Our Body Our Health (Jirkeena, Caafimaadkeena): Somali Women's Narratives on Sexual Health.

Sixty Somali women participated in the study; Table 1 provides detailed demographic information. Per inclusion criteria, all participants experienced FGC and were currently or had been sexually active; details about the circumstances of their FGC are in Table 2 . The University of Minnesota IRB reviewed and approved this study, (IRB ID: STUDY00002117) previous to recruitment. We used convenience and snowball sampling methods to recruit and interview 60 Somali women aged 21 – 45 in the Minneapolis-Saint Paul 7-county metropolitan area during June - October 2019. Bilingual community researchers recruited potential participants by tabling at events or starting a conversation in a community setting (university campuses, apartment buildings, community centers, community health fairs, Somali malls, resettlement agencies, etc.) and through their personal community connections --- resulting in 36 participants. Participants were encouraged to refer others (friends, family members, neighbors, etc.) to the study --- resulting in 24 participants. All interviews were conducted in person at the participant’s preferred location --- most ( n = 39, 65%) chose to meet in their home and others chose a friend’s home, university campus, research office, and other community locations. During scheduling, the interviewers informed the women about the interview process (e.g., sensitive sexual and relationship questions, average length of interview, consent form, audio recording) and arranged a meeting location. We used an in-depth, semi-structured interview, giving the interviewer an opportunity to ask probing questions when needed. Interviews ranged in length from 20 – 136 minutes ( M = 51 minutes, SD = 22 minutes). Two thirds ( n = 40) were conducted in Somali and one third ( n = 20) in English, based on participant preference. Due to differences between English and Somali, translators did not use word-for-word translation but rather translated words and concepts as close to the original meaning as possible. Somali interviews were translated into English in a two-step process. First, each interviewer/translator verbally translated their interviews using a digital recorder to create English audio files. Second, a bilingual Somali intern and a bilingual Community Advisory Board member back-checked all translations to ensure translation consistency and accuracy. All interviews were transcribed professionally. At the beginning of each interview, interviewers tried to create a safe and comfortable environment for the women to discuss their experiences by introducing themselves and getting to know something about each woman. Interviewers reviewed a written consent form (in English or Somali) with the participant and provided an overview of the study and purpose, reviewed interview procedures, and provided time for participants to ask questions and clarifications, and demonstrate their understanding of the study before signing the consent form. Women were able to take breaks and pause if needed at any time during the interview. Upon completion, each participant received a $75 gift card. Interviewers wrote field notes after each interview, reflecting on any observations, interview setting, participant’s perceived comfort and talkativeness, interruptions, distractions, or other challenges, relevant pre- or post-interview comments, reactions to the questions, etc. The interviewer guide consisted of semi-structured questions and probes based on study aims and previous literature. Questions covered a range of topics about Somali women who had experienced FGC, such as demographics, couple and family relationships, immigration history, FGC, sexual pain and coping strategies, deinfibulation and reinfibulation, sexual functioning, mental health, and healthcare experiences. We asked about pain when the participant first attempted intercourse, and when they last had sex. The interviewer described each FGC type and engaged in a conversation about their FGC story to collaboratively agree on which FGC type matched their experience (see Johnson-Agbakwu et al., 2023 for further explanation of this iterative process). Example questions are in Supplement 1 . This paper focused on the results of questions about women’s sexual desire, pleasure, orgasm, satisfaction, pain and coping. We took a participatory data analysis approach rooted in community-based participatory research (CBPR) that engaged community members as full partners during study development, data collection, analysis, result interpretation, and dissemination. Our community partners are from a community-driven research organization that emphasizes a participatory data analysis process and asset-based (i.e., strength-based) approach to maximize community inclusion in research (Somali, Latino, and Hmong Partnership for Health and Wellness (SoLaHmo)). The participatory data analysis team used a multistage approach to conduct an inductive thematic analysis of the data ( Jackson, 2008 ). First, five dyadic coding teams used open coding procedures to generate initial codes from five transcripts. Second, the data analysis team discussed these initial codes and reached consensus on a preliminary code tree which was entered into our qualitative data analysis software (Dedoose). Third, using the preliminary code tree, the data analysis team analyzed one interview together to ensure coding consistency across the five dyadic teams. Fourth, dyadic teams used the preliminary code tree to analyze the remaining interviews --- allowing new codes to emerge. New codes and revisions of existing codes were discussed at weekly meetings to continually refine the code tree. Last, data analysis team members met weekly to review the coded excerpts and codes, collapse codes, resolve coding discrepancies, select exemplar quotes, and review summaries of data. Discussions continued until consensus was achieved; if necessary, the data manager revised the codes applied to the transcript based on team decisions. We engaged the community advisory board in the summary stage of the analysis (described further in supplement 2 ). This allowed the team to gain insights and feedback from a broader group of community experts on key areas. We also defined and quantified three variables: sexual pain presence (yes/no), sexual pain intensity (0 – 10; 10 being worst pain), and whether the participant reported experience having an orgasm (yes, maybe, or no). We acknowledge that our social positionality, e.g., religious belief, cultural identity, profession, age, power position (between participant and interviewer and within the research team), and insider or outsider position relative to the Somali community, might impact how we collected, analyzed, and interpreted the data ( Jacobson & Mustafa, 2019 ; Muhammed et al., 2015 ). Thus, we practiced self-reflexivity throughout the research process to minimize implicit bias and better ensure the trustworthiness of results ( Muhammed et al., 2015 ). At the beginning of the research process, we completed a social positionality exercise ( Jacobson & Mustafa, 2019 ), which encouraged us to reflect on how our social location contributed to our view of our research topic, our interpretation of the data, how we will work together, and how participants may perceive us. This led to conversations about how our own backgrounds (e.g., religious, cultural, academic discipline, age) influenced our beliefs about sex, FGC, research methods, and other relevant topics. It allowed us to acknowledge differences, such as the history and conflict between religious groups represented on the team. We also reflected on how our professional identity influenced our interpretation of the practical and clinical implications of our findings. By utilizing this approach, we tried to move beyond the perceived dichotomy between academic and community staff, and come to the research team as individuals with intersecting worldviews. We feel it is important to be transparent about our backgrounds in this publication, but caution that the following identities are also somewhat reductionist and do not fully capture us entirely. All researchers who participated in data analysis and contributed to this manuscript identify as cisgender women with diverse religious backgrounds (Muslim, Atheist, Jewish, Catholic), ages (early 20’s to early 70’s), and cultural identities (Somali, Somali immigrant, Chinese, Canadian, and American with European ancestral roots). We also represent various disciplines, including Family Social Science, Family Therapy, Psychology, Public Health, Sociology, and Social Work.

