Recommendation 6: Women and girls who have undergone FGM and who are experiencing symptoms consistent with anxiety disorders, depression or PTSD disorders, should be offered mental health interventions that are adapted to their needs and consistent with WHO’s mhGAP guideline.

 

Strength of recommendation: Strong (low-certainty evidence) 

- Summary of the evidence -

 The evidence review for this recommendation included any mental health interventions aimed at women and/or girls living with FGM with symptoms consistent with anxiety, depression or PTSD, to assess outcomes including improvements in symptoms, body image and/or quality of life. This is an expansion from the previous guidelines which only included evidence on cognitive behavioural therapy as an intervention for women and girls diagnosed with anxiety, depression or PTSD. No study was identified to inform this recommendation. However, indirect evidence shared by GDG members suggested a positive effect of a multidisciplinary approach to the management of the psychosocial health of women and girls living with FGM. The GDG noted that indirect evidence exists on the benefits of mental health care when delivered as part of multidisciplinary care for women and girls living with FGM. This care should follow the existing WHO mental health recommendations and other guidance on management of anxiety, depression and PTSD, which should take into consideration the individual needs, contextual factors underlying the practice of FGM, and health systems factors in settings where the interventions are implemented. This would include a multidisciplinary approach and the inclusion of a person trained in delivering evidence-based psychological interventions for anxiety, depression and PTSD. This may be a mental health professional or a trained and supervised non-specialist, depending on the context and resources available.

- Rationale -

 The GDG noted that the strength of this recommendation relates to the evidence base on treatment for mental health conditions, as described in WHO’s Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders (94), which would be contextualized to the specific needs of the target population of this guideline – women and girls living with or at risk of FGM. The treatment approach should take into consideration individual factors related to identity, self-esteem and body image, especially when FGM status is discordant with social views of FGM. In addition, the treatment approach should consider health systems factors, including the ability of a therapist to establish rapport and create a sense of security when providing counselling and support, and the availability of and access to other support mechanisms, including family members and/or social services

- Implementation remarks - 

The GDG noted that in most areas where FGM is prevalent, there is a lack of well trained or specialist mental health practitioners, including psychologists and psychiatrists. As a result, any psychological interventions will likely need to be delivered by trained and supervised non-specialist health workers or community health workers, in line with WHO’s mhGAP guideline, which includes recommendations on task shifting for mental health service delivery at the primary care level (94). Non-specialists can be trained to identify, assess and manage care for women and girls living with FGM, performing tasks such as managing prescriptions for pharmacological care, delivering psychological interventions or referring patients to psychological services or specialist care where available

The GDG noted that WHO has existing recommendations on the treatment of each of the observed mental health outcomes of FGM (i.e. anxiety, depression, PTSD) and that regardless of the target population and underlying causes, many of the treatment approaches remain the same, and affected women and girls should be offered a person-centred and holistic treatment approach. It is important to note, however, that individual- and community-level factors need to be considered for women and girls living with FGM, given that they are survivors of childhood trauma that is also considered a form of physical and sexual abuse. Long-term sexual health complications, including sexual dysfunction and pain, can adversely affect psychological health as well. The GDG also highlighted the fact that psychological consequences may not be directly linked to FGM – they could also be a result of stigma and discrimination due to anti-FGM campaign messaging or other risk factors.

- Research gaps -

 There is a significant knowledge gap regarding the effectiveness of therapeutic interventions for the mental health conditions most common in FGM survivors, and how to adapt existing mental health services and psychological interventions culturally and contextually to respond to the specific needs of women and girls living with FGM. Future research should focus on establishing the effectiveness of these interventions among this population.