Themes, quotations and CERQual assessment
| Theme number | Theme heading | Studies (n) | CERQual assessment | Indicative quotes |
| Analytical theme 1: communication is key | ||||
| 1.1 | Language barriers and interpretation challenges | n=31 23 90 91 95–97 99–101 117–119 124 126–128 130 132–135 137 139–141 143 147–150 153 | High confidence | “I wish I had a way to communicate with the doctor directly. There are things that sometimes I want to say or ask but I feel embarrassed saying it through a translator, especially on the phone…They never translate what I’m saying. They tell me that is a shameful question…” (Sweden, p364)153 |
| 1.2 | ‘Can’t talk, not asked’: double silence and cultural taboo | n=37 25 89–91 93–96 99–101 112 115 117 118 120 121 123–128 130 132–135 138 140–146 151 153 | High confidence | “If they had asked me I would have told them, but I was never asked…I was worried and scared during my first pregnancy because I have heard people talk about the pain but I didn’t know how to tell them…I was shy.” (Scotland, p23–24)89 |
| 1.3 | Cultural (in)sensitivity | n=34 25 89 91 92 96–101 112 115–122 125 127 128 130 132 135 136 138–143 146–148 153 | Moderate confidence | “ The doctor was not comfortable with me. He asked if I enjoy violent sex with my husband. I don’t feel comfortable to talk about sex even with females— yet here is a male doctor examining my genitals and making mean comments.” (USA, p274)119 |
| Analytical theme 2: access to care: influenced by an interaction of multilevel community and health service processes | ||||
| 2.1 | Influence of cultural norms | n=35 93–95 97 99–101 112 113 117–121 124 126–130 132 133 137 139–141 143–147 149 150 153 | Moderate confidence |
“Even though we had FGM type 2 or 3, had a small vaginal opening and were virgins, we did not ask for de-infibulations before marriage because that is shameful in our culture. Most of us who have FGM had problems with penetration following marriage.” (New Zealand, p43)128
“In my country normally…people don’t go…usually people go to a psychologist if it is something like erm…maybe chronic issues that they cannot solve at all…or sometimes if it is abnormal…They think if you go to a psychologist you are mad or crazy.” (England, p6)93 |
| 2.2 | Influence of the family | n=19 90 91 93 94 97 99 100 113 118 121 124 126 130 132 136 144 149 150 153 | Moderate confidence | “I know my friend she wants to do that (deinfibulation) but her husband doesn’t let her…I told her, this is good for you - go and do. She said ok but her husband said no…Maybe if she did this (deinfibulation), it would have been a big problem in the family.” (England, p157)144 |
| 2.3 | Knowledge and information about FGM/C services | n=34 92 93 95–97 99–101 113–119 121 126 128 130–135 137 139 142 143 145 148–150 152 153 | Moderate confidence | “They need to have someone that talks to you before and while you have a baby. I would have wanted someone to help me and tell me what was going to happen but I never got that…You know someone who was specially trained so you only see people who understand FGM.” (England, p233)92 |
| 2.4 | ‘Hit and miss’ care | n=38 89 91 92 94–97 99–101 112 113 115 117–120 123–125 127 128 130–135 139–143 147 148 150–152 | High confidence | “Sometimes people go to one doctor after another describing their problems to them. They do not understand so they cannot find a solution. There was a woman who was suffering from bleeding and pain. When she went to the GP, he told her it was normal. He did not know how to treat her. She kept going several times and at last they opened her.” (England, p41)143 |
| Analytical theme 3: cultural and bodily dissonance: striving for cultural and bodily integrity | ||||
| 3.1 | Moving from normal to different | n=40 89 91–94 96 97 99–101 112 113 115–120 122–130 132–135 140 141 143 144 148 150–153 | High confidence | “Okay, now I’m missing something that other women has…Well the first shock was to find out that people here are not circumcised…You have to deal with that…I’m not the same as women here…and then I started to kind of - you grieve a bit, that ‘what is this thing that has been taken away from me?’…For me it has caused me lots of problems because when I went to health services, the minute that I say ‘I was circumcised’ it just create huge barrier between them and me, like you know - suddenly I’m from another planet.” (Australia, p23)100 |
| 3.2 | Threat to the self: reliving FGM/C pain during clinical interventions | n=28 89–92 94 95 99–101 112–114 119 120 126–128 130 133 134 136 137 140 143 148 149 151 152 | Moderate confidence | “You always remember it. They decide to cut me, and when she went to do it she didn’t explain to me and I panic. I nearly kick her. Two of the nurses held me down. That was it…I was a little girl again being held down.” (England, p228)92 |