The findings below are based on identified themes that addressed sexuality, including sexual desire/arousal/pleasure, orgasm, sexual pain, and sexual satisfaction. We describe each theme and subtheme below. In tables 3 and 4 , we present quotes from participants. Each quote is accompanied by a pseudonym, age, marital status, and type of FGC that the interviewee experienced; in the quotes below, T1 denotes FGC type 1, T2 denotes FGC type 2, etc. We asked participants how they experienced sexual desire and associated physiological sensations and if and how they had experienced sexual pleasure. The theme of sexual desire and/or pleasure arose spontaneously throughout the interviews, not just in response to specific questions. Although desire, interest, pleasure, and arousal may be conceptually distinct to sex researchers, participants spoke about these concepts interchangeably. Thus, we presented our results to reflect this. Participants described the physical sensation of sexual desire and/or arousal as “wetness,” “goosebumps,” “your body gets hot,” “tingly,” “my blood pressure rises.” Body parts named as involved in arousal included “genitals,” “my stomach and my heart,” “neck,” “breasts,” “thighs,” and “whole body.” Answering questions about the physical experience of sexual desire and arousal appeared challenging for some participants due to a reticence about discussing sexuality and/or lack of words within the Somali language. When discussing the emotional side of sexual desire, participants were more verbose. Words such as “happy,” “in the mood,” and “wanting” are examples of emotional descriptions. Sexual desire was also depicted as an internal process where physical sensations, emotions, and intimacy combine. Sexual desire was a necessary condition for having sex for some women. When asked to describe sexual desire, participants sometimes described behaviors that accompanied this feeling that signaled to their partner that they were in the mood, such as wearing the right clothes, cleaning themselves, or cleaning their home. For other participants, feelings of sexual desire and/or pleasure were elusive. At times, participants reported feeling no sexual pleasure or not having an awareness of sexual arousal, but chose not to elaborate. When participants did elaborate, they often linked their lack of physiological sensations to FGC. For example, Bilan ( table 3 ) described that she had goosebumps when thinking about her husband and found pleasure with her husband but not with vaginal intercourse. Participants shared that stress, illness, fatigue, and sexual pain all contributed to a decrease in their sexual interest on a given day. Under these circumstances, participants spoke about a decrease in sexual desire as temporary. When sexual pain was intermittent, participants noted a lack of sexual desire on that particular day, but not necessarily as shutting down sexual interest entirely. Other participants noted that their experiences of sexual pain affected their interest in sex entirely. The anticipation of pain also influenced desire. Despite the challenges of FGC, sexual desire, arousal, and/or pleasure can improve over time. Participants attributed this to becoming comfortable with sex over time, self-education, and practice; for some women this took months and others it took years. Widening the vaginal opening through sex, childbirth, or a deinfibulation procedure, may have decreased painful intercourse and therefore increased pleasure. We used an open-ended question about who in the marriage initiated sex --- as one possible indication of sexual desire. No one said that they always initiated sex. Some women stated that their husband was always the initiator, even if she was desirous, citing gendered expectations in Somali culture around sex, “shyness,” or “modesty.” Modesty was considered both a Somali norm and an Islamic value. In relationships where women never initiated sex due to a lack of sexual interest but their husband continued to have interest (i.e., desire discrepancy), negative feelings or relational conflict resulted. Cultural, FGC, and personal experiences shaped how initiation was felt. For example, Bishaaro (see quote in table 3 ) was in an arranged marriage when both she and her first husband were adolescents. Neither were prepared for navigating vaginal intercourse with a very small vaginal opening, and she described her wedding night as terrifying and painful. At the time of the interview, her previous experience remained a specter over her current marriage, which she described as a loving relationship. Despite the cultural norms around initiation, a subgroup of women communicated to their husbands that they wanted to have sex. This may appear as a tension between her sexual interest and wanting to be demure due to perceived cultural expectations. Using behavioral cues to initiate or demonstrate interest indirectly was one way to manage this tension. The women who felt that both parties initiated sex often, connected the initiation to whoever was in the mood for sex at any given time, without a gendered expectation. We asked about experiences of orgasm. A large majority of participants indicated they had experienced orgasm ( n = 45; 84%), whereas only 9% ( n = 5) said they had not, or were unsure ( n = 4; 7%). Six participants were not asked or chose not to answer. Though participants often said that it was difficult to describe an orgasm, upon reflection, the typical participant found words to describe the sensations and feelings. Words used to describe physical sensations included “awake,” “vibration,” “body out of control,” “wet.” Words connoting emotions included “emotionally satisfied,” “happy,” and “calm.” Other descriptors could be perceived as physical and/or emotional, depending on one’s subjective experience, such as “climax,” “peak,” “relieved,” “less stressed,” “good,” “pleasurable,” and “lighter.” We asked what it meant to be sexually satisfied. Most women discussed what sexual satisfaction meant to them, though there were women who did not relate to feeling sexually satisfied or likened it only to an absence of pain. Sexual satisfaction was described as an overall sense of well-being, feeling fulfilled, being healthy, enjoyment, and pleasure. The Somali word that was used the most often was raaxo , which translates to enjoyment in English. Enjoyment encompassed a range of experiences from pleasure and orgasm to the absence of pain. It may refer to self-focused pleasure or a shared experience of pleasure. The couple relationship was often intertwined with sexual satisfaction, where respect in the relationship seemed more salient than physical sensations. Communication was linked to higher sexual satisfaction