Psychological Health Outcomes of Female Genital Mutilation/Cutting among Women of Reproductive Age in Southeast Nigeria

Psychological Health Outcomes of Female Genital Mutilation/Cutting among Women of Reproductive Age in Southeast Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological Health Outcomes of Female Genital Mutilation/Cutting among Women of Reproductive Age in Southeast Nigeria Chioma Oliver, Antor Odu Ndep, Temidayo Akinreni, Precious Chidozie Azubuike This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8492256/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Female Genital Mutilation/Cutting (FGM/C) remains a deeply entrenched, harmful cultural practice with well-documented physical consequences; however, its psychological health outcomes remain underexplored in many settings, including Southeast Nigeria. Existing evidence suggests that FGM/C constitutes a traumatic experience with enduring implications for women’s mental health, emotional wellbeing, and psychosocial functioning. This study examined the psychological health outcomes of FGM/C among women of reproductive age in Southeast Nigeria. Methods A multisite cross-sectional quantitative design was used. The study involved 300 women aged 18 years and above drawn from rural communities in Ebonyi and Imo States, comprising 150 women who had undergone FGM/C and 150 women without FGM/C. Data were collected using a structured questionnaire and standardized psychological instruments: the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), PTSD Checklist (PCL-5 short form), and an adapted Emotional Intimacy Scale. Independent samples t -tests and chi-square tests were conducted using Stata version 17, with statistical significance set at p ≤ 0.05. Results Women who had undergone FGM/C reported significantly higher levels of psychological distress compared with non-FGM women. Mean depression scores were higher among the FGM group (17.2 ± 5.1) than the non-FGM group (11.3 ± 4.6; p < 0.01), while anxiety scores were similarly elevated (14.9 ± 4.8 vs. 9.8 ± 4.2; p < 0.001). More than half of women with FGM/C exhibited moderate-to-severe depressive and anxiety symptoms. Emotional intimacy was significantly lower among women with FGM/C, with greater emotional disconnection reported ( p < 0.001). Among women with FGM/C, 56.7% exhibited moderate-to-severe PTSD symptoms. Conclusions FGM/C is strongly associated with adverse psychological health outcomes, including depression, anxiety, post-traumatic stress symptoms, and reduced emotional intimacy. These findings demonstrate that beyond its physical harms, FGM/C imposes a substantial and enduring psychological burden on affected women. Integrating culturally sensitive, trauma-informed mental health services into reproductive and community health programmes is essential for addressing the psychological sequelae of FGM/C and improving women’s overall wellbeing in Southeast Nigeria. Female genital mutilation/cutting psychological health depression anxiety post-traumatic stress disorder emotional intimacy Southeast Nigeria Introduction Female Genital Mutilation or Cutting (FGM/C), sometimes referred to as female circumcision, remains one of the most persistent harmful cultural practices affecting women and girls across sub-Saharan Africa, the Middle East, and diaspora communities worldwide [ 1 – 3 ]. Despite sustained global advocacy and international commitments to eliminate the practice, including explicit targets under the Sustainable Development Goals (SDG 5.3), FGM/C continues to affect over 230 million women and girls globally, with approximately four million girls at risk annually [ 2 , 4 ]. The burden of FGM/C is disproportionately concentrated in sub-Saharan Africa, where prevalence remains high despite gradual declines in some countries [ 5 – 7 ]. Evidence from pooled analyses of Demographic and Health Surveys indicates that more than half of women aged 15–49 years in several African countries have undergone some form of FGM/C, with higher prevalence among older, rural, and less-educated women [ 8 – 10 ]. Nigeria alone accounts for nearly 10% of the global burden, with over 20 million survivors [ 11 ]. National surveys reveal that a majority of Nigerian girls are cut before their first birthday, underscoring the deeply entrenched nature of the practice and the limited agency of those affected [ 4 , 12 – 14 ]. Although prevalence has declined in some northern states [ 15 , 16 ], other regions, including parts of central and southeastern Nigeria, have recorded persistent or rising rates [ 13 ], particularly during periods of social disruption such as the COVID-19 pandemic [ 17 ]. In many Nigerian communities, FGM/C is justified as a marker of purity, femininity, and social acceptance, with cultural expectations transmitted across generations [ 18 ]. However, medical, psychological, and human rights frameworks unanimously affirm that FGM/C has no health benefits and is associated with lifelong adverse consequences [ 5 ]. While earlier research emphasized physical and obstetric complications, recent scholarship increasingly highlights the psychological health outcomes of FGM/C as a critical yet underexplored dimension of harm. Psychologically, FGM/C constitutes a traumatic experience, often performed in early childhood without consent, anesthesia, or adequate post-procedural care. Systematic reviews indicate that a substantial proportion of women living with FGM/C experience long-term psychological sequelae, including anxiety disorders, depressive symptoms, post-traumatic stress disorder (PTSD), low self-esteem, and emotional distress [ 19 , 20 ]. A global synthesis of evidence suggests that trauma-related symptoms are particularly pronounced among women subjected to more severe forms of cutting and those who lacked psychosocial support during or after the procedure [ 2 ]. The psychological consequences of FGM/C are frequently intertwined with disruptions in sexual health and bodily integrity. Physiologically induced sexual dysfunction, such as dyspareunia and reduced arousal, can exacerbate feelings of inadequacy, shame, and emotional withdrawal, further compromising mental well-being [ 21 , 22 ]. Psychosocial mechanisms, including internalized stigma, altered body image, and unresolved trauma, compound these effects and may persist throughout adulthood [ 23 ]. Although some women contextualize their experiences within culturally affirming narratives, the preponderance of evidence indicates that FGM/C exerts enduring negative effects on psychological health, particularly when cultural silence discourages disclosure or help-seeking [ 24 ]. In Southeast Nigeria, where communal norms and traditional authority structures remain influential, resistance to the abandonment of FGM/C persists despite legal prohibitions and advocacy efforts [ 25 , 26 ]. The continued medicalization of FGM/C by some health workers further legitimizes the practice and obscures its psychological harms [ 27 , 28 ]. These contextual factors not only sustain the practice but also limit access to mental health support for survivors, reinforcing cycles of silence, normalization, and untreated psychological distress. Methods Study design The study used a multi-site cross-sectional quantitative design. The use of quantitative techniques provided measurable insights into the prevalence and patterns of female genital mutilation/cutting (FGM/C) and its associated physical, psychological, and relational health outcomes among women in the study area. This design enabled systematic comparison between groups while ensuring robustness through the use of multiple quantitative measures and data sources [29]. Study setting The study was conducted in selected rural communities in Ebonyi and Imo States in South-East Nigeria, a region predominantly inhabited by the Igbo ethnic group and characterized by strong cultural traditions, extended family systems, and communal social organization. Ebonyi State lies between latitudes 5°40′–6°45′ North and longitudes 7°30′–8°30′ East, covering about 5,500 km² and comprising 13 Local Government Areas [30], while Imo State is situated between latitudes 5°10′–6°35′ North and longitudes 6°35′–7°28′ East, with a similar land area and 27 Local Government Areas [31]. Both states fall within the tropical rainforest zone and are dominated by agrarian rural settlements where access to specialized health services is limited, and where traditional practices, including Female Genital Mutilation/Cutting (FGM/C), remain influential despite legal and public health interventions. Study population and eligibility The study population comprised women aged 18 years and above living in rural communities of Ebonyi and Imo States in South-East Nigeria, where female genital mutilation/cutting (FGM/C) is still practiced [32]. These states were selected because they represent areas with a relatively high prevalence of the practice, making them appropriate for examining its health and social consequences [33]. This focus ensured that participants could provide information not only on the physical and psychological consequences of FGM/C but also on how the practice influences intimate relational dynamics such as communication, marital satisfaction, and emotional intimacy. Sample size and sampling The sample size for the study was determined using Fisher's formula for a single proportion (2004) as cited by Omisore et al. 2023 [34]. $$\:n\:=\frac{{z}^{2}pq}{{d}^{2}}\:=\:\frac{{z}^{2}p\left(1-p\right)}{{d}^{2}}$$ Where: n = the sample size where n = sample size for the population z = Level of confidence, which is 1.96 (i.e., 95% confidence interval) p = Set at 0.142. Prevalence of FGM/C in Nigeria as reported in the 2021 Multiple Indicator Cluster Survey (MICS) [12] q = probability of non-occurrence (1-P = 0.5) d = margin of error, which is 5% (0.05) Therefore, the sample size was calculated as follows: n = 1.96 2 × 0.142×(1-0.142) = 187.2 ≈ 187 0.05 2 The calculated sample size was 187, which was increased to 300 to allow for non-responses to maintain statistical validity and avoid an underpowered study [35], and to ensure cross-tabulation. The study sample consisted of 300 women drawn from the defined study population in Ebonyi and Imo States. The sample was divided equally into two groups: 150 women who had undergone female genital mutilation/cutting (FGM/C) and 150 women who had not. This comparative structure allowed the investigation to highlight differences and similarities in physical health outcomes, psychological well-being, and intimate partner relationship dynamics between the two groups. The study employed a purposive sampling technique with proportional allocation to ensure adequate representation of both women who had undergone FGM/C and those who had not. This approach was chosen because the investigation required a direct comparison between the two groups. A total of six Local Government Areas (LGAs) were selected purposively, three from Imo State (Oru West, Orsu, and Okigwe) and three from Ebonyi State (Abakaliki, Ikwo, and Ohaozara). These LGAs were deliberately chosen because reports and community records indicated relatively higher prevalence of FGM/C, making them suitable sites for identifying participants. From the target LGAs, a total of 300 women were recruited. To maintain balance and comparability, 50 participants were drawn from each LGA, with equal representation of 25 women who had undergone FGM/C and 25 women who had not. However, slight discrepancies occurred: in Abakaliki, 25 women with FGM/C were chosen, while 28 without FGM/C status were chosen, and in Ohaozara, 28 women with FGM/C were chosen compared to 25 without FGM/C status. Eligible participants were women aged 18 years and above who had been in an intimate partner relationship and who voluntarily provided informed consent. Women under 18, those unwilling to participate, and those with severe health conditions that might prevent effective participation were excluded. Study variables : Dependent variable: Psychological health outcomes (depression, anxiety, and post-traumatic stress symptoms). Independent variable: Female Genital Mutilation/Cutting (FGM/C) status. Instrument for data collection : Data were collected using a structured questionnaire and four standardized psychological scales. The questionnaire captured respondents’ socio-demographic characteristics, experiences of Female Genital Mutilation/Cutting (FGM/C), self-reported physical health outcomes (including chronic pain, infections, sexual dysfunction, and childbirth complications), as well as indicators of intimate partner relationship dynamics such as communication, marital satisfaction, and power balance. Psychological outcomes were assessed using validated instruments: the Patient Health Questionnaire (PHQ-9), a nine-item scale for depressive symptoms scored from 0–27 with established severity cut-offs [36]; the Generalized Anxiety Disorder Scale (GAD-7), a seven-item measure of anxiety scored from 0–21 with standard severity thresholds [37]; the Emotional Intimacy Scale (EIS), adapted to five items to assess emotional closeness or disconnection within intimate relationships, with higher scores indicating greater emotional distance [38]; and the PTSD Checklist (PCL-5, short form), a five-item tool assessing core post-traumatic stress symptoms scored from 0–20 and categorized into increasing levels of symptom severity [39]. Instrument validation and reliability The quantitative instruments used in this study demonstrated strong reliability and validity across diverse cultural and clinical contexts, supporting their appropriateness for the present research. The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7) have consistently shown good internal consistency and diagnostic accuracy in sub-Saharan Africa and beyond, with reported Cronbach’s alpha values ranging from approximately 0.81 to 0.85, and evidence of strong construct and criterion validity when assessed against clinical diagnostic interviews [40–43]. The Emotional Intimacy Scale (EIS) likewise demonstrated high internal consistency (α ≈ 0.88), good test–retest reliability, and strong construct validity through significant correlations with relationship satisfaction and psychological well-being [44]. Similarly, the Post-Traumatic Stress Disorder Checklist (PCL) has been widely validated across multiple populations and languages, with excellent internal consistency (α values often exceeding 0.90) and strong convergent and discriminant validity in distinguishing trauma-related symptoms from other psychological conditions [45–47]. Collectively, this body of evidence confirms that the instruments employed are both reliable and valid measures for assessing psychological health and relational outcomes in the study population. Data collection procedure Quantitative data were gathered by trained research assistants who personally administered the instruments. The field assistants were trained by the principal researcher on public relations, cultural sensitivity, questionnaire dissemination, and data collection to ensure completion, consistency, and accuracy. A total of 300 copies of the questionnaire were administered to respondents by the principal researcher and three (3) field assistants. Each participant was guided through the instruments in a private setting to ensure comfort, confidentiality, and accurate responses. The assistants recorded answers directly during the sessions and reviewed the completed forms immediately to check for clarity and completeness, thereby minimizing errors and missing values. Outcome measurement and data analysis All completed questionnaires were reviewed on the spot by trained research assistants to check for accuracy and completeness before submission. The data were then coded and entered into an electronic database, with regular verification to minimize entry errors. After cleaning, the dataset was exported into Stata (version 17) for analysis. Missing values were identified, and incomplete responses were excluded from the relevant computations to preserve data quality. Scores for psychological outcomes were computed in line with standardized scoring procedures for the PHQ-9, GAD-7, EIS, and PTSD instruments. Independent samples t-tests were used to compare mean psychological outcome scores (depression, anxiety, and post-traumatic stress symptoms) between groups, and chi-square tests were applied to assess associations between categorical variables. All statistical tests were conducted at a 5% level of significance (p ≤ 0.05). Ethical Approval: Ethical clearance was obtained from the Research and Ethics Committee of the Alex Ekwueme Federal University Teaching Hospital, Ebonyi state with approval number AEFUTH/REC/VOL1/2024/664, in accordance with the 2013 Declaration of Helsinki and the State Ministry of Health, Imo State. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human participants. Informed consent was obtained from every participant after a clear explanation of the study’s objectives, procedures, potential risks, and benefits. Participation was entirely voluntary, and respondents were informed of their right to withdraw at any stage without penalty. Anonymity and confidentiality were strictly maintained throughout data collection, analysis, and reporting. Sensitive interviews were conducted in private settings to ensure participants’ comfort and psychological safety, with referrals provided for those who exhibited distress during the study. The data obtained from this study were secured and password-protected in an online database accessible only to the principal investigator of the study. Results Table 1: Sociodemographic Characteristics of Respondents (N = 300) Variable Frequency (n) Percentage (%) Age Group (in years) 18–29 52 17.33 30–39 56 18.67 40–49 74 24.67 50–59 65 21.67 60–69 53 17.67 Marital Status Married 229 76.3 Divorced/Separated 26 8.7 Widowed 28 9.3 Others 17 5.7 Highest Education None 22 7.3 Primary 63 21.0 Secondary 133 44.3 Tertiary 82 27.3 Occupation Farmer 101 33.7 Petty trader 74 24.7 Tailor 33 11.0 Teacher 12 4.0 Health worker 13 4.3 Homemaker 19 6.3 Unemployed 13 4.3 Others 35 11.7 State Imo 150 50.0 Ebonyi 150 50.0 Ethnicity Igbo 300 100.0 Among the 300 respondents who participated in the study, there was an even representation from Imo and Ebonyi States (150 respondents each). Table 1 above presents the socio-demographic data for all participants. A large proportion of respondents were within the 40–49 years age group (24.7%), followed by those aged 50–59 years (21.7%), while respondents aged 18–29 years constituted the smallest proportion (17.3%). With respect to marital status, the majority of respondents were married (76.3%), whereas smaller proportions were widowed (9.3%), divorced or separated (8.7%), and classified under other marital categories (5.7%). In terms of educational attainment, most respondents had at least secondary education (44.3%), while over a quarter had tertiary education (27.3%); however, a notable proportion had only primary education (21.0%) or no formal education (7.3%). Occupationally, farming was the dominant livelihood (33.7%), followed by petty trading (24.7%), with smaller proportions engaged as tailors (11.0%), homemakers (6.3%), teachers (4.0%), health workers (4.3%), or unemployed (4.3%), while others accounted for 11.7%. Table 2: Item-Level Descriptives for Depression (PHQ-9), Anxiety (GAD-7), and EIS (Emotion) among women with and without FGM/C experience Scale / Items FGM = Yes (n=150) (Mean ± SD) FGM = No (n=150) (Mean ± SD) PHQ-9 (Depression) Little interest or pleasure 1.9 ± 0.7 1.3 ± 0.6 Feeling down or hopeless 2.0 ± 0.8 1.2 ± 0.7 Trouble sleeping 1.8 ± 0.7 1.1 ± 0.6 Feeling tired or having low energy 2.0 ± 0.7 1.2 ± 0.6 Poor appetite/overeating 1.7 ± 0.6 1.1 ± 0.5 Feeling bad about yourself 1.8 ± 0.7 1.0 ± 0.6 Trouble concentrating 1.8 ± 0.7 1.1 ± 0.6 Slow/fidgety movements 1.6 ± 0.6 1.0 ± 0.5 Thoughts of self-harm 1.3 ± 0.5 0.7 ± 0.4 Total PHQ-9 Score 17.2 ± 5.1 11.3 ± 4.6 GAD-7 (Anxiety) Feeling nervous, anxious, on edge 2.0 ± 0.7 1.2 ± 0.6 Not able to control worrying 2.1 ± 0.7 1.3 ± 0.6 Worrying about many things 2.0 ± 0.7 1.2 ± 0.6 Trouble relaxing 1.9 ± 0.6 1.1 ± 0.5 Being restless 1.8 ± 0.6 1.1 ± 0.5 Becoming irritable 1.7 ± 0.6 1.0 ± 0.5 Feeling afraid as if something awful might happen 1.9 ± 0.7 1.1 ± 0.6 Total GAD-7 Score 14.9 ± 4.8 9.8 ± 4.2 Emotional Intimacy Scale (EIS – Emotional Disconnection) I feel emotionally connected to my partner 2.3 ± 0.9 3.4 ± 1.0 My partner and I share thoughts and feelings openly 2.1 ± 0.8 3.5 ± 0.9 I feel emotionally distant from my partner 3.2 ± 1.0 2.1 ± 0.9 My partner understands my emotional needs 2.4 ± 0.9 3.6 ± 1.0 I feel a lack of emotional intimacy in my relationship 3.1 ± 1.1 2.0 ± 0.8 Total EIS (Disconnection) Score 13.1 ± 4.3 9.4 ± 3.7 The results from Table 2 above show the psychological effects of FGM/C on women. In the table, women with FGM reported higher levels of psychological distress and poorer emotional intimacy compared to those without FGM. On the PHQ-9, mean depression scores were higher among FGM women (17.2 ± 5.1) than non-FGM women (11.3 ± 4.6), with consistently elevated item scores such as feeling down, low energy, and poor self-worth. On the GAD-7, FGM women also scored higher for anxiety (14.9 ± 4.8) compared to non-FGM women (9.8 ± 4.2), reflecting greater difficulties with worry, nervousness, and relaxation. Regarding the Emotional Intimacy Scale, FGM women reported greater emotional disconnection (13.1 ± 4.3) compared to non-FGM women (9.4 ± 3.7), showing lower perceived emotional support and higher emotional distance in relationships. Table 3: Depression (PHQ-9), Anxiety (GAD-7), and EIS (Emotion) Summary Scores Scale/Items Categories / Range FGM = Yes (n=150) Percentage (%) FGM = No (n=150) Percentage (%) Total (n=300) Percentage (%) Mean ± SD Depression (PHQ-9) Normal (0–5) 10 6.7 30 20.0 40 13.3 17.2 ± 5.1 Mild (6–10) 20 13.3 45 30.0 65 21.7 Moderate (11–15) 40 26.7 35 23.3 75 25.0 Moderate Severe (16–20) 50 33.3 30 20.0 80 26.7 Severe (21–27) 30 20.0 10 6.7 40 13.3 Anxiety (GAD-7) Normal (0–5) 15 10.0 40 26.7 55 18.3 14.9 ± 4.8 Mild (6–10) 25 16.7 45 30.0 70 23.3 Moderate (11–15) 55 36.7 45 30.0 100 33.3 Severe (16–21) 55 36.7 20 13.3 75 25.0 Emotional Intimacy Scale (EIS – Disconnection) Mild (6–10) 25 16.7 55 36.7 80 26.7 13.1 ± 4.3 Moderate (11–17) 70 46.7 65 43.3 135 45.0 Severe (18–25) 55 36.7 30 20.0 85 28.3 In Table 3 above, the evaluation of psychological outcomes between women with and without FGM/C showed significant differences across depression, anxiety, and emotional intimacy. On the PHQ-9 depression scale, women with FGM/C reported markedly higher scores (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6). More than half of the FGM group (53.3%) fell within the moderate-to-severe categories, whereas only 26.7% of the non-FGM group did so. This finding highlights the heightened vulnerability of women with FGM to depressive symptoms. For the GAD-7, women with FGM/C recorded a mean anxiety score of 14.9 (SD = 4.8), while women without FGM recorded a mean score of 9.8 (SD = 4.2). In terms of severity, 73.4% of women with FGM reported moderate-to-severe anxiety, compared with 43.3% of women without FGM. Regarding the Emotional Intimacy Scale, women with FGM/C had a mean score of 13.1 (SD = 4.3), compared to 9.4 (SD = 3.7) for women without FGM. Severe emotional disconnection was reported by 36.7% of the FGM group and by 20.0% of the non-FGM group. Table 4: Independent Samples t-test of Depression (PHQ-9), Anxiety (GAD-7), and Emotional Intimacy (EIS) by FGM Status (N=300) Scale/Measure FGM Status N Mean Std. Dev Mean Diff t df Sig. (2-tailed) PHQ-9 (Depression) FGM (Yes) 150 17.2 5.1 5.9 10.23 298 .001* Non-FGM (No) 150 11.3 4.6 GAD-7 (Anxiety) FGM (Yes) 150 14.9 4.8 5.1 9.84 298 .0001* Non-FGM (No) 150 9.8 4.2 EIS (Emotional Intimacy) FGM (Yes) 150 18.6 4.9 4.7 8.72 298 .00001* Non-FGM (No) 150 13.9 4.4 *Represents significant values *Statistical significance based on p<0.05 Table 4 above reports findings relating to the independent samples t-test. Women who experienced FGM reported significantly higher levels of depression (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6), with a mean difference of 5.9 that was statistically significant (t(298) = 10.23, p < .01). Similarly, anxiety scores were higher among women with FGM (M = 14.9, SD = 4.8) than those without (M = 9.8, SD = 4.2), with a mean difference of 5.1 that reached statistical significance (t(298) = 9.84, p < .001). Emotional intimacy was also lower in the FGM group (M = 13.1, SD = 4.3) compared to the non-FGM group (M = 13.9, SD = 4.4), with a mean difference of 4.7 that was significant (t(298) = 8.72, p < .001). These results demonstrate that FGM is strongly associated with higher levels of depression and anxiety and with diminished emotional intimacy in relationships. Women who experienced FGM reported significantly higher levels of depression (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6), with a mean difference of 5.9 that was statistically significant (t(298) = 10.23, p < .01). Similarly, anxiety scores were higher among women with FGM (M = 14.9, SD = 4.8) than those without (M = 9.8, SD = 4.2), with a mean difference of 5.1 that