveness than has been reported inprevious research among Swedish-Somali women (Johnsdotter and Essén, 2004).
Another possible explanation may relate to the fact that most young women in
the sample were unmarried, without own sexual experiences. The face of
emerging life events, such as starting sexual relations, may prompt increased
reflection on the sexual impacts of FGC, as found in a UK study (Parikh et al.,2020). Encounters with western sexual partners have had a similar impact,
triggering thoughts about the adequacy of the body (Ziyada et al., 2020; Jordal etal., 2022). Most other women in the present sample had established their sexual
lives in the Somali context, where FGC was not discussed as hindering sexual
response and pleasure. Such an environment could potentially work as‘protective’ against experiencing FGC as a traumatizing, mutilating, or
victimizing event, as suggested in Schultz and Lien’s (2014) Norwegian study
among immigrants with FGC.
A third possible explanation to the varied results may relate to the study
sample. Some studies have drawn their sample from women opting for so-called
clitoral repair, potentially resulting in an over-representation of women vocallynegative toward their clitoridectomy (e.g. Jordal et al., 2022; Villani, 2019). The
present study included women with heterogenous backgrounds in terms of age,education, occupation, time and place of residence in Sweden. Most seemed moreor less connected to Somali networks and no interviewees expressed a wish to
distance from the Somali group or Somali culture, which may explain the varied
results. This hypothesis is supported by a Norwegian and a French study
suggesting women cohesive in western networks may share more similar views
to the majority population than women tied to traditional networks (Johansen and
Ahmed, 2021; Villani, 2019; Ziyada et al., 2020). The significance of networks
and sense of community belonging has yet just started to be explored in relation
to attitudes to FGC (Akinsulure-Smith et al., 2023; Johansen and Ahmed, 2021)
and might be one key to understand women’s attitudes and experiences of livingwith FGC in a country in which it is stigmatized. This merits further empirical
exploration. Such investigation should preferably explore the role of the specificsociocultural context.
Thus, the results of the current study, to some degree, provide support toprevious theories about how young women might be affected by the radical
change of social norms and understandings as regards FGC following migration
to an FGC-stigmatizing context. That young women established in Swedish
society seemed more resilient to negative and stigmatizing discourse thanpreviously suggested, however, calls for further studies. Some might claim thatanti-cutting messages of damage, violation and victimhood have failed if womenwith sunna-cutting disregard themselves as sexually harmed by FGC. Yet it also
has empowering potential, as the results imply a position as opponent to FGC yet
simultaneously identifying as whole in terms of self-understanding.

20Implications for sexual counselingIn this data set, women claimed sexual satisfaction was important and engaged invivid discussions of desire, pleasure, and orgasm as experienced by themselves
asserting sexual agency (c.f. Connor et al., 2023). To equalize only clitoral sexual
behavior with discourses of pleasure, and to dismiss vaginal-centered sexuality
as not-pleasure-focused, as sometimes suggested, could be seen as a case of justthe ethnocentrism and ‘arrogant perception,’ that the feminist scholar Isabelle
Gunning (1992) warns against. A more fruitful approach seems to be to start withwomen’s own descriptions of their lives and problems. As the study suggests,
pleasure and orgasm sometimes co-exist with negative feelings of pain, lowsexual responsiveness, or other sexual problems (e.g. Abdulcadir and Catania,
2021; Connor et al., 2023), which is important to acknowledge in all sexualhealth counseling, regardless of the patient being cut or not.
The results imply that the school context constitutes an important source of
information and mediation of social norms on FGC. This key role raises ethicalquestions of how to ensure that interventions targeting youths are followed up,
individually or in groups. An obvious risk is otherwise that young women are left
to comprehend and navigate between dramatically different messages about theirbodies and sexuality, on their own. Whereas the study shows that the school
context might be the first encounter for youths with a radically different discourse
on FGC than in their country of birth, the study also shows that these processesor re-evaluation sometimes have started long before migration. This is partly
owing to global campaigns, and sociopolitical changes in the women’s natal
countries (Powell and Yussuf, 2018). The fact that processes of change are
spurred from the bottom-up seems especially important to acknowledge inwelfare initiatives addressing FGC, in order to preserve trust and respect among
affected groups (Khaja et al., 2010).
The study points to the significance of establishing a common language on
sexuality for accurate and effective communication. When the interviewees saythat FGC is meant to reduce dareen or sexual feeling/s, it may inaccurately beinterpreted as reduced sexual physical sensations. This translation would fit thewestern notion which often equates loss of nerve tissue to loss of sexualsensations (e.g. Hosken 1993). However, as this study suggests, loss of sensation
was seldom the intended meaning. More often, the term was used to explain
sexual desire, or sexual responsiveness as a joint description of being receptive
and attentive to sexual thoughts and/or stimuli. The terminology has implications
for research methodology as well as sexual health counseling on FGC andunderscores the significance of establishing a joint understanding of terms used
(Connor et al., 2023).
In sexual health counseling on FGC, there seems also to be a point ininvestigating patients’ expectations about sexual inhibition and excitation in21

relation to FGC – as gendered and affected by social norms, as suggested in theDual control model (Janssen and Bancroft, 2023), not least in relation to popular
ideas about women losing all sexual responsiveness as an effect of FGC, or thatwomen who have not undergone FGC will have a constant and unruly sexualdesire (Sharif Mohamed et al., 2020).

Strengths and limitations
The current study provides an effort to explore the hypothesized potentiallystigmatizing influence of anti-cutting rhetoric on diaspora women’s selfunderstanding, comparing different generations of women. A strength of thestudy is the heterogeneity of the sample and the inclusion of younger women. The
study relied on gatekeepers to recruit participants, which may, however, imply
having missed out on perspectives of people who are not cohesive in social
networks (Van Meter, 1990). Further, this study used age, time in Sweden, andSwedish language as proxy for acculturation – with younger women presumably
more affected by Swedish discourses on FGC than older, newly arrived women.
The results, however, showed tendencies to more complex patterns. Additional
background information on the interviewees would have been useful to deepensuch an analysis. More studies on this would be welcomed.
Another limitation was the group sizes. Women sometimes self-recruited tofocus groups, resulting in large groups. While large group interviews provided
several perspectives at once, it came at the expense of ability to moderate,translate, and elicit perspectives from all participants. A combined method, wheresome women afterwards took part of individual interviews, helped contextualize
themes from the interviews and let other perspectives come forward. For
example, instances of trouble or disagreement from expected norms were voiced
to a greater extent in the individual interviews; thus the combined methods
provided complementary data.

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The study sheds light on the complex nature of FGC within thecontext of immigration, examining how girls’ and women’s
perception of the body and sexuality evolve in relation to
FGC when people move from a place where it is customary
to one where different norms prevail. The study also examines
how FGC is understood and managed from the perspective of
welfare workers.

MALMÖ UNIVERSITY PRESS
205 06 MALMÖ, SWEDEN
MAU.SEISBN 978-91-7877-471-5
ISSN 1653-538
DOI 0.24834/isbn.9789178774722

NORDIC SWAN ECOLABEL 3041 0903
Printed by Media-Tryck, Lund 2024

F

emale genital cutting (FGC), also known as female genital
mutilation, is a contested issue that exposes tensions between
diverse cultural values and beliefs about the body, health, andsexuality. In Sweden, there has long been national initiatives
aimed at developing care and strategies to end the practice.
Welfare workers in social work, healthcare, and schools have a
key role in interpreting and implementing this work.