PONE-D-24-11516Exploring support for medicalised female genital mutilation/cutting. A study on migrant women living in Italy (full title)PLOS ONE

Dear Dr. Ortensi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Joyce Jebet Cheptum

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have conducted the research in a rigorous manner. The dat depicted in the findings section supports the final conclusion and recommendations. The findings will definitely add to the knowledge base of the subject area. The authors have good command of English language which makes it easy to read and understand.

Reviewer #2: It would be appropriate to use references that are not more than 5 years to make the study more current. under the Methodology section, please organize it well under Methods and Materials and let there be clarity with the step by step ways that was used to achieve the results. otherwise replicability is not possible. You are trying to analyze an already qualitative study quantitatively and that should come with a step by step clarity.

Please add the qualitative data as a supplementary file or add the link where that can be assessed.

Reviewer #3: A research study was conducted which explores how migrant women from countries where FGM/C is practiced, living in Italy, view the medicalization of FGM/C and the traits of those who endorse this practice. The findings suggest that compared to women who unconditionally support the practice, those who advocate for medicalisation tend to have higher levels of education, be older, be in relationships, and come from countries where FGM/C is more frequently medicalised. Perceived advantages associated with greater endorsement of FGM/C medicalisation include religious sanction, improved marriage opportunities, hygiene considerations, and adherence to traditional cultural norms.

Minor revisions:

1- Table 2: Include the standard deviations that correspond to the means provided in this table.

2- Table 6: Indicate the meaning of the triple asterisks.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-24-11516R1Exploring support for Medicalised Female Genital Mutilation/Cutting. A study on migrant women living in ItalyPLOS ONE

Dear Dr. Ortensi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The revised manuscript has been assessed and the reviewers have provided their comments which are available below. Some additional revisions have been requested including further detail in the methodology and further discussion of the study limitations. Please address all of the outlined concerns in a revised version of the manuscript.

Please submit your revised manuscript by Jan 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Emma Campbell, Ph.D

Staff Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors work is carried out in a rigorous manner. The conclusions and recommendations are well supported by the findings of the study. This work has a great potential to add to the scientific knowledge in this field.

Reviewer #2: Line 99: 'At least to our knowledge' please delete this phrase and use a more appropriate scholarly phrase.

line 121-276: Please, fuse/merge the important points with the Introduction, or better separate it as as a review paper.

Instead of 'We' and 'Our' use this study. For example, line 334 can read 'The dependent variables was considered based on this question':

Please engage an English editor.

Lines 347-373; please put it in a table.

line 506-'Our" knowledge' please delete

311-320: Please attach as a supplementary

Reviewer #3: Minor revisions:

1- Table 2: For data summarized as percentages, add the corresponding sample size.

2- Table 6: Replace the "***" in the table with "<.001" which is less confusing since all p-values are <.001.

3- Several tables: P-values never equal zero. Express small p-values as <.001.

Reviewer #4: I would like to congratulate the authors for directing attention to the voices of small but brave respondents who expressed their support for medicalisation of FGM/C. No doubt this has a lot to offer in further exploration of the under-explored motivations for this support. This study though completed in Italy, is an eye opener for other destination countries for migrants such as Australia, UK and USA to invest in similar revisit of existing data or conduct new research.

It was a pleasure reviewing this revised version of the manuscript.

Best wishes.

Reviewer #5: I would like to congratulate the authors, this is truly fascinating paper based on a unique data set which significantly advances our understanding of attitudes to medicalized FGMC among migrant women in Italy. This paper will certainly be well cited, as it provides unique and important details on attitudes and needs of women who have migrated to Europe from high FGMC contexts, but also provides some insights into how attitudes may change overtime, towards medicalisation.

In can confirm that the authors have already made all the revisions required by reviewers 1 2, and 3, In addition, I would like to offer the authors’ the following comments and suggestions.