as it helped to tell one’s partner what does and does not feel good, in addition to providing a sense of shared intimacy --- though not all participants felt comfortable sharing their sexual interests with their husband. As Seynab (quote in table 3 ) pointed out anatomical changes made sexual communication all the more necessary to be able to adapt and feel satisfied. When asked about sexual satisfaction, participants discussed the necessity of spending time together. There was an implication that by being together, engaging in playfulness and building intimacy, sex would be more satisfying. They spoke about spending time doing explicitly sexual activities, such as foreplay and role plays, but also seemingly non-sexual things, such as watching a movie. The vast majority of participants (87%) reported having pain during the first days and/or weeks of attempting intercourse (typically the first week or month of marriage). The average pain intensity rating based on recollection was 8.8/10, on a 0 – 10 scale with 10 being the worst pain (reported range: 0 – 10). We distinguish “initial” sexual pain from “ongoing pain,” as it became apparent from the interviews that these experiences were qualitatively different. The language used to describe initial pain was vivid and indicated both physical and emotional intense pain. This difference was in part due to the difficulty with penetration through the sewn vulva; participants described needing to try multiple times before full penetration was possible. Sometimes participants sought out intervention before their next attempt, such as going to a doctor. Participants also described bleeding and swelling as a result of the intercourse attempts. A small number of participants noted that although they felt “discomfort” the first time they had sex, they did not label that discomfort “pain.” As noted in table 4 , Seynab (who had Type 4 FGC and described it as a “small prick”), distinguished pain from hurt by her ability to continue having sex. We asked women to recall if they continued to experience pain after the first month of marriage. Some participants (23%) continued to report pain beyond the first few weeks. For women with ongoing pain, they were asked to rate the level of pain the last time they had sex; the average intensity reported was 3.8/10, with 10 being the worst (reported range: 0 – 8). As this sample represented married, divorced, and widowed women, the phrase “last sex” is not precise or consistent across women. Sexual pain was not necessarily constant and could depend on the frequency of sex or other (unknown) reasons. Participants who endorsed ongoing pain typically described a reduced intensity of pain over time --- often because their opening became bigger, making pain more manageable. Participants noticed that a reduction in fear over time created less bodily tension. Some participants reported no ongoing pain when first asked, but on further exploration, reported sexual pain in their recent sexual experiences. It seemed that intense initial pain may have mitigated how they viewed their more recent pain. For example, Ifrah (age 36, divorced, T3) says she did not experience “any pain” the last time she had sex (when asked through a yes/no question), but shifted her language throughout the conversation and rated her pain as “4” (on a 0 to 10 scale) after describing her pain experience. We asked participants what strategies, if any, they employed to minimize sexual pain. A salient theme was the role of spousal support during those first painful sexual experiences, including compassion, gentleness, communication, and helping identify other resources to reduce pain (e.g., medical attention). How the husband approached these sexual experiences contributed to both the pain experience, but also her assessment of his character and a sign of love – or lack of love. Participants noted that their husbands appeared to hear or notice they were in pain and changed their behavior by slowing down and being gentle; foreplay was a form of gentleness, easing the process of the pain by taking more time and by being attuned to the woman’s expressed discomfort. By using strategies of communication, pacing, and knowing when to stop sex, both members of the couple benefitted and were able to create a positive shared experience. Husbands also demonstrated support by encouraging women to seek medical attention, such as deinfibulation, or obtaining medication or lubrication. Alternatively, there were women who described a lonely experience of being isolated in their own pain or having conflict with their husbands about seeking medical assistance. Participants also spoke about their husbands’ views of sexual pain as expected and normal. This could be reassuring --- but could also be felt as minimizing or not believing that the pain is real. Spousal support was also a salient theme for the women who had ongoing sexual pain. Compassion/gentleness, communication, and lack of verbal communication themes were found --- the same themes as for spousal support at initial attempts. Similarly, an understanding partner made it possible to find pain mitigating strategies that worked. However, in this group of participants with ongoing pain, a qualifier such as expressing disappointment, was sometimes attached to this statement of support. For participants with ongoing pain, communication was seen as a continuing process and a means to explore ways to either stop when in too much pain, to make adjustments, or to develop a shared understanding of the amount of pain she was in that day. Some remarried participants noted that in their first marriages, this communication was missing and that their sexual relationships improved when supportive communication about pain occurred with their new partners. However, spousal support was not a universal experience. Stopping during painful sex or avoiding sex out of anticipatory pain were strategies used to mitigate pain. This theme stood on its own, but was also woven into the earlier themes about communicating needs to a partner. This strategy involved being self-aware, able to share one’s individual needs, and a spouse who listened. Participants sought intervention through medical providers and pharmacists to assist with pain and/or bleeding. Over-the-counter pain medication, such as Tylenol or ibuprofen, or a numbing gel provided by a pharmacist, helped manage pain during the first few weeks of marriage. Participants spontaneously spoke of using lubrication as a strategy to minimize sexual pain, and other times, the interviewer asked in the context of a discussion about sexual pain. This was not asked of every participant. More participants reported using lubrication than not (17 did, 11 explicitly stated they did not). Types of lubrication included gels from a pharmacy, Vaseline, oil (either unspecified, olive, or coconut), and over-the-counter creams. Participants learned about lubricants from husbands, pharmacists, or others in their social network. At times, participants stated they wished they had known about lubrication earlier. Participants also noted that they discontinued using lube when their pain was reduced from extreme to milder pain Going to an emergency clinic or hospital was only mentioned during the first attempts at intercourse. Healthcare providers did not always know how to handle this situation and sent the woman home without assistance. Other times, the doctor provided deinfibulation or helped stop the bleeding. Participants shared stories of seeking out healthcare in numerous contexts, such as refugee camps, East African clinics, and U.S. clinics, but there was not a discernable pattern with regards to positive or negative care based on location. Participants shared stories of enduring painful sex both initially, and in an ongoing relationship. Generally, these stories about pain during initial and ongoing sex were not different in a meaningful way, except that some noted feeling a stronger sense of duty at the beginning of the marriage, as well as an expectation that pain would be brief and therefore easier to endure. One cognitive strategy women recounted was to ignore thoughts about pain while enduring it. Cultural norms about strength, modesty, a duty as wife and mother, all provided a sense that pain is to be endured, rather than invoking a need to intervene. Another strategy employed was to normalize the pain and create a sense of solidarity with other women who have also felt sexual pain. However, when discussing enduring painful sex, women recounted no pleasure from the experience and even an experience akin to dissociation.

In this qualitative study, we explored how a sample of Somali women living in the U.S. with FGC spoke about and experienced sexual pleasure and sexual pain. Participants reported varying experiences of sexual desire, arousal, and pleasure; many described orgasms even without having a Somali word that translated to the English word “orgasm.” We found that it was common for women to experience high levels of pain early in their sexual relationships, improvements in sexual pain over time, and development of coping skills to manage the pain --- often in partnership with their husband. Participants described engaging with healthcare professionals or pharmacists for means of reducing pain. Almost a quarter of all women reported ongoing sexual pain. FGC is one, but not the only, factor that shapes a woman’s sexual experiences. Women living with FGC navigate social norms and public discourse about female sexuality in their community, and in the case of migrants, within their host country’s society, as they make meaning about their experiences ( O’Neill and Palitto, 2021 ). Discourse about female genitals, sexual function, and sexual pleasure is often stigmatized, and therefore silenced, across many cultures throughout the world ( Atallah et al., 2016 ; Ford et al., 2019 ; Labuski, 2017 ). For example, in a large population-based sample of women in the U.S., 43% of those who reported having experienced painful sex did not tell their partner about the pain ( Herbenik et al., 2015 ). This silence can create barriers to accessing information and/or intervention for women distressed by gynecological and/or sexual problems (e.g., Connor et al., 2013 ; Thorpe et al., 2022 ). In our findings, we see a reflection of how FGC (e.g., level of cutting/sewing) intersects with emotional and social resources (e.g., relationship, acceptance of gender norms, access to medical care) to create diverse experiences. In the FGC literature, there is considerable evidence that FGC negatively affects female sexual functioning; in our study as well, a subgroup of women noted feeling a lack of sexual pleasure. On the other hand, the large majority of women indicated that they experience sexual pleasure --- as evidenced by the fact that 84% reported experiencing orgasm. According to numerous Islamic scholars, both the husband and the wife have a right to sexual satisfaction (Roald, 2001, as cited in Berg & Dennison, 2012 , p. 52). During qualitative interviews with Somali women in Minnesota, several participants discussed their beliefs that in Islam, it is a man’s duty to pleasure his wife and husbands are encouraged to ensure their wives are sexually satisfied in ways that are religiously sanctioned ( Connor et al., 2016 ). Our findings demonstrated that many women who have undergone FGC still care about, want to, and remain attuned to the importance and the right to sexual pleasure and healthier sexual relationships. Women’s narratives are full of women enjoying and looking forward to the pleasure of sexual intercourse, refusing to accept pain, demanding to be listened to, and possibly seeking divorce if partners refuse to heed their needs and requests for sexual pleasure. The findings illustrate agentic women, who seek sexual pleasure, information and knowledge from friends, family, internet, and healthcare providers. The physical damage done to the clitoris during FGC is one reason it is widely believed that women who have undergone FGC do not experience sexual pleasure. Our study, along with several others, refutes the common perception that all women who have experienced FGC are “asexual,” with a loss of sexual desire and pleasure ( Catania et al., 2007 ; Daneshkhah et al., 2017 ; Jacobson et al., 2018 ). There is evidence that the clitoris is frequently found intact after FGC ( Bazzoun et al., 2021 ). Additionally, circumcision only affects the visible glans of the clitoris --- which comprises less than 20% of the total mass of the clitoris; the crura and some of the clitoral body remain ( Chaisson et al., 2023 ). In their groundbreaking study, Abdulcadir, Botsikas et al (2016) , measured the structures of the clitoris, and sexual function, desire, and satisfaction with body image in women with and without FGC. Their results support their hypothesis that the tissues responsible for sexual pleasure, arousal, and orgasm are present in women with and without FGC. Similar to previous research (e.g., Mohammed et al., 2022 ; Rouzi et al., 2017 ; Yassin et al., 2018 ), participants in our study reported significant pain with intercourse, in particular at the beginning of marriage. Women often expressed an expectation of painful sex at the beginning, especially if they were infibulated. There was variance in how that expectation was handled. For some, normalizing and enduring pain was a means to withstand the