Secondary analysis of the 30 transcripts from the first study.

The objective for this first step was to systematically screen the 30 transcripts from the first study again, which had initially been inductively analysed to reveal specific turning points in the lives of the participants. In this secondary analysis, we aimed to examine how the emerging categories of emotion regulation and conflict of loyalty resolution were represented in the data. The turning points revealed in the first study constituted a starting list of categories for the secondary analysis of the transcripts. More precisely, we verified that the turning points were indeed associated with experiences and the expression of emotions as well as conflicts of loyalty, as we had hypothesised at the end of our first study. The data were synthesised using a framework analysis approach, a process that involves systematic indexing of responses in line with a given framework [36]. This was based on the dimensions of Gross’ model of emotion regulation [37] on the one hand and on the model of the processes of informing loyalty on the other [38].

The two theories referred to for this framework analysis may be briefly presented as follows:

Emotional regulation. Emotion regulation is a key contributor to social functioning and refers to the processes by which individuals influence what emotions they have when they have them, and how they experience and express them [37]. Such control processes may be conscious or automatic [37, 39] when responding to environmental demands and may take effect at one or more points in the emotion generative process. An umbrella term for the emotional state which is ‘affect’ is viewed by Gross [37], as stress responses, emotions such as anger, sadness, and mood such as feeling, or down. Affect refers to an individual’s life and beliefs that preclude the understanding of social life as a system of rules and norms [40]. Gross [37] develops a process model of emotion regulation which allows for the identification of when regulation may be understood to have occurred. The model has five major points of focus (situation selection, situation modification, attention deployment, appraisal, and response modulation). Emotion regulation is goal oriented. Goal oriented emotion regulation strategies related to bodily expression include emotion suppression, in which people actively try to inhibit their emotional expression [37]. Expressive suppression is defined as the inhibition of emotional expression, such that an outside observer would be unaware of an individual’s internal emotional experience [37]. The suppression does not always lead to the desired changes in emotional experience but can lead to a negative emotional experience instead.

Conflicts of loyalty. Loyalty is a feeling or an attitude of devoted attachment, even where it may not be deserved [38]. Loyalty conflicts occur when a person feels trapped in a disagreement between two people, and they expect the trapped person to support them over the other. The literature describes mainly children’s perceptions of one parent’s pressure to side against the other and the conflict is expressed by the feeling of being trapped, torn, or ‘caught between parents’ [38, 41]. Research on children in foster care presents a model of processes informing loyalty to help to understand the experience of children in foster care and how they negotiate living with a new family while retaining their place in their birth family [38]. The model that emerged from their results encompassed seven theoretical categories. These categories enabled different relationships children have with their parents’ loyalty to be distinguished: new realities; considering position; making sense; relating emotionally; working out loyalties; considering others’ perspectives; and self-determination.

Loyalty conflicts have generally been the focus of attention in the literature on children of divorced parents [41, 42], as well as in foster care literature [38]. It has not been applied to adults much; however, the concept seems essential in our study because the women felt trapped between what the community expects from them and what they want for their daughters.

Original analysis of the books (n = 10). All 10 books were read by the first and second author to identify the turning points in the women’s lives that had prompted them to change their views and attitudes toward the practice of FGM, and other related norms. These were compared to the turning points drawn from our previous study [8]. Then the two theoretical frameworks mentioned above were applied by the first author to systematically screen for expressions of emotions and conflicts of loyalty resolutions with those turning points.

Consultations with experts. In the third stage, after having confirmed that aspects of emotion regulation and conflicts of loyalty resolution were indeed present in the women’s narratives as they reported turning points in their lives, we submitted our results to the different experts included in our study to discuss our emerging theorisation, and to help us refine it, by collaboratively working out the interrelations between the two hypothesised mechanisms of change, i.e. emotion regulation and conflicts of loyalty resolution.