1) The authors report that FGMC support maybe under-reported in their data. In the discussion, the implications of mis-reporting for their main findings should be outlined. Specifically, I’m concerned that mis-reporting may not be equal across their sample, and that there could be a tendency for both under-reporting and even over-reporting among different sub-groups. For example, highly educated women may be more likely to mis-report in some way. A previous study that used both indirect and direct methods found that the most highly educated people are more likely to give socially desirable answers, under-reporting their “true” preferences for FGMC in self-reports (Gibson et al 2018). Is indicating that you prefer medicalized FGMC (which as you say sound more hygienic, lower health risk) a more socially desirable answer in the context of a survey undertaken in Italy? Or can we assume that all mis-reporting is equal across the women included in the survey – I’m not sure it can as its quite a diverse sample. The author should add this to the limitation section of the discussion, particularly re: the potential for educated people to give socially desirable responses to questions on FGMC support which has been shown before.

2) Also in the limitations section of the discussion. The authors may wish to explicitly discuss the implications of removing women who indicated they were “unsure” or refused to answer the survey. The sample may also be biased here. They should also indicate in the Measures section exactly how many women were excluded from the analyses.

3) Methods/ Discrete choice framework – further details of the survey and the DCE framework would be useful in the methods section. How were the items selected, and how were they presented to respondents? A real benefit of the DCE in measuring preferences, is that when designed well it can it mitigates against strategic biases.

4) “Regression towards unbiased favour” p23. I think the authors are making reference to the expectation that FGMC changes occur in one direction – from traditional cutting methods to medicalization to full abandonment. This is an interesting point and I wonder if this is theoretical or has actually been empirically tested? A bit more explanation would be helpful here. My understanding from the qualitative/anthropological literature is that FGMC may emerge 'de novo' or re-emerge under the right circumstances, so that we can’t be certain on of a simple pathways to abandonment.

5) Small points:

a. I suggest moving the bullet-point list of explanatory variables on p13 into a table for ease of reading and improved structure.

b. P15, end of first paragraph. There is a mention of model which controls for country of origin, but is not presented as the authors say they use a proxy for a “better fit”. Perhaps in the interests of transparency, this could be added to the Supporting Information.

Ref

Gibson MA, Gurmu E, Cobo B, Rueda MM, Scott IM (2018) Indirect questioning method reveals hidden support for female genital cutting in South Central Ethiopia. PLOS ONE 13(5): e0193985. https://doi.org/10.1371/journal.pone.0193985

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Jane W. Kabo

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Associate Professor Olayide Ogunsiji

Reviewer #5: Yes:  Mhairi Gibson

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

<div>PONE-D-24-11516R2Exploring support for medicalized female genital mutilation/cutting. A study on migrant women living in ItalyPLOS ONE

Dear Dr. Ortensi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 26 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Achenef Asmamaw Muche, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #5: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: No

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #5: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Minor revisions:

1- Table 2: For data summarized as percentages, add the corresponding sample size.

2- Table 6: Replace the "***" in the table with "<.001" which is less confusing since all

p-values are <.001.

3- Several tables: P-values never equal zero. Express small p-values as <.001.

Reviewer #5: Thank you for addressing the questions and comments constructively. It is a very interesting and worthwhile analyses. In general the manuscript reads well, however I note that some of the additional/clarifying text which has been added to R2 version needs some simple editing/rephrasing to improve clarity.

Line 505 - if I understand correctly, "unbiased support for FGMC" should be "unconditional support for FGMC"?

Line 507 - needs an extra clause or sentence to explain your argument. You express it clearly and concisely in your response to reviewers document - that it is your expectation that the most likely scenario is that women declare they are against the practice or similar. The text inserted in the manuscript and that pasted into the response to reviewer document are slightly different, so it might be worth checking this section carefully.

Line 521 - the statement "while the second group needs to be addressed, considering medicalization an an evolved form of FGMC" is unclear.

Line 522-3, ditto. Maybe replace "which may instead be fuelled by" with "in"

Line 525. "one does not expect a regression to an unbiased favour" needs rewording to improve clarity. I expect unbiased favour could be replaced with unconditional support. I would avoid first person terms like "one", and also the term "regression" for different reasons.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: No

Reviewer #5: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

<p>Exploring support for medicalized female genital mutilation/cutting. A study on migrant women living in Italy

PONE-D-24-11516R3

Dear Dr. Ortensi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Achenef Asmamaw Muche, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: