1. Lih-Mei Liao, PhD FBPsS Consultant Clinical Psychologist & Honorary Senior Lecturer UCL Institute for Women’s Health, London UK

2.  To suggest ways for delivering psychological expertise collaboratively in relation to FGM in the UK

3. Can be associated with none or all of these:  Physical – urinary problems, menstrual problems, infertility…, with impact on overall quality of life  Emotional - shame, fear, mistrust, low mood…  Sexual - diminished enjoyment, pain, lack of interest…  Social – compromised intimate relationships, withdrawal from social relationships…

4.  Few citable published studies  Personal testimonies and case studies: ◦ Retrospective (subject to recall bias/demand characteristics) ◦ Uncertainty about representativeness  Confounding factors - women who have undergone FGM may have been subjected to other stressors (e.g. social dislocation, poverty) that could lead to adverse psychological outcome  Time lag between any psychological problems and FGM defies simplistic linkage

5. Community factors (history, economics, living conditions, etc.) Family factors Procedural factors: type, extent, practitioner, conditions mitigating factors Immediate consequences long term constellation of consequences EMOTIONAL- e.g. shame, anxiety, guilt, anger, mistrust, low mood SEXUAL- e.g. painful intercourse, poor relationships, poor body image PHYSICAL- e.g. pain, incontinence infertility SOCIAL- e.g. avoidance, isolation

6. emotional distress sexual difficulties physical ill health social isolation RECOGNIZING NORMALIZTNG EDUCATING SIGNPOSTING PSYCHO- SEXUAL THERAPY PSYCHOLOGICAL THERAPY Psychological well being Damage limitation PSYCHIATRIC MANAGEMENT

7. Type of helpClient(s)Length of treatment FocusCharacteristic processes CounsellingUsually 1:1Unspecifie d; variable Non- directive Active listening Psycho- analytic (psychodyna mic) therapies Usually 1:1; but also couples and groups Typically long term Non- directive Problem- focused Development of insight through interpretation of feelings transferred from earlier attachments to therapist Cognitive and behavioural therapies 1:1 and groups Typically short- term Directive Problem- focused Strength- focused Goal-planning Skills building Agreed tasks between sessions Systemic (family) therapies Couples and families; but also individuals Typically short-term Directive Problem- focused Strength- focused Communications between family members Agreed tasks between sessions

8. Difficult to rationalise services without clear evidence of problem prevalence and treatment evidence. Currently women with psychological problems associated with FGM may end up accessing the following services:  Community organizations (e.g. FORWARD)  Primary care services (e.g. GP, well women clinics)  Sexual health clinics  Psychological therapy services  Psychiatry

9.  Peer support and counselling may not be effective for treating complex problems and co-morbidities presented by some women who have undergone FGM  Formal psychological therapy may not be the most appropriate response

10. A collaborative, integrated model combining evidence-based psychological skills and grass root experience that is currently less recognized, may be more ‘tailored’. For example, experienced psychologists and therapists could leave their consulting rooms in favour of: - providing training, supervision and emotional support for peer supporters working with communities known to be affected by FGM - helping to produce user-friendly self-help resources for communities - engaging directly with clients by organizing open days, focus groups or workshops to offer additional coping strategies - producing signpost information for women requiring psychological treatment in addition to the peer support they are receiving - helping to disseminate good practices to build evidence base

11. Raising the standard of care through education and training for mental and sexual health professionals via:  Assessment of knowledge and beliefs about FGM in select professional groups  Identify barriers to professional contributions using sound research methods  Target specific problems experienced by health professionals  Evaluate education and training initiatives  Disseminate good practices

12. Build psycho-educational initiatives with FGM stakeholders using improved research methodology to:  Assess knowledge and beliefs about FGM in affected communities in UK using a range of methods  Target at risk groups  Evaluate preventive interventions  Disseminate good practices!

13.  Psychological contributions are as yet unexploited  Potential contributions in future to improve ‘citable’ evidence of the psychological effects of FGM via research  Future contributions to clinical care and prevention initiatives to maximise effectiveness using evidence-based psychological methods