POST-TRAUMATIC STRESS DISORDER AMONG SOMALI GIRLS LIVING IN EASTLEIGH, NAIROBI, WHO HAVE UNDERGONE FEMALE GENITAL CUTTING. Presnters: Maimuna Mohamud Isse, Muthoni Mathai, John Mburu PCAF Regional Psychotrauma Conference: 13 th to 16 th July Venue: Nairobi University of Nairobi ISO 9001: Certified

Objective  The purpose of this presentation is to highlight the problem of Female Genital Cutting among the Somali in Kenya based on a study done for a Post Graduate Diploma in Psychotrauma at the department of Psychiatry University of Nairobi in 2014

Introduction and background  Female genital mutilation/cutting (FGM)/C is defined as comprising 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.  FGM/C is recognized internationally as a violation of the human rights of girls and women and is a violation of the rights of children (Who 2010).  The practice is widespread in Africa.  Associated with severe health and psychosocial consequences

Classification of FGM (WHO, UNICEF, UNFPA, 1997). Type I FGM,

Type II female genital mutilation, (WHO, UNICEF, UNFPA, 1997). Type II FGM,

Type III female genital mutilation (WHO, UNICEF, UNFPA, 1997). Type III FGM,

Prevalence of FGM in the world  An estimated 100 to 140 million girls and women in the world today have undergone some form of female genital mutilation/Cutting.  An est. 2 million girls are at risk from the practice each year.  The great majority of affected women live in sub-Saharan Africa, but the practice is also known in parts of the Middle East and Asia.  As a result of migration the practice has spread to other western countries.

FGM/C in Africa and Middle East Percentage of girls and women aged 15 to 49 who have undergone FGM/C by Country (2013) /

FGM in Africa  Most women who have experienced FGM live in one of the 28 countries in Africa or the Middle East where FGM is practiced.  Recent survey data, available for 18 of these countries, show the prevalence of FGM to range from 5% to 97% of the female population.

FGM in Kenya  The prevalence of FGM in girls and women (aged years) is est. at 27.1%. (KDHS 2008/2009)  There is a wide regional and ethnic difference  nearly universal among Somali at 98% Ethnic groupPrevalence Somali98% Abagusii96% Maasai94% Taita Taveta62% Kalenjin49% Embu43% Meru41% Kikuyu33% Mijikenda/Swahili<5%

PTSD and FGM Research suggests that women who have undergone FGM/C are at an increased risk of developing psychological and emotional health problems In a study in Senegal more than 90% of circumcised subjects described severe pain and feeling of intense fear helplessness, and horror at time of the trauma and more than 80% continued to have flash backs (Stotland 2005).

Review of literature cont…………… Another study found that the severity of psychological problems was related to the severity of mutilation. Women who had undergone Types I and II showed lesser adverse psychological effects compared to those who had undergone Type III, which has been linked with post-traumatic stress disorder (Behrendit and Moritz S.)

Study objectives  Overall objective The study aimed at establishing the psychological impact of FGM among Somali girls in Kenya.  Specific objectives 1. To establish the demographic profile of Somali girls who have undergone FGM. 2. To establish the prevalence of PTSD among Somali girls who have undergone FGM. 3. To explore girls attitudes towards FGM

Study Method  Study Design: A descriptive cross- sectional study  Study Sites: An Educational Centre in Eastleigh. This school is predominantly attended by Somali ethnic students and as such, was purposively selected for this study  Sampling and sample The study sampled all female students at the Educational Centre in Eastleigh from form 1 to 4

Study Population according to the 2009 census the Somali ethnic groups in Kenya are 2,385,572 people University of Nairobi ISO 9001: Certified

Data Collection Instruments  1. Social demographic data instrument. Researcher designed- was used to collect data on age, class, ethnic group, nationality, political status, type of FGM if known and age at which FGM was performed and if girls would choose to have their daughters cut in future  2. The impact of Event Scale-R (IES-R) Is a self administered report scale designed to measure the intensity of trauma- related symptoms on 3 separate dimensions: Hyper-arousal, intrusive thoughts and behavioral avoidance. It yields a total score from the summation of the Hyper-arousal, intrusion and avoidance subscale scores.

Ethical approval and Study limitation  Study proposal was reviewed and approved by ERC KNH/UON  The study was limited in scope and time since. It only looked at one school in Eastleigh and one ethnic group.