reached statistical significance (t(298) = 9.84, p < .001). Emotional intimacy was also lower in the FGM group (M = 13.1, SD = 4.3) compared to the non-FGM group (M = 13.9, SD = 4.4), with a mean difference of 4.7 that was significant (t(298) = 8.72, p < .001). These results demonstrate that FGM is strongly associated with higher levels of depression and anxiety and with diminished emotional intimacy in relationships. Table 5: Distribution of PTSD Symptoms (PCL-5, 5 items) among Women with FGM (n = 150) PTSD Category (PCL-5, 5 items) Score Range Frequency (n) Percentage (%) Mean ± SD Min Max Normal / Minimal 0 – 5 25 16.7 Mild 6 – 10 40 26.7 12.4 ± 3.9 3 20 Moderate 11 – 15 55 36.7 Severe 16 – 20 30 20.0 Total 150 100 Table 5 above shows the distribution of PTSD symptoms among women with FGM. About 16.7% of the women fell in the normal or minimal range, while 26.7% reported mild symptoms. The largest group, 36.7%, had moderate symptoms, and another 20.0% experienced severe PTSD symptoms. The overall mean score was 12.4 ± 3.9, with scores ranging from 3 to 20. Most women scored in the moderate-to-severe range, suggesting that PTSD symptoms are common and often clinically significant among women with FGM. Discussion The Psychological Effects of FGM/C on Women The findings of this study indicate that women who have undergone FGM/C experience greater psychological distress and reduced emotional intimacy compared with their non-FGM counterparts. Participants reported higher levels of depression and anxiety, alongside difficulties in forming and maintaining close emotional bonds with their partners. These outcomes highlight the profound psychological impact of FGM/C, demonstrating that the practice not only affects mental health but also undermines relational well-being and the quality of intimate relationships. Analysis of the psychological outcomes aligns with global and African literature documenting the enduring mental health consequences of FGM/C. Pallitto et al. (2025) [20], in a meta-analysis of 78 studies involving 486,949 women, found that FGM is associated not only with obstetric and gynecological complications but also with significantly higher rates of depression, anxiety, and somatoform disorders [20]. Similarly, O’Neill and Pallitto (2021) [48] highlighted the traumatic nature of FGM, noting that women frequently recall the procedure with vivid distress, often experienced as betrayal when performed by trusted family members or under social coercion [48]. These accounts demonstrate that FGM is inherently traumatic, with immediate physical pain translating into long-term emotional and cognitive sequelae, such as low self-esteem, body image disturbances, and feelings of inadequacy. From a feminist theoretical perspective, these psychological outcomes reflect the broader structural violence embedded in FGM/C as a gendered practice [49]. Feminist scholars conceptualize FGM/C as a mechanism of bodily control that regulates female sexuality and enforces compliance with patriarchal norms that prioritize chastity, endurance, and marital suitability [50–52]. The internalization of pain, silence, and emotional suppression reported by women in this study illustrates how psychological distress is not merely an individual pathology but a socially produced outcome of gendered power relations. The betrayal experienced when cutting is performed or sanctioned by trusted family members further compounds trauma, transforming FGM/C into both a physical violation and a rupture of relational trust [53]. This framing helps explain why symptoms such as low self-worth, shame, and emotional withdrawal persist long after the physical wound has healed. Clinical, case report, and field-based studies further corroborate these findings. Knipscheer et al. (2015) [54], examined 66 immigrant women from Somalia, Sudan, Eritrea, and Sierra Leone, revealing that a third of participants exceeded thresholds for affective or anxiety disorders, while 17.5% showed symptoms indicative of post-traumatic stress disorder (PTSD) [54]. Further studies, such as a case report, found that infibulated women (Type III FGM) were particularly vulnerable, exhibiting vivid traumatic recollections, hyperarousal, flashbacks, and anticipatory fears during sexual activity, menstruation, or childbirth [55]. Similarly, Köbach et al. (2018) [56], found that Ethiopian women subjected to Type II and Type III FGM experienced cyclical depression and anxiety, with neuroendocrinological evidence supporting the physiological embedding of trauma [56]. These studies underscore that the psychological impact of FGM is not transient; it is chronic, pervasive, and amplified by the severity of the procedure. African-specific studies, including Nigeria, highlight the interplay between social pressures and psychological outcomes [57–60]. Omigbodun et al. (2022) [57], in a qualitative study of 38 Izzi women in Southeast Nigeria found that adolescents often sought FGM to gain social acceptance, despite awareness of its negative consequences [57]. The study revealed that social coercion, stigma, and the desire for cultural conformity exacerbate psychological distress, manifesting as anxiety, depressive symptoms, and emotional withdrawal. This finding reflects a broader pattern whereby cultural imperatives and social norms intensify the psychological burden of FGM, particularly when community enforcement intersects with intimate family dynamics. These findings are best understood through the lens of Social Norms Theory, which emphasizes that behaviors such as FGM/C are sustained not solely by personal belief but by collective expectations about what is socially required and morally acceptable [61,62]. In contexts where conformity is rewarded with acceptance and non-compliance is punished through stigma or exclusion, women may endure significant psychological distress to maintain social belonging [63]. The anxiety, emotional withdrawal, and depressive symptoms observed among participants therefore reflect the psychological costs of navigating a normative environment in which resistance to FGM/C carries relational and social risks [64]. This theoretical perspective clarifies why awareness of harm does not automatically translate into psychological relief or empowerment. Previous evidence in tandem with the results from our study consistently shows that the psychological consequences of FGM/C extend beyond immediate pain to long-term mental health challenges, including depression, anxiety, PTSD, somatization, emotional disconnection, and impaired sexual and relational functioning [65,66]. Similarly, findings from the study support existing evidence that FGM/C exerts profound and multi-dimensional psychological effects on women. The elevated depression and anxiety scores, alongside reduced emotional intimacy, reflect the chronic and pervasive nature of FGM-related trauma [67]. When considered alongside global and regional evidence, these findings highlight the urgent need for culturally sensitive, trauma-informed interventions that address both immediate and long-term psychological outcomes. Integrating mental health services into reproductive health frameworks, fostering resilience, and actively engaging communities to challenge cultural norms remain critical strategies for mitigating the enduring psychological harm of FGM/C. The emotional effects of FGM/C on women The findings from this study indicate that women who had undergone FGM/C experienced notably lower levels of emotional intimacy with their partners compared to their non-FGM counterparts. Many participants reported severe emotional disconnection, highlighting that beyond the established physical and psychological health consequences, FGM/C also imposes a significant burden on relational well-being. These results suggest that the practice weakens the emotional bonds that are essential for healthy intimate partnerships, corroborating earlier evidence from other African contexts, where FGM/C was associated with reduced sexual satisfaction and diminished marital closeness, communication, and mutual trust [22,48,68]. Qualitative research similarly supports this conclusion. Jordal et al. (2022) [69], in a study of 44 in-depth interviews with migrant women in Sweden, found that FGM/C survivors often described not only physical pain and sexual dysfunction but also persistent relational insecurities, such as fear of abandonment, diminished ability to trust, and a sense of emotional distance from their spouses [69]. Many participants linked these feelings directly to their experiences of FGM/C, which had eroded their capacity to feel pleasure and confidence in intimacy. In parallel, Shafaati Laleh et al. (2022) [70], demonstrated in Iran that women with FGM/C had substantially lower scores on sexual quality of life and higher reports of spousal conflict and infidelity [70]. Taken together, these studies indicate that FGM/C undermines both physical intimacy and emotional connection, compounding the burden women carry within intimate partnerships. The current findings also reveal how the erosion of emotional intimacy may be tied to broader patterns of gendered power imbalances. Feminist theorists argue that patriarchal systems condition women’s worth on their ability to conform to cultural norms around sexuality and marital submission [71]. This resonates with the patterns observed in this study, where women who had undergone FGM/C were more likely to report reduced influence in decision-making and diminished capacity to assert their needs within relationships. The emotional disconnection captured in the EIS scores can therefore be read not simply as an interpersonal deficit but as a structural outcome of patriarchal systems that simultaneously enforce and perpetuate FGM/C. Women who experience persistent pain, reduced satisfaction, and emotional withdrawal following FGM/C may perceive limited benefits in seeking help, either because they view their situation as normative within their cultural context or because they fear stigma if they disclose sexual dissatisfaction [72,73]. PTSD Symptom Distribution among Women with FGM The findings of this study indicate that symptoms of post-traumatic stress disorder (PTSD) are highly prevalent among women who have undergone FGM/C. Many participants exhibited moderate to severe trauma-related symptoms, suggesting that FGM/C leaves enduring psychological scars. Beyond its immediate physical consequences, the practice significantly compromises mental health and daily functioning, manifesting as persistent trauma, heightened distress, and emotional vulnerability. This underscores the long-term psychological burden of FGM/C and highlights the need for targeted mental health interventions for affected women. These results are consistent with previous studies documenting high rates of trauma-related morbidity among survivors of FGM. Virk et al. (2025) [73], in a retrospective observational study of 50 asylum seekers evaluated at the Weill Cornell Center for Human Rights, found that 86% of participants reported psychological symptoms, with 32% meeting formal diagnostic criteria for PTSD, major depressive disorder, or generalized anxiety disorder [73]. The similarity in the proportion of women with moderate-to-severe PTSD symptoms in the present study (56.7%) underscores that FGM should be recognized as a trauma-inducing event with mental health sequelae comparable to other forms of gender-based violence. The persistence of nightmares, aversion to sexual activity, and hyperarousal described in the Virk et al. cohort mirrors the symptomatic burden observed in the current findings [73]. The findings also align with those of Jordal et al. (2022) [69], who documented that women in Sweden with a history of FGM described pervasive fear of intimacy, insecurity, and anxiety in relationships [69]. While their study did not explicitly quantify PTSD, the described symptoms, emotional withdrawal, fear of abandonment, and intrusive memories during intimacy, are hallmarks of trauma-related disorders. Similarly, Esho et al. (2017) [74], in Kenya linked sexual dysfunction among circumcised women to relational distress, which is often mediated through trauma-like symptoms of fear, avoidance, and psychological disconnection [74]. However, it is important to note that not all women with FGM develop clinically significant PTSD, as reflected in the 16.7% of participants in this study who scored in the minimal range. Howard and Gibson (2022) [75], in their large-scale analysis across six Sub-Saharan countries, emphasized that experiences of gendered practices such as FGM are mediated by context, resilience, and community support [75]. Cultural framing of FGM as a rite of passage may buffer against overt symptom expression in some settings, while migration to contexts that stigmatize FGM may amplify distress through social isolation and identity conflict [76]. This suggests that PTSD prevalence among FGM survivors is shaped not only by the act of cutting but also by the socio-ecological environment in which survivors live. The findings from this study add to the growing evidence that PTSD symptoms are both prevalent and clinically significant among women with FGM. The distribution observed, where the majority fall in moderate-to-severe ranges, underscores the urgent need for routine psychological screening in reproductive health and community health programs targeting survivors. Interventions should integrate culturally sensitive trauma-informed care, recognizing the dual burden of physical harm and psychological distress. Addressing PTSD in this context is critical not only for individual mental health recovery but also for enhancing women’s relational well-being, reproductive health, and social participation. Strengths and limitations of the study This study has several strengths. First, the use of a multi-site cross-sectional quantitative design across two states (Ebonyi and Imo) enhanced the robustness and comparative depth of the findings by capturing variations across different rural contexts. Also, this study employed validated and widely used psychological instruments (PHQ-9, GAD-7, EIS, and PCL), all of which have demonstrated strong reliability and validity across diverse populations, including sub-Saharan Africa. This enhances confidence in the accuracy and consistency of psychological measurements. Despite these strengths, our study has its limitations. First, the cross-sectional design restricts the ability to establish causal relationships between FGM/C and observed health or relational outcomes. While associations can be identified, temporal ordering cannot be confirmed. Second, the study relies on self-reported data, which may be affected by recall bias and social desirability bias, particularly given the sensitive and stigmatized nature of FGM/C and intimate partner dynamics. Conclusion This study demonstrates that Female Genital Mutilation/Cutting (FGM/C) is significantly associated with adverse psychological health outcomes among women of reproductive age in Southeast Nigeria. Women who had undergone FGM/C reported markedly higher levels of depression, anxiety, and post-traumatic stress symptoms compared with women without FGM/C, alongside greater emotional disconnection within intimate relationships. These findings confirm that FGM/C constitutes a profound psychological trauma with enduring effects that extend beyond physical harm to compromise mental wellbeing, emotional functioning, and relational stability across the course of life. The results further highlight the need to reconceptualize FGM/C as both a mental health and human rights issue embedded within complex socio-cultural systems. Persistent cultural norms, stigma, and limited access to mental health services in rural communities contribute to the normalization and under-treatment of psychological distress among survivors. Addressing the burden of FGM/C therefore requires culturally sensitive, trauma-informed interventions that integrate psychological screening, counseling, and psychosocial support into reproductive and community health services, alongside sustained advocacy and policy enforcement aimed at eliminating the practice and supporting survivors’ recovery. Declarations Ethical approval: A joint ethical clearance for was obtained from the Research and Ethics Committee of the Alex Ekwueme Federal University Teaching Hospital, Ebonyi state with approval number AEFUTH/REC/VOL1/2024/66. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human participants [77]. Consent to participate: Informed consent was obtained from every participant after a clear explanation of the study’s objectives, procedures, potential risks, and benefits. Participation was entirely voluntary, and respondents were informed of their right to withdraw at any stage without penalty. Anonymity and confidentiality were strictly maintained throughout data collection, analysis, and reporting. Sensitive interviews were conducted in private settings to ensure participants’ comfort and psychological safety, with referrals provided for those who exhibited distress during the study. The data obtained from this study were secured and password-protected in an online database accessible only to the principal investigator of the study. Authors' contributions: CO conceptualized the study and led the development of study methods and data collection. CO and AON contributed to the study design, methods, and the development of study materials. CO, PCA and AON contributed to data collection, data analysis, and writing of results. PCA, CO, and TA supported the development of the manuscript and critical reviews. AON supervised and provided critical oversight on the project and manuscript. All authors read and approve the final manuscript. Acknowledgements: The authors would like to thank all the participants for their valuable time and contributions to the study. Funding: The authors received no financial support for the research and publication of this article. Consent to publish: Not applicable. Data availability: All data relevant to the study, including data collection instruments, are accessible upon reasonable request. Interested researchers should contact the corresponding author. Conflicts of interest: The authors report no conflicts of interest or other disclosures relevant to this work Clinical Trial Number: Not applicable. 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Evans C, Tweheyo R, McGarry J, Eldridge J, Albert J, Nkoyo V et al. Discussion, implications and recommendations [Internet]. In: Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews. NIHR Journals Library; 2019 [cited 2025 Dec 31]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546405/ Turner J, Tancred T. Maternity care provision for women living with female genital mutilation/cutting: A qualitative study from a high asylum-seeking dispersal context in the UK. Int J Health Plann Manage. 2023;38:790–804. Esho T, Kimani S, Nyamongo I, Kimani V, Muniu S, Kigondu C, et al. The heat goes away: Sexual disorders of married women with female genital mutilation/cutting in Kenya. Reprod Health. 2017;14:undefined–undefined. Howard JAD, Gibson MA. No relationship found between Female Genital Cutting and Intimate Partner Violence across six sub-Saharan African countries. Glob Public Health. 2022;17:2704–19. DeLaet D. FGM and genital cutting across borders: cultural biases in the contestation of global human rights. Identities. 2024;32:1–20. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191–4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8492256","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586685875,"identity":"f10e0926-06dc-4fff-963a-0e69072ee34b","order_by":0,"name":"Chioma Oliver","email":"","orcid":"","institution":"School of Public Health, Texila American University, Guyana, South America","correspondingAuthor":false,"prefix":"","firstName":"Chioma","middleName":"","lastName":"Oliver","suffix":""},{"id":586685876,"identity":"fd791308-9d15-442e-b34e-863fed673349","order_by":1,"name":"Antor Odu Ndep","email":"","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Antor","middleName":"Odu","lastName":"Ndep","suffix":""},{"id":586685877,"identity":"7cc7b085-c71e-4764-b748-bea24fe7c79e","order_by":2,"name":"Temidayo Akinreni","email":"","orcid":"","institution":"Equality, Diversity, and Inclusion Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK","correspondingAuthor":false,"prefix":"","firstName":"Temidayo","middleName":"","lastName":"Akinreni","suffix":""},{"id":586685878,"identity":"2f61e701-7286-437a-b5ef-dfc1078c5878","order_by":3,"name":"Precious Chidozie Azubuike","email":"data:image/png;base64,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","orcid":"","institution":"Health Development Initiative, Kigali, Rwanda","correspondingAuthor":true,"prefix":"","firstName":"Precious","middleName":"Chidozie","lastName":"Azubuike","suffix":""}],"badges":[],"createdAt":"2025-12-31 21:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8492256/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8492256/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104884141,"identity":"faffc312-036c-40e0-9f0c-b6cf69c8c55a","added_by":"auto","created_at":"2026-03-18 09:44:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1429102,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8492256/v1/0170d825-0fa7-4e93-8ee0-725f5b091fa4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Health Outcomes of Female Genital Mutilation/Cutting among Women of Reproductive Age in Southeast Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFemale Genital Mutilation or Cutting (FGM/C), sometimes referred to as female circumcision, remains one of the most persistent harmful cultural practices affecting women and girls across sub-Saharan Africa, the Middle East, and diaspora communities worldwide [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite sustained global advocacy and international commitments to eliminate the practice, including explicit targets under the Sustainable Development Goals (SDG 5.3), FGM/C continues to affect over 230\u0026nbsp;million women and girls globally, with approximately four million girls at risk annually [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The burden of FGM/C is disproportionately concentrated in sub-Saharan Africa, where prevalence remains high despite gradual declines in some countries [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence from pooled analyses of Demographic and Health Surveys indicates that more than half of women aged 15\u0026ndash;49 years in several African countries have undergone some form of FGM/C, with higher prevalence among older, rural, and less-educated women [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Nigeria alone accounts for nearly 10% of the global burden, with over 20\u0026nbsp;million survivors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. National surveys reveal that a majority of Nigerian girls are cut before their first birthday, underscoring the deeply entrenched nature of the practice and the limited agency of those affected [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although prevalence has declined in some northern states [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], other regions, including parts of central and southeastern Nigeria, have recorded persistent or rising rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], particularly during periods of social disruption such as the COVID-19 pandemic [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In many Nigerian communities, FGM/C is justified as a marker of purity, femininity, and social acceptance, with cultural expectations transmitted across generations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, medical, psychological, and human rights frameworks unanimously affirm that FGM/C has no health benefits and is associated with lifelong adverse consequences [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While earlier research emphasized physical and obstetric complications, recent scholarship increasingly highlights the psychological health outcomes of FGM/C as a critical yet underexplored dimension of harm.