experience. For this group of participants, cognitive strategies such as ignoring or suppressing thoughts, as indicated in the endurance pain models ( Hasenbring and Verbundt, 2010 ), allowed one to endure, or as Aisha stated – “take it like a champ.” However, there appeared to be little benefit in enduring pain beyond allowing the opening to widen for women who were sewn; this widening could also be achieved through deinfibulation. As pain continued, some participants noted that they began to avoid sex all together. Though avoidance was framed as a problematic coping strategy in the fear-avoidance literature, in the context of sexual pain, stopping and avoiding penetrative sex can be a coping strategy as it allows for healing, agency, and an opportunity to seek medical attention instead of enduring the pain. Participants who stopped painful sex, often used resilience strategies with their partners and found ways to minimize pain by changing the pace of sex, using lubrication, and/or seeking medical attention ( Sturgeon and Zautra, 2010 ). By its nature, sexuality is relational. Several theoretical models and a large body of research point to the interactional nature of sexual satisfaction, pleasure, and function (e.g., Girard et al., 2023 ; Freihart, Sears, and Meston, 2020 ; Hertlein, Gambescia, and Weeks, 2019 ; Lawrance and Byers, 1995 ), such that one’s assessment of intimacy and relationship satisfaction impacts the sexual experience and vice versa. In the present study, Somali women’s reflection on their complex sexual experiences showcased the interactional nature of sexual relationships in this population --- cis-gender heterosexual Somali women. Women’s articulations of the significance of their male partner’s supporting role in addressing pain in early and later sexual encounters, emerged as critical to women’s sexual satisfaction and improvement or reduction of painful sex. We would argue that there is a great need to include Somali men in future research, as well as larger community educational initiatives. Participants discussed the helplessness and confusion that men experienced when noticing her physical pain. Cultural assumptions suggest that Somali men support FGC, as they benefit from control of women and women’s sexuality ( Kelly & Hillard, 2005 ). While the historical and persistent continuity of this practice is linked to these assumptions, our research also testified to how both men and women are embedded in a cultural practice transmitted over generations, where the ramifications impacted both partners. In the quotes from participants, we saw men who were not patient or sympathetic to women’s suffering, but we also saw men who were caring and supportive of the needs of their spouses. Underscoring the cultural forces driving FGC that negatively impacted both men and women is necessary to promote larger understandings of structural pressures/forces in society and their powerful, invisible hand in social reproduction of detrimental practices such as FGC. Enlisting Somali men with their invested interests in working towards the eradication of this practice is paramount. Conversely, our findings illustrated how the privileging of men’s sexual pleasure over women’s continues in many couples, as women often feel “obligation” to attend to men’s sexual needs even when this causes substantial pain. There are a number of research implications of this study. Researchers should be aware that specific terms used by sex researchers to delineate concepts of sexual pleasure, desire, and satisfaction could all be synonymous to individuals not embedded in academic or clinical settings. In the current study, this may partially be due to translation and language limitations, though those of us who are clinicians have observed these same sexual language limitations in our sex therapy practices with clients from all backgrounds. Participants were able to describe the experience of having an orgasm, but did not know the word for orgasm in Somali. We recommend that future researchers provide clear descriptions of what sexual terms mean, especially in quantitative surveys where meaning cannot be clarified by an interviewer. Participants described pain clearly, however it is always unclear how one’s personality, culture, and previous history of pain influences how a person quantifies pain on a Likert scale. As noted in the findings, some participants reported no pain, but in discussion described ongoing pain in their sexual relationships. This may be due to cultural norms to not openly discuss negative experiences in marriages or stoicism ( Finnström & Söderhamn, 2006 ; Jacobson et al., 2018 ) or that the extreme pain during their first tries at vaginal intercourse may lead to a perception that milder pain is not relevant. Researchers should build in multiple methods of assessing pain experiences. Further research is needed to understand what causes some women to develop chronic pain, while pain subsides for others. Given the variation in sexual pain responses in a sample of women who have all experienced FGC, it is clear that cutting was not solely responsible for ongoing pain. Examination of resilience factors, in addition to risk factors, is needed to better assist women to find effective coping strategies. Our theoretical models about pain often obfuscate the resilience of individuals living with pain by focusing only on maladaptive pain strategies. Adding questions about coping with pain, resulted in the salient finding that male sexual partners have the capacity to assist with mitigating sexual pain. Involvement of male partners in future research seems essential to understanding the full picture. There is a considerable amount of research suggesting that healthcare providers do not have the requisite resources and knowledge to adequately address the healthcare needs and sexual issues of women who have experienced FGC ( Dawson et al., 2015 ; Jacobson et al., 2023 ; Libritti et al., 2023). Healthcare providers should not shy away from this important discussion. Our findings demonstrated that many Somali women have active sex lives, but like many, could benefit from further sex education. Circumcised women who are preparing for marriage could benefit from counseling on ways to increase pleasure and sexual satisfaction, to manage pain with lubrication and, when relevant, deinfibulation. Researchers in Norway found that circumcised Somali women expressed an interest in psychotherapy, if available, to address sexual issues from FGC ( Ziyada et al., 2020 ). In their study and ours, some participants expressed a cultural norm of modesty and/or sexual passivity; these norms should be considered in delivering psychotherapy or sex therapy to Somali