Socio Demographic Profile of Somali girls in the study  50.9% (n=172) were Kenyan Somalis  49.1% (n=166) were Somali refugees  Average age was ±3.229 years.  Majority of the girls were in the age bracket 15 to 24 years  Ranging from 15 to34 years

Socio Demographic Profile of Somali girls in the study  50.9% (n=172) were Kenyan Somalis  49.1% (n=166) were Somali refugees  Average age was ±3.229 years.  Majority of the girls were in the age bracket 15 to 24 years  Ranging from 15 to34 years

Distribution by FGC status of the Somali Girls  85.8% (n=429) of the girls sampled had undergone FGM/C/Circumcision.  14.2% (n=71) of the girls had not been undergone FGC.  Every 4 in 5 Somali girls sampled in the study had undergone FGC.

Age at which FGC done  18.9% (n=81) had undergone FGM between 0 and 5 years  68.8% (n=295) 6 – 10 years  11.9% (n=51) 11 – 15 years  0.5% (n=2)

Year of High school study  There was no significant relationship between FGM and current year of study. (p=0.288). Form of study Proportion Circumcised Form 187.6% (78) Form 280.0% (64) Form 386.4% (89) Form 489.0% (130)

Parents level of education The study analysed the Mother and father level of education in association to whether girls had undergone FGC  There was no significant relationship between level of education of fathers and their daughters’ circumcision status. ( p=0.950).  There was no significant relationship between level of education of mothers and their daughters circumcision (p=0.230)

Attitude towards FGM  34.8% (n=168) of the girls said they approved of it- as it was culturally acceptable and a normal occurrence among the Somali community  65.2% (n=315) disapproved as- an archaic and backward cultural practice that denied women of their peace during delivery.

Desire by girls to circumcise their daughters in the future  28% (n=135) girls said they would Circumcise their daughters- of these 92.6% (125) were circumcised and 7.4% (10) were not.  72% ( n=341) girls said they would not circumcise their daughters- of these 83.0% (283) were circumcised and 17.0% (58) were not  Girls who had been cut were significantly more likely to express a desire to cut their daughters in future (p=0.004)

Distribution of PTSD Symptoms  Evaluation based on the scores of IES-r,  21.7% (n=107) of the girls did not show any signs of Post traumatic stress  33.6% (n=166) of the girls exhibited several symptoms of post traumatic stress  44.7% (n=221) had scores above the cut off point for PTSD

Distribution of PTS Symptoms  21.7% (n=107) did not show any signs of Post traumatic stress  33.6% (n=166) exhibited several symptoms of post traumatic stress  44.7% (n=221) had scores above the cut off point for PTSD

PTSD prevalence by Circumcision Status  PTSD prevalence among the girls who had gone through FGM is more than twice the prevalence of PTSD among the uncircumcised Somali girls.  Circumcised girls %, n=209),  Uncircumcised girls – (17.6%, n=12)  PTSD was significantly Associated with FGC- (p=0.001)

Current age and age at “cut” and PTSD Age specific PTSD prevalence among Somali girls Age in YearsPTSD Cases 15 – % (105) 20 – % (98) 25 – % (16) 30 – % (2) PTSD prevalence specific to age at “cut” of Somali Girls Age in years PTSD Cases 0 – % (38) 6 – % (146) 11 – % (24) 16 – % (1) No significant Association between age at “cut” and PTSD No significant Association between current age and PTSD

Discussion  A huge proportion of the population in the study were or still are Somali refugees who lost many years in the anarchy of their country, with an average age higher than the school age in Nairobi

Discussion ct  The prevalence of FGC in the community is high and concordant to the Kenya Demographic and Health Survey 2008/9 (38).  FGC is not associated with a specific age cohort but high across all age cohorts because circumcision in Somali culture is not a rite of passage to womanhood as in other Kenyan ethnic groups.

Discussion Ct  The prevalence of PTSD among girls who had undergone FGC is higher than in the general population but lower than that found by Ndiema among Maasai girls (37).  However Ndiema’s study was done in a rescue home where the girls had recently under gone FGC and had had the added trauma of early forced marriage and dislocation to a rescue home.  The risk of perpetuation of FGC is particularly high among girls who had undergone the cut in this community.

Conclusion  Despite the current legislation banning the practice in Kenya, Somali girls are at high risk of undergoing FGC which is associated with the high prevalence of PTSD, irrespective of the level of education of the parents.

Recommendations  Based on the findings above, the following recommendations are hereby made:-  Somali parents through available channels such as the religious meeting places or Caucasus organized for purposes of community empowerment should be educated on the effects, both physical and psychological, of Female Genital Mutilation especially among young girls.  There is need for Intervention measures to treat the survivors

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