\u003c/p\u003e \u003cp\u003ePsychologically, FGM/C constitutes a traumatic experience, often performed in early childhood without consent, anesthesia, or adequate post-procedural care. Systematic reviews indicate that a substantial proportion of women living with FGM/C experience long-term psychological sequelae, including anxiety disorders, depressive symptoms, post-traumatic stress disorder (PTSD), low self-esteem, and emotional distress [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A global synthesis of evidence suggests that trauma-related symptoms are particularly pronounced among women subjected to more severe forms of cutting and those who lacked psychosocial support during or after the procedure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The psychological consequences of FGM/C are frequently intertwined with disruptions in sexual health and bodily integrity. Physiologically induced sexual dysfunction, such as dyspareunia and reduced arousal, can exacerbate feelings of inadequacy, shame, and emotional withdrawal, further compromising mental well-being [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Psychosocial mechanisms, including internalized stigma, altered body image, and unresolved trauma, compound these effects and may persist throughout adulthood [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although some women contextualize their experiences within culturally affirming narratives, the preponderance of evidence indicates that FGM/C exerts enduring negative effects on psychological health, particularly when cultural silence discourages disclosure or help-seeking [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Southeast Nigeria, where communal norms and traditional authority structures remain influential, resistance to the abandonment of FGM/C persists despite legal prohibitions and advocacy efforts [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The continued medicalization of FGM/C by some health workers further legitimizes the practice and obscures its psychological harms [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These contextual factors not only sustain the practice but also limit access to mental health support for survivors, reinforcing cycles of silence, normalization, and untreated psychological distress.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study used a multi-site cross-sectional quantitative design. The use of quantitative techniques provided measurable insights into the prevalence and patterns of female genital mutilation/cutting (FGM/C) and its associated physical, psychological, and relational health outcomes among women in the study area. This design enabled systematic comparison between groups while ensuring robustness through the use of multiple quantitative measures and data sources [29].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in selected rural communities in Ebonyi and Imo States in South-East Nigeria, a region predominantly inhabited by the Igbo ethnic group and characterized by strong cultural traditions, extended family systems, and communal social organization. Ebonyi State lies between latitudes 5\u0026deg;40\u0026prime;\u0026ndash;6\u0026deg;45\u0026prime; North and longitudes 7\u0026deg;30\u0026prime;\u0026ndash;8\u0026deg;30\u0026prime; East, covering about 5,500 km\u0026sup2; and comprising 13 Local Government Areas [30], while Imo State is situated between latitudes 5\u0026deg;10\u0026prime;\u0026ndash;6\u0026deg;35\u0026prime; North and longitudes 6\u0026deg;35\u0026prime;\u0026ndash;7\u0026deg;28\u0026prime; East, with a similar land area and 27 Local Government Areas [31]. Both states fall within the tropical rainforest zone and are dominated by agrarian rural settlements where access to specialized health services is limited, and where traditional practices, including Female Genital Mutilation/Cutting (FGM/C), remain influential despite legal and public health interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and eligibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population comprised women aged 18 years and above living in rural communities of Ebonyi and Imo States in South-East Nigeria, where female genital mutilation/cutting (FGM/C) is still practiced [32]. These states were selected because they represent areas with a relatively high prevalence of the practice, making them appropriate for examining its health and social consequences [33]. This focus ensured that participants could provide information not only on the physical and psychological consequences of FGM/C but also on how the practice influences intimate relational dynamics such as communication, marital satisfaction, and emotional intimacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size for the study was determined using Fisher\u0026apos;s formula for a single proportion (2004) as cited by Omisore et al. 2023 [34].\u003c/p\u003e\n\u003cdiv id=\"Equa\"\u003e\n \u003cdiv id=\"FileID_Equa\" name=\"EquationSource\"\u003e$$\\:n\\:=\\frac{{z}^{2}pq}{{d}^{2}}\\:=\\:\\frac{{z}^{2}p\\left(1-p\\right)}{{d}^{2}}$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eWhere:\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;the sample size\u003c/p\u003e\n\u003cp\u003ewhere n\u0026thinsp;=\u0026thinsp;sample size for the population\u003c/p\u003e\n\u003cp\u003ez\u0026thinsp;=\u0026thinsp;Level of confidence, which is 1.96 (i.e., 95% confidence interval)\u003c/p\u003e\n\u003cp\u003ep\u0026thinsp;=\u0026thinsp;Set at 0.142. Prevalence of FGM/C in Nigeria as reported in the 2021 Multiple Indicator Cluster Survey (MICS) [12]\u003c/p\u003e\n\u003cp\u003eq\u0026thinsp;=\u0026thinsp;probability of non-occurrence (1-P\u0026thinsp;=\u0026thinsp;0.5)\u003c/p\u003e\n\u003cp\u003ed\u0026thinsp;=\u0026thinsp;margin of error, which is 5% (0.05)\u003c/p\u003e\n\u003cp\u003eTherefore, the sample size was calculated as follows:\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;1.96\u003csup\u003e2\u003c/sup\u003e\u0026times; 0.142\u0026times;(1-0.142)\u0026thinsp;=\u0026thinsp;187.2\u0026thinsp;\u0026asymp;\u0026thinsp;187\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0.05\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eThe calculated sample size was 187, which was increased to 300 to allow for non-responses to maintain statistical validity and avoid an underpowered study [35], and to ensure cross-tabulation.\u003c/p\u003e\n \u003cp\u003eThe study sample consisted of 300 women drawn from the defined study population in Ebonyi and Imo States. The sample was divided equally into two groups: 150 women who had undergone female genital mutilation/cutting (FGM/C) and 150 women who had not. This comparative structure allowed the investigation to highlight differences and similarities in physical health outcomes, psychological well-being, and intimate partner relationship dynamics between the two groups.\u003c/p\u003e\n \u003cp\u003eThe study employed a purposive sampling technique with proportional allocation to ensure adequate representation of both women who had undergone FGM/C and those who had not. This approach was chosen because the investigation required a direct comparison between the two groups. A total of six Local Government Areas (LGAs) were selected purposively, three from Imo State (Oru West, Orsu, and Okigwe) and three from Ebonyi State (Abakaliki, Ikwo, and Ohaozara). These LGAs were deliberately chosen because reports and community records indicated relatively higher prevalence of FGM/C, making them suitable sites for identifying participants. From the target LGAs, a total of 300 women were recruited.\u003c/p\u003e\n \u003cp\u003eTo maintain balance and comparability, 50 participants were drawn from each LGA, with equal representation of 25 women who had undergone FGM/C and 25 women who had not. However, slight discrepancies occurred: in Abakaliki, 25 women with FGM/C were chosen, while 28 without FGM/C status were chosen, and in Ohaozara, 28 women with FGM/C were chosen compared to 25 without FGM/C status. Eligible participants were women aged 18 years and above who had been in an intimate partner relationship and who voluntarily provided informed consent. Women under 18, those unwilling to participate, and those with severe health conditions that might prevent effective participation were excluded.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStudy variables\u003c/strong\u003e: Dependent variable: Psychological health outcomes (depression, anxiety, and post-traumatic stress symptoms). Independent variable: Female Genital Mutilation/Cutting (FGM/C) status.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInstrument for data collection\u003c/strong\u003e: Data were collected using a structured questionnaire and four standardized psychological scales. The questionnaire captured respondents\u0026rsquo; socio-demographic characteristics, experiences of Female Genital Mutilation/Cutting (FGM/C), self-reported physical health outcomes (including chronic pain, infections, sexual dysfunction, and childbirth complications), as well as indicators of intimate partner relationship dynamics such as communication, marital satisfaction, and power balance. Psychological outcomes were assessed using validated instruments: the Patient Health Questionnaire (PHQ-9), a nine-item scale for depressive symptoms scored from 0\u0026ndash;27 with established severity cut-offs [36]; the Generalized Anxiety Disorder Scale (GAD-7), a seven-item measure of anxiety scored from 0\u0026ndash;21 with standard severity thresholds [37]; the Emotional Intimacy Scale (EIS), adapted to five items to assess emotional closeness or disconnection within intimate relationships, with higher scores indicating greater emotional distance [38]; and the PTSD Checklist (PCL-5, short form), a five-item tool assessing core post-traumatic stress symptoms scored from 0\u0026ndash;20 and categorized into increasing levels of symptom severity [39].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInstrument validation and reliability\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe quantitative instruments used in this study demonstrated strong reliability and validity across diverse cultural and clinical contexts, supporting their appropriateness for the present research. The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7) have consistently shown good internal consistency and diagnostic accuracy in sub-Saharan Africa and beyond, with reported Cronbach\u0026rsquo;s alpha values ranging from approximately 0.81 to 0.85, and evidence of strong construct and criterion validity when assessed against clinical diagnostic interviews [40\u0026ndash;43].\u003c/p\u003e\n \u003cp\u003eThe Emotional Intimacy Scale (EIS) likewise demonstrated high internal consistency (\u0026alpha;\u0026thinsp;\u0026asymp;\u0026thinsp;0.88), good test\u0026ndash;retest reliability, and strong construct validity through significant correlations with relationship satisfaction and psychological well-being [44]. Similarly, the Post-Traumatic Stress Disorder Checklist (PCL) has been widely validated across multiple populations and languages, with excellent internal consistency (\u0026alpha; values often exceeding 0.90) and strong convergent and discriminant validity in distinguishing trauma-related symptoms from other psychological conditions [45\u0026ndash;47]. Collectively, this body of evidence confirms that the instruments employed are both reliable and valid measures for assessing psychological health and relational outcomes in the study population.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eData collection procedure\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eQuantitative data were gathered by trained research assistants who personally administered the instruments. The field assistants were trained by the principal researcher on public relations, cultural sensitivity, questionnaire dissemination, and data collection to ensure completion, consistency, and accuracy. A total of 300 copies of the questionnaire were administered to respondents by the principal researcher and three (3) field assistants. Each participant was guided through the instruments in a private setting to ensure comfort, confidentiality, and accurate responses. The assistants recorded answers directly during the sessions and reviewed the completed forms immediately to check for clarity and completeness, thereby minimizing errors and missing values.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome measurement and data analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAll completed questionnaires were reviewed on the spot by trained research assistants to check for accuracy and completeness before submission. The data were then coded and entered into an electronic database, with regular verification to minimize entry errors. After cleaning, the dataset was exported into Stata (version 17) for analysis. Missing values were identified, and incomplete responses were excluded from the relevant computations to preserve data quality. Scores for psychological outcomes were computed in line with standardized scoring procedures for the PHQ-9, GAD-7, EIS, and PTSD instruments.\u003c/p\u003e\n \u003cp\u003eIndependent samples t-tests were used to compare mean psychological outcome scores (depression, anxiety, and post-traumatic stress symptoms) between groups, and chi-square tests were applied to assess associations between categorical variables. All statistical tests were conducted at a 5% level of significance (p\u0026thinsp;\u0026le;\u0026thinsp;0.05).\u003c/p\u003e\n\u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003eEthical clearance was obtained from the Research and Ethics Committee of the Alex Ekwueme Federal University Teaching Hospital, Ebonyi state with approval number AEFUTH/REC/VOL1/2024/664, in accordance with the 2013 Declaration of Helsinki and the State Ministry of Health, Imo State. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human participants. Informed consent was obtained from every participant after a clear explanation of the study\u0026rsquo;s objectives, procedures, potential risks, and benefits. Participation was entirely voluntary, and respondents were informed of their right to withdraw at any stage without penalty. Anonymity and confidentiality were strictly maintained throughout data collection, analysis, and reporting. Sensitive interviews were conducted in private settings to ensure participants\u0026rsquo; comfort and psychological safety, with referrals provided for those who exhibited distress during the study. \u0026nbsp;The data obtained from this study were secured and password-protected in an online database accessible only to the principal investigator of the study. \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Sociodemographic Characteristics of Respondents (N = 300)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Group (in years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e18\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e17.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e18.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e24.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e21.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e60\u0026ndash;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e17.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e76.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eDivorced/Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e44.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003ePetty trader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eTailor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eTeacher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eHealth worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eHomemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eImo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eEbonyi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eIgbo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the 300 respondents who participated in the study, there was an even representation from Imo and Ebonyi States (150 respondents each). Table 1 above presents the socio-demographic data for all participants. A large proportion of respondents were within the 40\u0026ndash;49 years age group (24.7%), followed by those aged 50\u0026ndash;59 years (21.7%), while respondents aged 18\u0026ndash;29 years constituted the smallest proportion (17.3%). With respect to marital status, the majority of respondents were married (76.3%), whereas smaller proportions were widowed (9.3%), divorced or separated (8.7%), and classified under other marital categories (5.7%). In terms of educational attainment, most respondents had at least secondary education (44.3%), while over a quarter had tertiary education (27.3%); however, a notable proportion had only primary education (21.0%) or no formal education (7.3%). Occupationally, farming was the dominant livelihood (33.7%), followed by petty trading (24.7%), with smaller proportions engaged as tailors (11.0%), homemakers (6.3%), teachers (4.0%), health workers (4.3%), or unemployed (4.3%), while others accounted for 11.7%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Item-Level Descriptives for Depression (PHQ-9), Anxiety (GAD-7), and EIS (Emotion)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eamong women with and without FGM/C experience\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"840\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale / Items\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGM = Yes (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGM = No (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 836px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ-9 (Depression)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eLittle interest or pleasure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eFeeling down or hopeless\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eTrouble sleeping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eFeeling tired or having low energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003ePoor appetite/overeating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.7 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eFeeling bad about yourself\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.0 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eTrouble concentrating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eSlow/fidgety movements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.6 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.0 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eThoughts of self-harm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e0.7 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal PHQ-9 Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e17.2 \u0026plusmn; 5.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.3 \u0026plusmn; 4.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 836px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGAD-7 (Anxiety)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eFeeling nervous, anxious, on edge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eNot able to control worrying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eWorrying about many things\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eTrouble relaxing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eBeing restless\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eBecoming irritable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.7 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.0 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eFeeling afraid as if something awful might happen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal GAD-7 Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.9 \u0026plusmn; 4.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.8 \u0026plusmn; 4.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 836px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional Intimacy Scale (EIS \u0026ndash; Emotional Disconnection)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eI feel emotionally connected to my partner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e3.4 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eMy partner and I share thoughts and feelings openly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eI feel emotionally distant from my partner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eMy partner understands my emotional needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e3.6 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eI feel a lack of emotional intimacy in my relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal EIS (Disconnection) Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.1 \u0026plusmn; 4.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.4 \u0026plusmn; 3.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe results from Table 2 above show the psychological effects of FGM/C on women. In the table, women with FGM reported higher levels of psychological distress and poorer emotional intimacy compared to those without FGM. On the PHQ-9, mean depression scores were higher among FGM women (17.2 \u0026plusmn; 5.1) than non-FGM women (11.3 \u0026plusmn; 4.6), with consistently elevated item scores such as feeling down, low energy, and poor self-worth. On the GAD-7, FGM women also scored higher for anxiety (14.9 \u0026plusmn; 4.8) compared to non-FGM women (9.8 \u0026plusmn; 4.2), reflecting greater difficulties with worry, nervousness, and relaxation. Regarding the Emotional Intimacy Scale, FGM women reported greater emotional disconnection (13.1 \u0026plusmn; 4.3) compared to non-FGM women (9.4 \u0026plusmn; 3.7), showing lower perceived emotional support and higher emotional distance in relationships.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTable 3: Depression (PHQ-9), Anxiety (GAD-7), and EIS (Emotion) Summary Scores\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"728\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale/Items\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories / Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGM = Yes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGM = No (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n=300)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression (PHQ-9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eNormal (0\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e17.2 \u0026plusmn; 5.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eMild (6\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eModerate (11\u0026ndash;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eModerate Severe (16\u0026ndash;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eSevere (21\u0026ndash;27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety (GAD-7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eNormal (0\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.9 \u0026plusmn; 4.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eMild (6\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eModerate (11\u0026ndash;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eSevere (16\u0026ndash;21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional Intimacy Scale (EIS \u0026ndash; Disconnection)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eMild (6\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.1 \u0026plusmn; 4.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eModerate (11\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003eSevere (18\u0026ndash;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn Table 3 above, the evaluation of psychological outcomes between women with and without FGM/C showed significant differences across depression, anxiety, and emotional intimacy. On the PHQ-9 depression scale, women with FGM/C reported markedly higher scores (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6). More than half of the FGM group (53.3%) fell within the moderate-to-severe categories, whereas only 26.7% of the non-FGM group did so. This finding highlights the heightened vulnerability of women with FGM to depressive symptoms.\u003c/p\u003e\n\u003cp\u003eFor the GAD-7, women with FGM/C recorded a mean anxiety score of 14.9 (SD = 4.8), while women without FGM recorded a mean score of 9.8 (SD = 4.2). In terms of severity, 73.4% of women with FGM reported moderate-to-severe anxiety, compared with 43.3% of women without FGM. Regarding the Emotional Intimacy Scale, women with FGM/C had a mean score of 13.1 (SD = 4.3), compared to 9.4 (SD = 3.7) for women without FGM. Severe emotional disconnection was reported by 36.7% of the FGM group and by 20.0% of the non-FGM group.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTable 4: Independent Samples t-test of Depression (PHQ-9), Anxiety (GAD-7), and Emotional Intimacy (EIS) by FGM Status (N=300)\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"704\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale/Measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGM Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStd.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDev\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. (2-tailed)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ-9 (Depression)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eFGM (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e10.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eNon-FGM (No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e11.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGAD-7 (Anxiety)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eFGM (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e9.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.0001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eNon-FGM (No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEIS (Emotional Intimacy)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eFGM (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e8.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.00001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003eNon-FGM (No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Represents significant values \u003cem\u003e*Statistical significance based on p\u0026lt;0.05\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 above reports findings relating to the independent samples t-test. Women who experienced FGM reported significantly higher levels of depression (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6), with a mean difference of 5.9 that was statistically significant (t(298) = 10.23, p \u0026lt; .01). Similarly, anxiety scores were higher among women with FGM (M = 14.9, SD = 4.8) than those without (M = 9.8, SD = 4.2), with a mean difference of 5.1 that reached statistical significance (t(298) = 9.84, p \u0026lt; .001). Emotional intimacy was also lower in the FGM group (M = 13.1, SD = 4.3) compared to the non-FGM group (M = 13.9, SD = 4.4), with a mean difference of 4.7 that was significant (t(298) = 8.72, p \u0026lt; .001). These results demonstrate that FGM is strongly associated with higher levels of depression and anxiety and with diminished emotional intimacy in relationships. Women who experienced FGM reported significantly higher levels of depression (M = 17.2, SD = 5.1) compared to non-FGM women (M = 11.3, SD = 4.6), with a mean difference of 5.9 that was statistically significant (t(298) = 10.23, p \u0026lt; .01). Similarly, anxiety scores were higher among women with FGM (M = 14.9, SD = 4.8) than those without (M = 9.8, SD = 4.2), with a mean difference of 5.1 that reached statistical significance (t(298) = 9.84, p \u0026lt; .001). Emotional intimacy was also lower in the FGM group (M = 13.1, SD = 4.3) compared to the non-FGM group (M = 13.9, SD = 4.4), with a mean difference of 4.7 that was significant (t(298) = 8.72, p \u0026lt; .001). These results demonstrate that FGM is strongly associated with higher levels of depression and anxiety and with diminished emotional intimacy in relationships.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTable 5: Distribution of PTSD Symptoms (PCL-5, 5 items) among Women with FGM (n = 150)\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePTSD Category\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(PCL-5, 5 items)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eScore Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNormal / Minimal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 \u0026ndash; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e12.4 \u0026plusmn; 3.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 \u0026ndash; 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 \u0026ndash; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e150\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5 above shows the distribution of PTSD symptoms among women with FGM. About 16.7% of the women fell in the normal or minimal range, while 26.7% reported mild symptoms. The largest group, 36.7%, had moderate symptoms, and another 20.0% experienced severe PTSD symptoms. The overall mean score was 12.4 \u0026plusmn; 3.9, with scores ranging from 3 to 20. Most women scored in the moderate-to-severe range, suggesting that PTSD symptoms are common and often clinically significant among women with FGM.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eThe Psychological Effects of FGM/C on Women\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study indicate that women who have undergone FGM/C experience greater psychological distress and reduced emotional intimacy compared with their non-FGM counterparts. Participants reported higher levels of depression and anxiety, alongside difficulties in forming and maintaining close emotional bonds with their partners. These outcomes highlight the profound psychological impact of FGM/C, demonstrating that the practice not only affects mental health but also undermines relational well-being and the quality of intimate relationships.\u003c/p\u003e\n\u003cp\u003eAnalysis of the psychological outcomes aligns with global and African literature documenting the enduring mental health consequences of FGM/C. Pallitto et al. (2025) [20], in a meta-analysis of 78 studies involving 486,949 women, found that FGM is associated not only with obstetric and gynecological complications but also with significantly higher rates of depression, anxiety, and somatoform disorders [20]. Similarly, O’Neill and Pallitto (2021) [48] highlighted the traumatic nature of FGM, noting that women frequently recall the procedure with vivid distress, often experienced as betrayal when performed by trusted family members or under social coercion [48]. These accounts demonstrate that FGM is inherently traumatic, with immediate physical pain translating into long-term emotional and cognitive sequelae, such as low self-esteem, body image disturbances, and feelings of inadequacy.\u003c/p\u003e\n\u003cp\u003eFrom a feminist theoretical perspective, these psychological outcomes reflect the broader structural violence embedded in FGM/C as a gendered practice [49]. Feminist scholars conceptualize FGM/C as a mechanism of bodily control that regulates female sexuality and enforces compliance with patriarchal norms that prioritize chastity, endurance, and marital suitability [50–52]. The internalization of pain, silence, and emotional suppression reported by women in this study illustrates how psychological distress is not merely an individual pathology but a socially produced outcome of gendered power relations. The betrayal experienced when cutting is performed or sanctioned by trusted family members further compounds trauma, transforming FGM/C into both a physical violation and a rupture of relational trust [53]. This framing helps explain why symptoms such as low self-worth, shame, and emotional withdrawal persist long after the physical wound has healed.\u003c/p\u003e\n\u003cp\u003eClinical, case report, and field-based studies further corroborate these findings. Knipscheer et al. (2015) [54], examined 66 immigrant women from Somalia, Sudan, Eritrea, and Sierra Leone, revealing that a third of participants exceeded thresholds for affective or anxiety disorders, while 17.5% showed symptoms indicative of post-traumatic stress disorder (PTSD) [54]. Further studies, such as a case report, found that infibulated women (Type III FGM) were particularly vulnerable, exhibiting vivid traumatic recollections, hyperarousal, flashbacks, and anticipatory fears during sexual activity, menstruation, or childbirth [55]. Similarly, Köbach et al. (2018) [56], found that Ethiopian women subjected to Type II and Type III FGM experienced cyclical depression and anxiety, with neuroendocrinological evidence supporting the physiological embedding of trauma [56]. These studies underscore that the psychological impact of FGM is not transient; it is chronic, pervasive, and amplified by the severity of the procedure.\u003c/p\u003e\n\u003cp\u003eAfrican-specific studies, including Nigeria, highlight the interplay between social pressures and psychological outcomes [57–60]. Omigbodun et al. (2022) [57], in a qualitative study of 38 Izzi women in Southeast Nigeria found that adolescents often sought FGM to gain social acceptance, despite awareness of its negative consequences [57]. The study revealed that social coercion, stigma, and the desire for cultural conformity exacerbate psychological distress, manifesting as anxiety, depressive symptoms, and emotional withdrawal. This finding reflects a broader pattern whereby cultural imperatives and social norms intensify the psychological burden of FGM, particularly when community enforcement intersects with intimate family dynamics. These findings are best understood through the lens of Social Norms Theory, which emphasizes that behaviors such as FGM/C are sustained not solely by personal belief but by collective expectations about what is socially required and morally acceptable [61,62]. In contexts where conformity is rewarded with acceptance and non-compliance is punished through stigma or exclusion, women may endure significant psychological distress to maintain social belonging [63]. The anxiety, emotional withdrawal, and depressive symptoms observed among participants therefore reflect the psychological costs of navigating a normative environment in which resistance to FGM/C carries relational and social risks [64]. This theoretical perspective clarifies why awareness of harm does not automatically translate into psychological relief or empowerment.\u003c/p\u003e\n\u003cp\u003ePrevious evidence in tandem with the results from our study consistently shows that the psychological consequences of FGM/C extend beyond immediate pain to long-term mental health challenges, including depression, anxiety, PTSD, somatization, emotional disconnection, and impaired sexual and relational functioning [65,66]. Similarly, findings from the study support existing evidence that FGM/C exerts profound and multi-dimensional psychological effects on women. The elevated depression and anxiety scores, alongside reduced emotional intimacy, reflect the chronic and pervasive nature of FGM-related trauma [67]. When considered alongside global and regional evidence, these findings highlight the urgent need for culturally sensitive, trauma-informed interventions that address both immediate and long-term psychological outcomes. Integrating mental health services into reproductive health frameworks, fostering resilience, and actively engaging communities to challenge cultural norms remain critical strategies for mitigating the enduring psychological harm of FGM/C.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe emotional effects of FGM/C on women\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings from this study indicate that women who had undergone FGM/C experienced notably lower levels of emotional intimacy with their partners compared to their non-FGM counterparts. Many participants reported severe emotional disconnection, highlighting that beyond the established physical and psychological health consequences, FGM/C also imposes a significant burden on relational well-being. These results suggest that the practice weakens the emotional bonds that are essential for healthy intimate partnerships, corroborating earlier evidence from other African contexts, where FGM/C was associated with reduced sexual satisfaction and diminished marital closeness, communication, and mutual trust [22,48,68].\u003c/p\u003e\n\u003cp\u003eQualitative research similarly supports this conclusion. Jordal et al. (2022) [69], in a study of 44 in-depth interviews with migrant women in Sweden, found that FGM/C survivors often described not only physical pain and sexual dysfunction but also persistent relational insecurities, such as fear of abandonment, diminished ability to trust, and a sense of emotional distance from their spouses [69]. Many participants linked these feelings directly to their experiences of FGM/C, which had eroded their capacity to feel pleasure and confidence in intimacy. In parallel, Shafaati Laleh et al. (2022) [70], demonstrated in Iran that women with FGM/C had substantially lower scores on sexual quality of life and higher reports of spousal conflict and infidelity [70]. Taken together, these studies indicate that FGM/C undermines both physical intimacy and emotional connection, compounding the burden women carry within intimate partnerships.\u003c/p\u003e\n\u003cp\u003eThe current findings also reveal how the erosion of emotional intimacy may be tied to broader patterns of gendered power imbalances. Feminist theorists argue that patriarchal systems condition women’s worth on their ability to conform to cultural norms around sexuality and marital submission [71]. This resonates with the patterns observed in this study, where women who had undergone FGM/C were more likely to report reduced influence in decision-making and diminished capacity to assert their needs within relationships. The emotional disconnection captured in the EIS scores can therefore be read not simply as an interpersonal deficit but as a structural outcome of patriarchal systems that simultaneously enforce and perpetuate FGM/C. Women who experience persistent pain, reduced satisfaction, and emotional withdrawal following FGM/C may perceive limited benefits in seeking help, either because they view their situation as normative within their cultural context or because they fear stigma if they disclose sexual dissatisfaction [72,73].