Psycho Sexual Health
Overview of therapeutic services
Holistic care: an overview of current solutions
WHO (2018) and therapists working with FGM survivors (GAMS Belgium, 2020; Coho C. et al., 2016) agree on the need to adopt a holistic approach addressing both mental and physical health, psychological, physical, sexual and social considerations. Care must nevertheless be individualised, adapted to each woman whose life history, protection mechanisms and resilience are unique (Coho C. et al., 2016) and be sensitive to both the culture of the woman and her priorities with regard to psychiatry so to best work in pairs with them (GAMS Belgium, 2020; Coho C. et al., 2016).
The therapeutic accompaniment of women living with FGM aims to “support the process of identity reconstruction and enable the person who consults to regain possession and awareness of their experience, their feelings, their resources and their autonomy” (GAMS Belgium, 2020), to help them to (re)build and regain a positive image of themselves and their social relationships.
In this context, the relationship developed between the therapist and the woman is central and determining in a successful support and in “the shaping of the resources that the individual develops in order to manage emotional and psychological stress” (Coho C., et al., p.28). In a practical guide (Coho C., et al.), four English therapists agree with this, pointing out the importance of “attachment theory” applicable to the patient-therapist relationship. The therapist is seen as a trustworthy person , a support for the woman concerned, enabling her to feel safe, listened to and thus more able to talk. In this sense, a kind, warm welcome from the woman and a non-judgemental approach is essential in order to build an alliance with the woman and to begin a progressive work respecting her rhythm and needs. “Therapeutic work develops on the basis of the bond that is woven between therapist and consultant” (GAMS Belgium, 2020, p.92).
Various therapeutic approaches, both individual and collective, can be envisaged in order to meet the needs of the woman and to accompany her in her work both in terms of her state of mind, her body and her relationships with others. They all have the same objectives, namely to develop mechanisms for regulating emotions and protection, to confront traumatic memory, to restructure key meanings, to change the memory process, to improve knowledge of her anatomy, her body and the health consequences of FGM (WHO, 2018; Coho C. et al., 2019). They are by no means mutually exclusive but, on the contrary, complementary and allow work to be carried out from the individual to the collective and vice versa.
The three-step approach developed by Judith Herman to follow trauma survivors can be applied to therapies for women living with FGM (Coho C. et al., 2020, p.30). It involves phases of :
- Stabilisation: creating a safe, secure and safe space by providing practical help to the consultant and accompanying her in internal stabilisation to enable her to talk and unveil her emotions;
- Trauma treatment and bereavement: supporting the processing of traumatic memories;
- Reconnection: helping the consultant to reconnect with others and herself.
Some examples of existing psycho-sexual care services
The psycho-body approach aims to treat physical and psychological trauma by reconciling and reuniting body and psyche. It “invites the person to become more aware of his or her bodily feelings” (GAMS Belgium, 2020, p.96), i.e. to get to know himself or herself, to listen and to trust his or her body. It is particularly appropriate for women who are victims of gender-based violence and helps to counter the obstacles linked to the lack of determination of the trauma experienced by physical and behavioural exercises.
A brief therapy complements other approaches and focuses on raising awareness of the positive resources available to women by setting small, concrete goals and exercises for managing and coping with stress. It “allows women to feel that they are regaining control of their lives despite a still difficult reality context” (GAMS Belgium, 2020, p.99) and to reinforce their optimism.
EMDR (Eye Movement Desensitisation and Reprocessing) works directly on the storage of the event in the traumatic memory and seeks to reprogram and move it into the memory of the autobiographical past where the reminiscences of the event are accompanied by a lesser emotional charge. In order to do this, the therapist uses sensory stimulation when the traumatic event resurfaces and repeats it until the associated emotions are attenuated or even neutralised.
Art therapy (creativity) makes it possible to facilitate the communication and expression of the consulting woman by using symbols and figures rather than language which is sometimes insufficient or difficult to use.
Psychosexual therapy may be appropriate to help the woman reconnect with and re-appropriate her sexuality as a source of pleasure, to improve her self-esteem, her body and her genitals. It is particularly indicated to accompany (before and/or after) reconstructive surgery operations.
The Body Expression Workshop is one of the possible collective approaches to work on body awareness, i.e. the “subjective awareness of body sensations coming from stimuli from inside and outside the body” (GAMS Belgium, 2020, p.113), in particular through dance. It allows both to re-appropriate one’s body and to interact with others.
The discussion groups allow women to confront and share their experiences, to break with social isolation in which they often find themselves, to learn again how to trust others. They can also be particularly appropriate in contexts where the subject of FGM and its contexts areaboo, in order to free individual speech through the empowerment effect of the group.
Reconstructive surgery can be adapted for certain women in the continuity of their psycho-sexual accompaniment. It can be part of a process of identity (re)construction, a way of (re)appropriating and reconnecting with one’s femininity. It can also act as a symbolic and voluntary restitution of what was removed without consent in childhood and as a means of repairing the visible stigma that may reflect the trauma suffered. The physical, aesthetic and symbolic recovery thus allowed can also work to improve sexual and intimate life (Sharif M., 2020; GAMS Belgium, 2020).
With the increase in requests for clitoral reconstruction, the question of why was quickly raised. The importance of stigmatising and victimising discourse on the sexuality of circumcised women and the desire to conform to social standards surrounding the female genitalia was highlighted (Johnsdotter S., 2019). Recourse to the operation is not a solution in itself and is not suitable for all women, as a growing body of research shows (Johnsdotter S., 2019; Mohamed S. et al., 2018; Nawal M. et al., 2019). Sometimes psycho-sexual therapy is sufficient to meet women’s needs without surgery, underscoring the need not to underestimate the importance of holistic and multidisciplinary approaches in caring for women living with FGM.
The role of prevention
The best way to effectively prevent the psychological consequences of FGM is to fight against its practice. To do this, warning about the potential psychological consequences (as well as physical and sexual) of FGM can help to raise awareness of the issue and advocate for its abandonment by highlighting its harmful effects on the health of the women concerned. The International Centre for Research on Women (Sankoh O., et al, 2019) thus believes it is important to combat FGM as a social norm, to address the gender norms that motivate it and the stigma attached to the non-excision of girls. It stresses the importance of understanding the impact of gender norms on the mental health of girls as well as obstacles to their well-being and then addressing these by improving the factors that can protect them and enhance their well-being.
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