Transcript Disclosure: dynamics, dilemmas

Lih-Mei Liao, PhD FBPsS
Consultant Clinical Psychologist & Honorary Senior Lecturer
UCL Institute for Women’s Health, London UK
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To suggest ways for delivering psychological expertise
collaboratively in relation to FGM in the UK
Can be associated with none or all of these:
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Physical – urinary problems, menstrual problems,
infertility…, with impact on overall quality of life
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Emotional - shame, fear, mistrust, low mood…
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Sexual - diminished enjoyment, pain, lack of interest…
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Social – compromised intimate relationships, withdrawal
from social relationships…
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Few citable published studies
Personal testimonies and case studies:
◦ Retrospective (subject to recall bias/demand characteristics)
◦ Uncertainty about representativeness
Confounding factors - women who have undergone FGM may
have been subjected to other stressors (e.g. social dislocation,
poverty) that could lead to adverse psychological outcome
Time lag between any psychological problems and FGM defies
simplistic linkage
PHYSICALe.g. pain,
incontinence
infertility
SEXUALe.g. painful
intercourse, poor
relationships,
poor body image
EMOTIONALe.g. shame, anxiety,
guilt, anger,
mistrust, low mood
SOCIALe.g. avoidance,
isolation
long term constellation of consequences
mitigating factors
Immediate consequences
mitigating factors
Procedural factors: type, extent, practitioner, conditions
Family
factors
Community factors
(history, economics,
living conditions, etc.)
Psychological well being
PSYCHOSEXUAL
THERAPY
Damage limitation
PSYCHOLOGICAL
THERAPY
PSYCHIATRIC
MANAGEMENT
RECOGNIZING
NORMALIZTNG
EDUCATING
physical
ill
health
social
isolation
SIGNPOSTING
sexual
difficulties
emotional
distress
Type of help
Client(s)
Length of
treatment
Focus
Characteristic processes
Counselling
Usually 1:1
Unspecifie
d; variable
Nondirective
Active listening
Psychoanalytic
(psychodyna
mic)
therapies
Usually 1:1;
but also
couples and
groups
Typically
long term
Nondirective
Problemfocused
Development of insight
through interpretation of
feelings transferred from
earlier attachments to
therapist
Cognitive
and
behavioural
therapies
1:1 and
groups
Typically
shortterm
Directive
Problemfocused
Strengthfocused
Goal-planning
Skills building
Agreed tasks between
sessions
Systemic
(family)
therapies
Couples and
families; but
also
individuals
Typically
short-term
Directive
Problemfocused
Strengthfocused
Communications between
family members
Agreed tasks between
sessions
Difficult to rationalise services without clear evidence of
problem prevalence and treatment evidence. Currently
women with psychological problems associated with FGM
may end up accessing the following services:

Community organizations (e.g. FORWARD)
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Primary care services (e.g. GP, well women clinics)
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Sexual health clinics
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Psychological therapy services
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Psychiatry

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Peer support and counselling may not be effective for treating
complex problems and co-morbidities presented by some
women who have undergone FGM
Formal psychological therapy may not be the most
appropriate response
A collaborative, integrated model combining evidence-based
psychological skills and grass root experience that is currently
less recognized, may be more ‘tailored’. For example,
experienced psychologists and therapists could leave their
consulting rooms in favour of:
- providing training, supervision and emotional support for
peer supporters working with communities known to be
affected by FGM
- helping to produce user-friendly self-help resources for
communities
- engaging directly with clients by organizing open days, focus
groups or workshops to offer additional coping strategies
- producing signpost information for women requiring
psychological treatment in addition to the peer support they
are receiving
- helping to disseminate good practices to build evidence base
Raising the standard of care through education and training for
mental and sexual health professionals via:
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Assessment of knowledge and beliefs about FGM in select
professional groups

Identify barriers to professional contributions using sound
research methods
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Target specific problems experienced by health professionals
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Evaluate education and training initiatives
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Disseminate good practices
Build psycho-educational initiatives with FGM stakeholders
using improved research methodology to:
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Assess knowledge and beliefs about FGM in affected
communities in UK using a range of methods
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Target at risk groups
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Evaluate preventive interventions
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Disseminate good practices!
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Psychological contributions are as yet unexploited
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Potential contributions in future to improve ‘citable’ evidence
of the psychological effects of FGM via research

Future contributions to clinical care and prevention initiatives
to maximise effectiveness using evidence-based
psychological methods