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePTSD Symptom Distribution among Women with FGM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study indicate that symptoms of post-traumatic stress disorder (PTSD) are highly prevalent among women who have undergone FGM/C. Many participants exhibited moderate to severe trauma-related symptoms, suggesting that FGM/C leaves enduring psychological scars. Beyond its immediate physical consequences, the practice significantly compromises mental health and daily functioning, manifesting as persistent trauma, heightened distress, and emotional vulnerability. This underscores the long-term psychological burden of FGM/C and highlights the need for targeted mental health interventions for affected women. These results are consistent with previous studies documenting high rates of trauma-related morbidity among survivors of FGM. Virk et al. (2025) [73], in a retrospective observational study of 50 asylum seekers evaluated at the Weill Cornell Center for Human Rights, found that 86% of participants reported psychological symptoms, with 32% meeting formal diagnostic criteria for PTSD, major depressive disorder, or generalized anxiety disorder [73]. The similarity in the proportion of women with moderate-to-severe PTSD symptoms in the present study (56.7%) underscores that FGM should be recognized as a trauma-inducing event with mental health sequelae comparable to other forms of gender-based violence. The persistence of nightmares, aversion to sexual activity, and hyperarousal described in the Virk et al. cohort mirrors the symptomatic burden observed in the current findings [73].\u003c/p\u003e\n\u003cp\u003eThe findings also align with those of Jordal et al. (2022) [69], who documented that women in Sweden with a history of FGM described pervasive fear of intimacy, insecurity, and anxiety in relationships [69]. While their study did not explicitly quantify PTSD, the described symptoms, emotional withdrawal, fear of abandonment, and intrusive memories during intimacy, are hallmarks of trauma-related disorders. Similarly, Esho et al. (2017) [74], in Kenya linked sexual dysfunction among circumcised women to relational distress, which is often mediated through trauma-like symptoms of fear, avoidance, and psychological disconnection [74]. However, it is important to note that not all women with FGM develop clinically significant PTSD, as reflected in the 16.7% of participants in this study who scored in the minimal range. Howard and Gibson (2022) [75], in their large-scale analysis across six Sub-Saharan countries, emphasized that experiences of gendered practices such as FGM are mediated by context, resilience, and community support [75]. Cultural framing of FGM as a rite of passage may buffer against overt symptom expression in some settings, while migration to contexts that stigmatize FGM may amplify distress through social isolation and identity conflict [76]. This suggests that PTSD prevalence among FGM survivors is shaped not only by the act of cutting but also by the socio-ecological environment in which survivors live.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings from this study add to the growing evidence that PTSD symptoms are both prevalent and clinically significant among women with FGM. The distribution observed, where the majority fall in moderate-to-severe ranges, underscores the urgent need for routine psychological screening in reproductive health and community health programs targeting survivors. Interventions should integrate culturally sensitive trauma-informed care, recognizing the dual burden of physical harm and psychological distress. Addressing PTSD in this context is critical not only for individual mental health recovery but also for enhancing women’s relational well-being, reproductive health, and social participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several strengths. First, the use of a multi-site cross-sectional quantitative design across two states (Ebonyi and Imo) enhanced the robustness and comparative depth of the findings by capturing variations across different rural contexts. Also, this study employed validated and widely used psychological instruments (PHQ-9, GAD-7, EIS, and PCL), all of which have demonstrated strong reliability and validity across diverse populations, including sub-Saharan Africa. This enhances confidence in the accuracy and consistency of psychological measurements.\u003c/p\u003e\n\u003cp\u003eDespite these strengths, our study has its limitations. First, the cross-sectional design restricts the ability to establish causal relationships between FGM/C and observed health or relational outcomes. While associations can be identified, temporal ordering cannot be confirmed. Second, the study relies on self-reported data, which may be affected by recall bias and social desirability bias, particularly given the sensitive and stigmatized nature of FGM/C and intimate partner dynamics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that Female Genital Mutilation/Cutting (FGM/C) is significantly associated with adverse psychological health outcomes among women of reproductive age in Southeast Nigeria. Women who had undergone FGM/C reported markedly higher levels of depression, anxiety, and post-traumatic stress symptoms compared with women without FGM/C, alongside greater emotional disconnection within intimate relationships. These findings confirm that FGM/C constitutes a profound psychological trauma with enduring effects that extend beyond physical harm to compromise mental wellbeing, emotional functioning, and relational stability across the course of life. The results further highlight the need to reconceptualize FGM/C as both a mental health and human rights issue embedded within complex socio-cultural systems. Persistent cultural norms, stigma, and limited access to mental health services in rural communities contribute to the normalization and under-treatment of psychological distress among survivors. Addressing the burden of FGM/C therefore requires culturally sensitive, trauma-informed interventions that integrate psychological screening, counseling, and psychosocial support into reproductive and community health services, alongside sustained advocacy and policy enforcement aimed at eliminating the practice and supporting survivors’ recovery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eA joint ethical clearance for was obtained from the Research and Ethics Committee of the Alex Ekwueme Federal University Teaching Hospital, Ebonyi state with approval number AEFUTH/REC/VOL1/2024/66. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human participants [77].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from every participant after a clear explanation of the study’s objectives, procedures, potential risks, and benefits. Participation was entirely voluntary, and respondents were informed of their right to withdraw at any stage without penalty. Anonymity and confidentiality were strictly maintained throughout data collection, analysis, and reporting. Sensitive interviews were conducted in private settings to ensure participants’ comfort and psychological safety, with referrals provided for those who exhibited distress during the study. \u0026nbsp;The data obtained from this study were secured and password-protected in an online database accessible only to the principal investigator of the study. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003eCO conceptualized the study and led the development of study methods and data collection. CO and AON contributed to the study design, methods, and the development of study materials. CO, PCA and AON contributed to data collection, data analysis, and writing of results. PCA, CO, and TA supported the development of the manuscript and critical reviews. AON supervised and provided critical oversight on the project and manuscript. All authors read and approve the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank all the participants for their valuable time and contributions to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no financial support for the research and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eAll data relevant to the study, including data collection instruments, are accessible upon reasonable request. Interested researchers should contact the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors report no conflicts of interest or other disclosures relevant to this work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCDC. Female Genital Mutilation/Cutting (FGM/C) [Internet]. Reprod. Health2025 [cited 2025 Dec 31];Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/reproductive-health/women-health/female-genital-mutilation-cutting.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/reproductive-health/women-health/female-genital-mutilation-cutting.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. 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No relationship found between Female Genital Cutting and Intimate Partner Violence across six sub-Saharan African countries. Glob Public Health. 2022;17:2704\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeLaet D. FGM and genital cutting across borders: cultural biases in the contestation of global human rights. Identities. 2024;32:1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Female genital mutilation/cutting, psychological health, depression, anxiety, post-traumatic stress disorder, emotional intimacy, Southeast Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-8492256/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8492256/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFemale Genital Mutilation/Cutting (FGM/C) remains a deeply entrenched, harmful cultural practice with well-documented physical consequences; however, its psychological health outcomes remain underexplored in many settings, including Southeast Nigeria. Existing evidence suggests that FGM/C constitutes a traumatic experience with enduring implications for women\u0026rsquo;s mental health, emotional wellbeing, and psychosocial functioning. This study examined the psychological health outcomes of FGM/C among women of reproductive age in Southeast Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA multisite cross-sectional quantitative design was used. The study involved 300 women aged 18 years and above drawn from rural communities in Ebonyi and Imo States, comprising 150 women who had undergone FGM/C and 150 women without FGM/C. Data were collected using a structured questionnaire and standardized psychological instruments: the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), PTSD Checklist (PCL-5 short form), and an adapted Emotional Intimacy Scale. Independent samples \u003cem\u003et\u003c/em\u003e-tests and chi-square tests were conducted using Stata version 17, with statistical significance set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWomen who had undergone FGM/C reported significantly higher levels of psychological distress compared with non-FGM women. Mean depression scores were higher among the FGM group (17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1) than the non-FGM group (11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), while anxiety scores were similarly elevated (14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 vs. 9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). More than half of women with FGM/C exhibited moderate-to-severe depressive and anxiety symptoms. Emotional intimacy was significantly lower among women with FGM/C, with greater emotional disconnection reported (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among women with FGM/C, 56.7% exhibited moderate-to-severe PTSD symptoms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFGM/C is strongly associated with adverse psychological health outcomes, including depression, anxiety, post-traumatic stress symptoms, and reduced emotional intimacy. These findings demonstrate that beyond its physical harms, FGM/C imposes a substantial and enduring psychological burden on affected women. Integrating culturally sensitive, trauma-informed mental health services into reproductive and community health programmes is essential for addressing the psychological sequelae of FGM/C and improving women\u0026rsquo;s overall wellbeing in Southeast Nigeria.\u003c/p\u003e","manuscriptTitle":"Psychological Health Outcomes of Female Genital Mutilation/Cutting among Women of Reproductive Age in Southeast Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 11:03:25","doi":"10.21203/rs.3.rs-8492256/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51d039ae-26e9-4089-867f-258a4afc2c64","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:43:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 11:03:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8492256","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8492256","identity":"rs-8492256","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}