| 3.3 | Being opened: complexities around deinfibulation | n=28 89 92–97 100 101 112 113 115 116 118 120 121 124 128–130 133 134 143 144 146 148 150 152 | Moderate confidence | “She [Somali lady] hadn’t talked to friends about it, just the midwife…She said: ‘When I met the midwife she told me a lot about FGM. The midwife said to me ‘If you want I can open it for you. If you don’t want that I won’t’. We talked about it a lot. After four months I tell her ‘I want you to open it for me. Do me a small operation.” (Scotland, p31)134 |
| 3.4 | Being changed: complexities around reinfibulation | n=19 92 94 96 98 100 101 112 113 115 116 118 124 129 130 134 144 146 148 152 | Moderate confidence | “I became a victim in Sudan already when I was 4 years old; I had no choice. Now I have to become a victim again after delivery, when the midwives refuse to resuture me. I just ask for a few stitches, not to have an open wound.” (Sweden, p53)130 |
| Analytical theme 4: disempowering care encounters | ||||
| 4.1 | Being exposed and humiliated | n=40 25 89–92 95–97 99–101 112 113 115–120 122 125–128 130 132–138 140–143 146 148 151 153 | High confidence |
“Me - I was installed with my legs spread apart - they all came to see…and I didn’t see any reason why they came to see me except for the fact that I was excised. All those people who came, who entered into my intimacy without my authorization, who didn’t ask me if it bothered me…I felt that it was an aggression.” (France, p308)90
“They showed no respect to me, I understand now why people don’t want to talk about it to the midwife. I will tell anyone not to tell them about being circumcised.” (Scotland, p23)89 |
| 4.2 | Being judged and stereotyped | n=36 23 25 89–93 96 97 99–101 112 113 115–119 122–125 127 130 132 133 139–143 145 147 148 153 | High confidence | “One participant…described that a German gynaecologist (a woman) looked at her with so much pity and irritation after the physical examination that she felt for the first time in her life that she was not normal…she felt that she was treated like a victim who could not be talked to rationally. The participant decided…to abstain from consulting German doctors.” (Germany, p83)125 |
| 4.3 | Lacking choice, power and control | n=32 89–92 94 95 97 99–101 112 113 116–121 123 125 127 130–134 139 141 143 145 146 148 150 | High confidence | “I can’t say that the birth went well. The midwife said that I couldn’t give birth without being cut. otherwise the baby won’t come without a caesarean section or I can lose the baby. Nobody asked me what I thought. I was there in pain…without pain relief, nothing.” (France, p308)90 |
| 4.4 | Feeling unsafe and vulnerable | n=46 23 25 89–97 99–101 112–121 123 125 126 128 130–135 139–141 143 145–148 150–153 | High confidence | “They didn’t know what they were doing, and uh, they, you know they had to give me more cuts then in an awkward way…I was telling the doctor to cut the FGM and totally he ignored me. And he was cutting in the sides instead of cutting the front. It was very degrading and I am very distressed to think about it.” (Australia, p25)100 |
| Analytical theme 5: positive care encounters | ||||
| 5.1 | Trusting and appreciating providers and the system | n=34 90 92–96 99–101 112–115 117–120 123–125 127 128 130–132 134 135 139 143 145 146 148 150 153 | High confidence |
“I was lucky when I met a midwife in Sweden who knew about circumcised women. This was a great help to make me feel secure because it was my first time to be pregnant and to live far from my parents and family.” (Sweden, p219)94
“I know a friend that had to be opened before her delivery. She was lucky because she had found a midwife who knew about FGM - and she booked her to have the operation before the delivery.” (England, p15)140 |
| 5.2 | Voicing healthcare needs and preferences | n=45 25 89–97 100 101 112 113 115 116 118–120 122–124 127–130 132–135 137–143 145–148 150–153 | High confidence | “A while ago, all the women used to choose caesarean to give birth but now the health services know about women who are circumcised. They know of their situations and the complications they can have during maternity like bleeding and that they need help with the opening before the baby comes. When the health services don’t know about your condition, they refer people to other services. There are some who are understanding, especially if different communities come to attend the clinics or hospitals, as they get more oriented on the different cultures of the communities.” (England, p43)143 |
CERQual, Confidence in Evidence from Reviews of Qualitative Research; FGM/C, female genital mutilation/cutting.