The notes taken during the different discussions were compared and analysed by the first and last authors to further clarify our emerging theorisation, which was also discussed with co-author FR on several occasions and enriched through a review of some published material suggested by the experts. For instance, to understand trauma and its impacts on the body, we read the literature of Van der Kolk [43]; Rothschild [44]; Salmona [45], and Hoschild [46]. To become more familiar with narratives and the capabilities approach, we read the books of Botbol-Baum [47] on ‘Bioethics dans les pays du Sud’ [Bioethics in the southern countries] and Nussbaum [48] on women and human development, the capabilities approach. We iteratively pursued this theorising and integrative process, until we came up with a model with five stages (Emotion suppression, The awakening, The clash, Reappropriation of self, and Reconciliation), which we present hereafter in our results section, to explain the process of the change of attitudes in women with FGM as they move from being full members of their community at the cost of suppressing their emotions and denying their selves to becoming their whole selves while symbolically remaining members of their communities of origin. The results hereafter are presented according to the five stages of our proposed model, and integrate the findings from all three steps of our analysis.

Emotion suppression.

Our results show that women’s emotions were often repressed and suppressed before the turning points. Emotions are socially constructed so culture has an impact on the expression of emotions. Girls are taught to be brave and not to cry during the procedure to prevent disgracing their families.

“Afterwards, we are told: you must remain courageous, never complain, you have passed the first stage, there will be others that will come with pain too, but do not forget that a good woman must always bear the pain, and must suffer.” Interv_2

“… I got used to being in pain; not crying anymore but clenching my teeth…later on, I continued clenching my teeth as I was always told…”

Kanko [49]

Before the occurrence of the turning points, the suppression of emotions was associated with the acceptance and internalisation of the practice of FGM. The women used to comply with the social norm as prescribed by the patriarchy. The patriarchal system determines and prescribes how individuals ought to behave regarding certain feelings (affect) and emotions. The cultural grounding of emotional expression is reflected in the whole procedure when at times, women are instructed to be brave and endure pain and suffering without complaint. This is a norm in the patriarchal system. Even though the women were not allowed to express any emotion, they felt them, and they were affected by them. Some women described their initiation stage as being taught about their gender roles by the older women who are the guardians of the tradition. They were guided by the instructions from the older women to endure pain and suffering as their accepted fate. Fear was what generally drove women to comply with the social norm to avoid being ostracised and isolated from the community and have their daughters unmarried.

“I was constantly in fear and felt the anger, but I did not know where they were coming from. Because something tells you why ‘you’? And during the initiation phase, they talked about your recognition as part of the community, you are going to become a woman, you are going to serve the cakes, you are going to be pure and say good prayers but they will never tell you the intensity of the pain, just to bear it and not talk about it. It’s like you are being plunged into the unknown which is unbearable and that’s the problem.” Expert with lived experience.

The suppression of emotions which results in the inhibition of the emotional expression is one of the response components according to Gross’ model [37]. It represents the last stage of Gross’ model while it is the starting point of our model. Suppressing emotions ensures community membership and the women usually do as they are instructed to respect the elders. Silence is also imposed by the patriarchy and the women are trained socially to bear the pain at important moments of their lives (for instance, first sexual intercourse on the wedding night, as well as at childbirth and not screaming during labour).

“The patriarchy uses violence to assign identity and thus, construction of cultural identity is through the bearing of pain without complaint, so involving suppression of emotions” Expert in Psychology and Traumatic memory.

The awakening.

At the second stage of our model, which we call the awakening, emotions are expressed with the turning points described in the narratives of the women who participated in our previous study, as well as those from the norm leaders whose testimonies we analysed.

“The emotions that were expressed evolved with the process of emancipation and questioning of norms. These were ‘affects’ that were acknowledgement that precedes the change of norms. Turning points may be seen as a normative conversion, allowing the capability to act against one’s s community beliefs, which is also a definition of emancipation. This conversion of self is indeed a turning point for it allows going beyond the conflicting emotions between community and self”. Expert in Philosophy and Bioethics.

At this stage, the emotions are felt and acknowledged. In Gross’ model, the acknowledgement refers to the attention deployment stage, and to the events and emotions it generates. As they recalled the turning points in their lives, most women described sensations in their bodies in the form of pain in the womb and goosebumps. These prompted them to reflect on their own experiences of the procedure of FGM, which in turn awakened their traumatic memories. They described these turning points as events causing them to relive the procedure of FGM, thus experiencing emotions of fear, helplessness, and betrayal.

“[…] then on the skype, my mother-in-law had called me…soon you will be with us, I have prepared everything, and the circumciser is ready to purify the little one like this, she will be clean and everything. Baf! It was like a slap! I felt something in my belly”. Interv_1

“My stomach sank as I recalled the sound of scissors, the horror and the fear that overwhelmed me when I faced the men in white coat…”

Miré [50]

We know from our previous study [8] that there might be different types of events leading to turning points and thus the awakening of emotions. In some narratives, an encounter with a health professional (a gynaecologist or psychologist) was key in provoking the awakening. The role of others when old memories are stirred up and emotions relived and expressed by the women, sometimes for the first time is crucial. Indeed, the women need to experience a sort of ‘safety net’ while their negative emotions are recalled as they reconsider their own experiences of the procedure of FGM.

At that stage, most of the women reported vivid emotions such as anger, fear, despair, and suffering, which they had been used to conceal not only from others but also from themselves. With external help, the traumatic nature of their experience would be acknowledged, thus allowing their emotions to be integrated as part of their experiences and selves, rather than suppressed again.

“The dimension of trauma should be considered here as there is violence against women’s bodily integrity. Also, in their traumatic experience, the women’s sense of identity may have split due to their emotions and stress (traumatic cleavage). Being supported by a professional who is used to dealing with trauma when they relive it, could therefore be considered the starting point to building their new identity and a way to foster it in a personal and subjective way” Expert in Psychology and Identity issues

An expert considered how the acknowledgement and expressions of negative emotions were crucial at that stage to help the women move forward in changing their attitudes towards the practice of FGM as they enabled the up regulation of these negative emotions. Negative emotions are not to be down regulated at this stage but up regulated instead.

“The rising of negative emotions is important for women to acknowledge and accept them, and thus, the up-regulation of these negative emotions will push the women to do something and act” Expert in Emotion Competence

The negative emotions relived by the women interviewed in our study as well as those whose published testimonies were analysed. These emotions were derived from the consequences of FGM and brought a lot of traumas into the women’s lives. For example, trauma made one woman bleed in painful circumstances, even when unrelated to FGM.

“Anything that upset me makes me bleed…I can’t believe I am bleeding again, at hearing about the Brussels’ attack.”

Bowin [51]

The clash.

In the third step of our model, which we refer to as the clash, we looked at how the awakening and up regulation of negative emotions, that were associated with the acknowledgement of trauma led to inner conflicts of loyalty. Women experienced conflicts of loyalty when they wanted to protect their daughters as they did not want them to go through the same experiences. This gave them to have some mixed feelings as they became aware of different norms and values that would define them in different ways, in their own eyes and that of their community of origin. The feeling of being trapped between the two constituted a conflict of loyalty. As they experienced such conflicts of loyalty, the women became further aware of their bodily sensations and emotions such as embarrassment, shock, fear, etc.

“I was constantly in fear and felt the anger, but I did not know where they were coming from[…] your own community has fooled you; you feel bad because you want to be a good woman according to the religious norms of the community”. Expert with Lived Experience

At this stage, the negative emotions are still present. This makes the women try to come out of that state. However, the conflict of loyalty generates in turn new sufferings and negative emotions and needs to be solved to gain peace. According to Dansey et al.’s model informing loyalty [38]. Considering one’s own position is a key stage to moving past this when trapped in a conflict of loyalty. In our study, the women at this stage would consider their positions as mothers and the devoted attachment to both their daughters and their communities would conflict, thus prompting them to work out how to prioritise those loyalties. This was the stage where a need was perceived to weigh up and choose, to emerge from the conflicts they were experiencing. Indeed, choosing to protect their daughters by not perpetuating the practice would isolate and even ostracise them from their communities of origin. The women, therefore, reported experiencing conflicting representations of motherhood: what made them believe they were good mothers in their own eyes and that of the society in their host country by protecting their daughters from the practice of FGM, would make them bad and irresponsible mothers instead in the eyes of their own mothers and their communities of origin. Deciding to protect their daughters, meant the death of their affiliation with their original communities because they were defying the prescribed norms established by the patriarchal system.

“I think of my daughter…but I want to be a good mother in my community also » Interv_15

“…I was convinced that I was born free, not with a pot in one hand and a broom in the other…I couldn’t understand how a hand that caressed you, wiped your tears, reassured you, comforted you, could hurt you…I was confused…but I was committed to my sister and brothers, not to abandon them.”

Barry [52]

Along with conflicts of loyalty, conflict of interest might be experienced, as women may be trapped in the feeling of losing the status that they gained through the procedure of FGM. Moreover, when women oppose a norm, their opposition becomes an element that disturbs and endangers the patriarchal system as a whole.

Re-appropriation of self.

The next step in our model which we named Re-appropriation of self suggests that as they move forward, the women need to actively engage in processes of Re-appropriation of self whereby they accept the need to reconsider their positions and see and value themselves for what they are. This is different then, from what is valued in their communities of origin. This is what Dansey et al. [38] call the recognition of a new position and re-conceptualisation of a sense of value.

Re-appropriation of self is an important stage in the women’s journey. It entails their identity re-appropriation as well as that of their bodies and sexuality. The women explored their responsibility to themselves and sought to re-appropriate their identity and rebuild their self-esteem and self-confidence. Some women became aware of their inner internal agency and were able to identify and express personal qualities such as being curious and stubborn in response to the patriarchal system that sees women as subordinates. Acknowledging such personal characteristics enabled them to preserve their sense of self. One woman reported:

“I’m a bit stubborn, there are things I didn’t accept. For example, I couldn’t stand the veil before the wedding and after the wedding, I wore it in my own way, that’s me.” (Interv_4)

This stage also entails women starting to think by and for themselves to discern their identity as distinct from the one imposed by the community. At this stage, the participants in our study as well as the women who shared their testimonies through published material started to value what they wanted for themselves instead of what the community wanted for and from them. There was an awareness of their internal drive to claim back what they had lost and therefore, their bodies could be reclaimed. The women recognised that some aspects of their future were within their control by wanting to undergo the reconstruction with regards to the lost physical part of themselves (the clitoris) so as to regain their sexuality. The control over their own lives placed more responsibilities on them to make changes to improve their lives. This was a shift from the powerlessness they felt before the turning points and while they were dealing with conflicts of loyalty. As a woman participant reported:

“I had wanted to gain something but rather I lost something instead and that they never told me I felt betrayed. Now, I want it back, I want to do the reconstruction of the clitoris” Interv_3

The issue of responsibility is an important part of the journey at this stage. Accepting responsibility for themselves and making their own decisions for their wellbeing and that of their daughters gave them control over their own lives. The women’s sense of self-worth increased as the positive emotions were released at this stage of resolving the conflict of loyalty.

“The re-appropriation of the body and sexuality implies the responsibility towards oneself and others; responsibility and identity are articulated. This re-appropriation seeks to (re)define and (re)delimit not only identity but also the roles between oneself and others; that is to say the power and the competencies belonging to each, entering into the transaction by allocating responsibilities with their duties with respect to others” Expert in Transcultural Psychology.

In addition to the help or advice received from professionals, those women who had a partner from a different cultural background stated how they had been helped by their partner to understand that sexual intercourse ought not to be painful and that they had a right to be satisfied with their sexual lives. This is an important role played by the others in the women’s change of attitudes.

“The fact that my partner supports me, encourages me, and has offered to help me with the reconstruction, and that he will pay the costs has also given me strength to move forward and I feel valued” Interv_12

The women acknowledged the viewpoints of the professionals and partners but made their own decisions, which signals the phase of Considering others’ perspectives in Dansey et al.’s model as important for influencing individuals’ positions and loyalties. In Gross’ model, this stage refers to the Situation modification which in our study was materialised by actions such as fleeing with their daughters, going forward with clitoris reconstruction or defibulation or writing a book (becoming an activist). They made sense of their situation by realising that they did not have to suffer without saying anything. Women also reckoned that the assistance from the safety net of helping agencies (for example the non-profit organisations and some health professionals such as psychologists), was important in this phase of dealing with their emotions of fear, anger, and the accompanying traumas. This was an empowering experience for the women, as they saw these relationships as contributing a positive contribution to their wellbeing. Some positive emotions were brought up when the women felt supported by significant others.

At this stage of their journey, Self-determination was established by the choice the women made in another context which enabled them to prevent further FGM. The women reported their ability to be assertive and make plans for themselves for the future, for their comfort, and for independent lives. This encouraged them to have positive feelings about themselves and think positively about their future. They also made plans for their relationships with their children, families, and new romantic partners.

“You see, I have plans, a lot of plans for the future, first of all, I tell myself that, I’m going to move to France so that I’ll be close to my parents and then do something else, like going back to school and furthering my education” Interv_4

Reconciliation.

In the last stage of our model, women have managed to not only reappropriate themselves and their bodies but also to reconcile themselves, even if sometimes just symbolically, with their mothers and communities. At this stage, the women expressed being able to identify with their mothers, understood that they could not have acted differently, and ultimately forgave them for what they were once subjected to. They did not apportion any blame to their mothers.

“And when I think that my grandmother certainly underwent this in a more archaic way … I say to myself that we need to understand them…” Interv_9.

At this stage, the empathy the women felt towards their mothers enabled them to overcome their sense of blame towards them. They became able to relate emotionally again to their mothers. Many participants reported their struggle to understand why their mothers had them undergo FGM. But they also thought of the fact that their mothers had gone through the procedure in an even more violent way than they had. Some women reported anger towards their mothers, but later did not want to blame them.

At last, the women at this stage report being able to forgive their mothers for what they have once been subjected to, as they acknowledge their mothers did probably not have a choice to act differently because of the social pressure inherent to the context and time at the moment. By contrast, they see themselves as having a choice, especially in the context of their Western host countries where the practice of FGM is prohibited by law.

Forgiveness towards their mothers led to a symbolic reconciliation with the community. Some women participants depicted a transformation in their perspectives through their acceptance and forgiveness of themselves and their mothers. By forgiving their mother, the women did not condone their mothers’ actions but rather they freed themselves from the anger and the negative feelings that had threatened their wellbeing. As one woman put it: “I love my mother and my people” Interv_13. They understood that forgiving their mothers was part of the process that would enable them to move forward and be part of the community again, even if just symbolically. They let go of anger and blame towards their mothers.

“Letting go allowed me to live my life so that I don’t live other people’s lives. Then, I gradually learned to regain confidence in my parents. I undertook not to judge my mother anymore…But I wouldn’t want her story to be really mine, nor that of my children”

Kanko [49]

“Our mothers, my grandmother, are the bearers of this tradition to please the men but it is ignorance. And when you realise that, your anger fades away, you just know that you can’t be like them…I have to protect my daughter and other little girls who undergo the practice during the school holidays. I am less angry today”

Bah [53]

At this stage, by seeing themselves as different from their mothers yet being able to identify with them and forgive them, the women demonstrate to have developed a Self-determination capacity despite their powerless position and to be able to successfully Work out their conflicting loyalties as Dansey et al.’s model [38] suggests.

“I first began to reconcile myself with the part of my body that was ignored, and then with my community so as not to blame anyone”

Koita [54]