women. Inclusion of a partner in counseling could help address ways to minimize pain through pacing, encouraging experimentation with positions that may reduce pain, providing permission to stop intercourse if too painful, and seeking necessary medical interventions. Several considerations may limit the generalizability of study findings. The sampling strategy was limited to convenience sampling in one specific community. Minnesota has a diverse and large Somali population with its own cultural enclave; some cultural norms may be different from Somali populations that have migrated elsewhere. Similarly, Somalia is only one of 28 countries where FGC is practiced; some findings may generalize to other populations and others may not. As talking about sexuality in Somali communities is taboo, we suspect that our sample may represent individuals who are more receptive to speaking openly than others in the Somali community; this may have resulted in a sample that is also open to sexual experiences outside of cultural norms ( Connor et al., 2016 ). Our study population reported cisgender and heterosexual identities; endorsement of a LGBTQ+ identity continues to be stigmatized in the broader Somali community and therefore those with a minoritized gender and/or sexual identity may not present as such to a Somali researcher ( Hunt et al., 2018 ). In this qualitative study, we were unable to do a clinical interview or exam to determine if factors outside of FGC may contribute to sexual pain (e.g., endometriosis) or untangle how pain and lack of desire influence one another. Despite the limitations, the study has many strengths. We recruited at a faster pace than anticipated, which we attribute to the population’s readiness to discuss these topics and the skills and trustworthiness of our interviewers (authors 4, 6, and 7). Participants engaged in meaningful dialogues, shared personal information, and appeared to find purpose in the discussion given that many participants referred family and/or friends. We had a diverse group of individuals working on the design and analysis component of the study, bringing community, clinical, and public health knowledge. The use of participatory analysis, the community advisory board, and iterative processes (e.g., reviewing data with multiple individuals as interpretation transpired), allowed for greater trustworthiness of the data. By having multiple perspectives, we can view the impact of FGC on sexuality as complex and varying across people. The bulk of literature on FGC focuses on problems associated with FGC, with the exception of manuscripts describing surgical interventions (e.g., Bazzoun et al., 2021 ; Berg, Taraldsen, Said, Sørbye, & Vangen, 2018); both very important and necessary topics. However, focusing predominantly on these topics leaves little guidance for the millions of women who have already experienced FGC and the healthcare providers who interact with them beyond surgery. We have highlighted resilience factors, in particular the agency of women to find their own sexual pleasure, relational skills of communicative and compassionate partners, and engagement in medical and pharmaceutical interventions. Through intensive semi-structured, face-to-face interviews with 60 Somali women living in a metropolitan area with the largest Somali population in the U.S.A, we explored how circumcised Somali women experienced, discussed, and handled sexual pleasure and pain. We found that it was common for women with FGC to experience high levels of pain early in their sexual relationships, improvements in sexual pain over time, and development of coping skills to manage the pain --- often in partnership with their husband and with the help of healthcare professionals or pharmacists. We found evidence of avoidance and endurance, and of positive coping strategies --- communication, social support, and medical intervention. Many still care about, want to, and remain attuned to the importance and the right to sexual pleasure and healthy sexual relationships. Women’s articulations are filled with narratives of enjoying and looking forward to the pleasure of sexual intercourse, refusing to accept pain, demanding to be listened to, and of even seeking divorce when partners refuse to heed their requests for sexual pleasure and/or assistance in managing sexual pain. Our findings depict agentic women --- who seek sexual pleasure, information, and knowledge from their partner, friends, family, internet, and healthcare providers.

There has been an ongoing human and sexual rights campaign globally to end the practice of female genital cutting due to the impact on sexual and physical health for women impacted by it ( Obiora et al., 2020 ; UNICEF, 2020 ). Female genital cutting (FGC), also called female circumcision and female genital mutilation, encompasses “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons” ( WHO, 1997 ). The focus on eradication efforts is certainly necessary, but less effort has focused on how to meet the sexual health needs of women who have already been through the procedure --- leaving little medical and psychological guidance for this large number of women to address coping with the aftermath. Despite efforts to eradicate FGC, UNICEF estimates that worldwide, at least 200 million women and girls alive today have been subjected to the practice, with estimates of Somali women as high as 99% ( UNICEF, 2023 ). Thus, there is a significant and urgent need to address the sexual health of Somali women. Somali women’s daily interactions with healthcare systems require those systems to be prepared to adequately address all health needs of Somali women and other refugee populations. To provide competent care to Somali women, providers need to understand various health outcomes of FGC, including compromised sexual health. The purpose of this qualitative study was to develop a better understanding of how circumcised Somali women living in the U.S. experience and talk about sexual pleasure and pain, and cope with sexual pain. Our aim is to understand the nuances of sexuality in the context of FGC through elevating the voices of affected women. The term “female genital mutilation” (FGM) has been important to galvanize support in the worldwide movement to eradicate the practice, it is worth noting that this term has criticized for being judgmental and alienating ( ACOG, 2007 ; von Rège & Campion, 2017 ). Critics argue that use of FGM terminology promotes cultural imperialism by targeting forms of female genital procedures found predominantly in Africa, the Middle East, and Southeast Asia, while remaining silent on non-criminalized genital surgeries more common in North America and Europe, such as labiaplasty or piercing ( Abdi, 2018 ; Earp & Johnsdotter, 2021 ). Moreover, attempts to eradicate FGC might be hindered if those societies where the practice is most prevalent resist the reform of FGC because of their perception of outsider influence, programs, and funding. As such, we use the term female genital cutting (FGC) or female circumcision . We agree with arguments that posit that the term “ circumcision ” is misleading given the extent of female anatomy often altered by FGC, as well as the harmful effects of FGC on girls’ and women’s health ( Andro et al., 2016 ). However, at times, we use terminology that is commonly used by the Minnesota Somali community as discussed in our Community Advisory Board meetings, including “circumcision,” “excision,” and “cutting,” so that our work does not alienate the Somali community from the knowledge gained through this project. Our use of these terms does not deny the harmful health impact of this practice on girls and women worldwide, nor suggest that non-criminalized genital surgeries on adults are equivalent to medically unnecessary (and often extensive) cutting of girls’ genitals. The Federal Republic of Somalia, also known as Somalia, is located in Eastern Africa. About 2.5 million Somalis are currently displaced within Somalia, and hundreds of thousands of people have fled Somalia because of political instability, drought, floods, famine, and the emergence of terror groups that further instability ( Hammond, 2014 ; Yuen et al., 2022 ). Somalis have migrated to all continents, establishing Somali diasporic communities across the globe, with the highest population numbers in neighboring countries, the United States, and the United Kingdom ( Hammond, 2014 ). The largest Somali community living in the U.S. (82,890) is in the Minneapolis-St. Paul metropolitan area --- the site of this study. ( Minnesota Compass, 2022 ).A large portion of the Somali community in Minnesota dates to the early 1990s, when the U.S. government offered resettlement programs to vulnerable families living in refugee camps ( Abdi, 2015 ; Yusuf, 2012 ). The Somali community is now part and parcel of all Minnesota institutions, including its healthcare centers. FGC continues to occur in countries throughout Africa (28 countries), parts of the Middle East, Southeast Asia, and countries where there are immigrants from these regions ( UNICEF, 2013 ). The precise historical and geographic origins of FGC are lost in history, but it is generally believed that it is an ancient practice, predating current monotheistic religions, such as Islam and Christianity ( Andro et al., 2016 ). FGC is often performed by a traditional practitioner, a local woman who holds this role in her community, when a girl is between ages 4 and 10 years of age; less commonly, a health care provider may perform the FGC in a setting such as a hospital ( Andro et al., 2016 ; Kelly & Hillard, 2005 ). The World Health Organization (2008 , 2016 ) categorizes FGC into four types: Type 1 (Clitoridectomy) - Partial or total removal of the clitoris (glans) or the clitoral hood (prepuce) or both; Type 2 (Excision) - Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora; Type 3 (Infibulation) - Narrowing of the vaginal opening/introitus through the creation of a covering seal by cutting and positioning the labia minora or the labia majora or both over the opening --- with or without excision of the clitoris; Type 4 (Other) - All other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing, etc.. Since 1990, at least 288 clinical surveys of varying quality have examined the medical consequences of FGC ( Sarayloo et al., 2019 ). Not surprisingly, there are numerous physical health risks associated with FGC, often exacerbated or ameliorated by the conditions under which FGC takes place (age, person who performed the procedure, health care setting or not) and the type of FGC. Established long-term health risks include urinary symptoms/infections; mycoses/fungal infections; post-partum risks, such as tearing and deep tears (e.g., Andro et al., 2014 ; Berg et al., 2014 ; Ndiaye et al., 2010 ; Wuest et al., 2009). There are fewer studies on the socio-emotional consequences of FGC; one recent review found 23 articles addressing these consequences ( O’Neill and Pallito, 2021 ). Research within countries with high and low FGC prevalence have demonstrated a negative impact on sexual health, and consequently, marital relationships; additional consequences for those living in the diaspora include stigma, potential conflict with elder relatives, and inadequate and discriminatory healthcare experiences ( O’Neill and Palitto, 2021 ). There is evidence that FGC is related to an increase in mental health symptoms, such as PTSD symptoms and anxiety, in particular for those with Type 3 and those who recall the cutting ( Abdall and Galea, 2019 ; Vloeberghs et al., 2012 ). As noted, FGC Types 1, 2, and 3 involve removal of clitoral tissue. Knowledge of the clitoris goes back “to Greek, Persian, and Arabic writers on medicine and surgery;” clitoral functions and anatomy are discussed by several European scientists in the 1400’s, 1500’s, and 1800’s (Stringer & Becker, 2011, p. 132) as this 1559 quote by Realdo Colombo from De re anatomica (Professor of Anatomy at the Sapienza Papal University in Rome, Italy) illustrates, ...it is the principal seat of women’s enjoyment in intercourse; so that if you not only rub it with your penis, but even touch it with your little finger, the pleasure causes their seed to flow forth in all directions, swifter than the wind…it should be called the love or sweetness of Venus (Stringer & Becker, 2011, p. 131). Cultures practicing FGC also recognize the importance of the clitoris, with the prevalent belief that the clitoris is the seat of a woman’s sexual desire --- and some believing that without circumcision, a woman’s sexual desire would be beyond their husband’s capacity to meet it ( Fahmy et al., 2010 ). Thus, it is not surprising that studies have found a detrimental impact of FGC on sexual health ( Berg & Denison, 2012 ). Mohammed et al. (2022) collected sexual function data from 255 women seeking medical care in Somalia. To our knowledge, this is the only study that has been done with women residing in Somalia in the past 30 years. They found that 89% of participants had scores indicating sexual dysfunction, as measured by the Female Sexual Function Index (FSFI), and women with Type 3 had higher rates of sexual dysfunction on all subscales (desire, arousal, lubrication, orgasm, satisfaction, and pain). Review articles examining sexual dysfunction and FGC across various ethnic populations and host countries have found that FGC is associated with lower sexual satisfaction, desire, and possibly orgasm rates, though there is high heterogeneity in effect sizes across studies ( Johnsdotter, 2018 ; Nzinga et al., 2021 ; Perez-Lopez et al., 2020 ). Johnsdotter (2018) cautions that sexual dysfunction is not a foregone conclusion for all women who have experienced FGC and notes that the conceptualization of sexual dysfunction in most quantitative measures comes from a North American or European perspective (e.g., criteria for DSM-5 sexual dysfunctions were predominantly established in North America and Europe). Mazloomdoost and Pauls (2015) also conclude that though many women are negatively impacted due to removal of clitoral tissue and possible nerve damage, it’s possible that some women can achieve sexual pleasure through the remaining clitoral tissue. Therefore, sex therapy should be offered to impacted women to explore the possibility of improved sexual functioning. Increased risk of sexual pain after FGC is a consistent research finding in most studies. In their meta-analysis of the impact of FGC on sexual function, Berg and Denison (2012) examined findings across 15 studies, predominantly done in central African populations with Type 1 and Type 2;, they reported that the relative risk of sexual pain increased by 1.5 for those who had experienced FGC over those who had not. Berg and Denison (2012) concluded that further research was needed in women who experienced Type 3. Since Berg and Denison’s meta-analysis, studies conducted in North Africa, East Africa, and the Middle East report higher rates of sexual pain, as reported by women with FGC Type 1, 2, and 3 than women without FGC ( Daneshkhah et al., 2017 ; Ismail et al., 2017 ; Mohammed et al., 2022 ; Yassin et al., 2018 ). Women with Type 3 are more likely to report sexual pain than women with Type 1 and 2 in studies using multiple methods and across geographical locations. For example, higher levels of pain in women who have been infibulated than those with other FGC types have been reported in cross-sectional survey studies of East African women living in their home country and abroad ( Mohammed et al., 2022 ; Rouzi et al., 2017 ; Yassin et al., 2018 ), a chart review study of predominantly East African women in Switzerland ( Bazzoun et al., 2021 ), and a qualitative study of Somali women in the Midwestern U.S. ( Connor et al., 2016 ). Possible reasons for increased pain include rigid scar tissue, tearing, hypertonicity in pelvic floor, and recurrent infections ( Bazzoun et al., 2021 ; Berg & Denison, 2012 ; Einstein et al., 2008 ). For women who have been infibulated, opening the tissue at the introitus to create a larger space for penetration, referred to in this manuscript as deinfibulation, is one common surgery that typically decreases sexual pain ( Catania et al., 2007 ; Nour et al., 2006 ). However, some Somali women who were deinfibulated continue to report chronic sexual pain ( Johansen, 2002 ). Some studies report no differences in pain between circumcised women versus uncircumcised women (e.g., Anis et al., 2012 ; Kheir, 2017 ; Raheem et al., 2018 ). These studies included participants who predominantly experienced Type 1 FGC ( Anis et al., 2012 ; Raheem et al., 2018 ), rather than Types 2 and 3. Social norms may also affect the reporting of pain; for example, Kheir (2017) noted a strong cultural norm against expressing pain in the Sudanese culture and hypothesized that participants chose not to report pain they had experienced. Qualitative research provides further understanding of how sexual pain is experienced in women who have experienced FGC ( Finnström & Söderhamn, 2006 ). For example, in qualitative interviews, Somali women have noted that being stoic in the face of pain is an important social norm ( Finnström & Söderhamn, 2006 ; Jacobson et al., 2018 ; Johansen, 2002 ). Johansen (2002) asserts, in her qualitative study of Somali women living in Norway, that the experience of pain is context specific. Some may experience pain as normal before migrating, but ascribe a different meaning after migration to a different culture. Various conceptual frameworks have examined how individuals cope with pain, including the fear avoidance model ( Vlaeyen & Linton, 2000 ), endurance models ( Hasenbring & Verbunt, 2010 ), and resilience models ( Sturgeon & Zautra, 2010 ). These models have been used in research with various types of pain, such as back or headaches. The focus of the fear-avoidance model is on how negative affect contributes to one’s interpretation of pain and resulting behaviors. For example, pain can be viewed as catastrophic. This interpretation may cause hypervigilance and avoidance of using the affected body part, reducing opportunities for healing ( Vlaeyen & Linton, 2000 ). In the endurance model, an individual’s cognitive processes, such as ignoring and/or minimizing pain signals, leads to enduring pain without modifying behaviors. Endurance of pain may cause other further negative outcomes, such as damage to tissues ( Hasenbring & Verbunt, 2010 ). In both models, maladaptive processes are hypothesized to lead to poorer outcomes, however, neither identifies protective or resilience factors. The resilience model ( Sturgeon & Zautra, 2010 ), articulates potential factors that can buffer the negative impact of pain, such as positive social support and utilization of coping skills. Researchers have applied fear avoidance and endurance models to sexual pain due to vulvodynia and established that components of each model can be applied to painful sex (e.g., Eckdahl et al., 2018 ; Myrtveit-Stensrud et al., 2023 ; Thomtén & Linton, 2013 ). For example, in a longitudinal study, catastrophizing and fear-avoidance beliefs were associated with increased pain ( Eckdahl et al., 2018 ). In qualitative work, Myrtveit-Stensrud et al., 2023 found evidence of women with vulvodynia that were stuck in a cycle of fear and avoidance, as well as women who endured painful sex – often upon the advice of their social network and/or healthcare professionals. A resilience perspective is missing in the sexual pain research literature. We argued in our previous theoretical work that both resilience and risk factors should be considered when examining sexual pain --- especially in marginalized populations who have experienced a momentous event such as FGC ( Connor et al., 2021a , Connor et al., 2021b ). There are several gaps in the existing literature that we aimed to address. We added a resilience lens, including coping strategies, experiences of pleasure, and cultural norms. Given the heterogeneity in findings across quantitative studies, we also aimed to further understand how our sample of Somali women experienced sexuality and FGC by using qualitative interviews.