Sex is one of the basic drives. Impairment of this drive can lead to a profound effect on the persons’ quality of life and other aspects of functioning 1. Masters and Johnson have found that sexual dysfunction occurs in 50% of all marriages. Genophobia is the fear of sexual intercourse 2. People with this fear may be frightened of any sexual behavior, or only of intercourse itself 3. People develop genophobia for several reasons. Like all phobias, the main cause is former incidents of severe trauma, especially sexual assaults or abuse. These incidents violate the victim’s trust and take away her sense of right to self-determination 4. Another possible cause of genophobia is the cultural upbringing and religious teachings that increase the feeling of intense shame and guilt about sex. Others may have the fear due to lack of confidence in their self-image or their body image and medical illness 4.
In a meta-analysis study by Chen and colleagues, it was found that there was a statistically significant association between sexual abuse and suicide, depressive disorders, anxiety disorders, post-traumatic stress disorder, eating disorders, and sleep disorders. These associations continued irrespective of the age at which abuse occurred. No link was found between sexual abuse and schizophrenia, somatoform disorders, or bipolar disorder 5. Sobański et al.6 found that traumatic events and circumstances relating to sexuality increase the risk for development of many dysfunctions later in sexual life or relationship.
According to UNICEF Global Databases, an estimated 100–140 million girls and women have undergone female genital mutation (FGM); Egypt has one of the highest prevalence (91%) 7,8. In other studies, the prevalence of the problem in Egypt vary according to different governorates from 17% (Delta and North coast governorates) to 91% (in the southern Upper Egypt cities) 9,10. In Egypt, circumcision of women or FGM is a cruel procedure, a cultural tradition. FGM is performed to minimize sexual desire and to preserve virginity 11. Baasher reported that this surgical interference constitutes a serious threat to the child, causing a major physical and psychological trauma 12. It deprives women of sexual pleasure and precipitates many psychological problems 12. Circumcision is nowadays considered illegal; in addition, both Fatwas and Church in Egypt announced opposition to FGM, but this is not enough to eliminate it 13. We still need more effort to change these cultural beliefs 1,14. Although it is a very important area in our culture, until now there is are very limited studies discussing this topic 1.
The hypothesis of this study was that female circumcision is a childhood sexual abuse that could play an important role in genophobia later on in life. The aim of this study was to assess the association between female circumcision and genophobia.
Study locality and duration
This study was carried out in the Outpatient Gynecology Department, Mansoura University, during the period from 1 April 2013 to 31 March 2014.
This was a cross-sectional comparative study that was conducted for a duration of 1 year.
All patients who came to Mansoura University Hospital, Gynecology Department, outpatient clinic, for the treatment of genophobia (166 patients) were examined by a gynecologist to exclude any organic cause of pain that could precipitate in genophobia. Sixty-five patients were excluded because of the presence of organic causes. After exclusion of patients with organic causes, the remaining patients were referred to a psychiatrist. Three patients refused to participate in this study and so they were excluded from this study. All patients were interviewed using the Mini-International Neuropsychiatric Interview version 5. The scale had been previously translated and validated into Arabic 15. All patients were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) criteria for specific phobia (genophobia) 3.
A specially designed sheet was used to collect the needed information. It included age, education, residence, socioeconomic standard, religious background, sex information, and patients’ feeling or reaction toward circumcision.
Patients were classified into social classes I, II, III, or IV according to an Egyptian Classification 16. IQ was assessed using the Wechsler Adult Intelligence Scale-Revised 17. Anxiety was assessed using the Arabic version Hamilton Anxiety Scale 18,19. Depression was assessed using the Arabic Form of Hamilton Depression Scales 20. Self-esteem was assessed using the Arabic translation of Rosenberg Self-Esteem Scale 21,22 and the Arabic version of the Female Sexual Function Index 23,24.
The exclusion criteria of this study included associated mental retardation (IQ below 70 using the Arabic version of Wechsler Adult Intelligence Scale-Revised) and any gynecological illness that could cause pain, dysparonia, and vaginsmus. Common organic problems associated with loss of desire include chronic illness, thyroid disorders, congenital disfigurement, and pituitary disorders. Clinically, language or hearing disability made it difficult to understand the patients or to complete the instrument used in this study.
This study was approved by the Mansoura Faculty of Medicine, ethics committee, and then it was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Written informed consent was obtained from all participants before inclusion in the study.
Parametric data were summarized as means and SDs. Nonparametric data were described as frequencies and percentages. The χ2-test and t-test were used to measure associations found in different nonparametric data and parametric data, respectively. The results were computed using the SPSS, version 20 program (Statistical Package for the Social Science; SPSS Inc., Chicago, Illinois, USA).
Table 1 demonstrates that, although there was no statistically significant difference in the age between circumcised and noncircumcised women, lower level of education and lower socioeconomic standard were found in circumcised women than in noncircumcised women. Being a resident of rural area was more prevalent in circumcised women than in noncircumcised women. No information, or insufficient or wrong premarital sexual information was more prevalent among circumcised than among uncircumcised women. In addition, complicated bad reaction to circumcision was found to be more than average in circumcised women with genophobia.
Anxiety and depression scores were statistically significantly higher in circumcised than in noncircumcised women. In addition, all sexual functions (libido, lubrication, orgasm, satisfaction, and pain) were better in noncircumcised than in circumcised women (Table 2). Lower self-esteem, moderate anxiety, severe anxiety, and all degrees of depression were much prevalent in circumcised than in noncircumcised women (Table 3). Twenty-seven patients were found to fulfill DSM-IV-TR criteria for major depressive disorder and 11 patients fulfill Panic attack criteria. Other phobias were found in 19 patients, generalized anxiety disorder was found in three patients, and obsessive compulsive disorder in five patients (noncircumcised patients). No patient was diagnosed as having bipolar disorder, schizophrenia, or substance abuse.
The results of the present study demonstrated that genophobia was more prevalent among circumcised women (65.3%) than among noncircumcised women (34.7%). In addition, complicated bad reaction to circumcision was found to be more than average reaction in circumcised women with genophobia. This could be related to the fact that phobia usually developed after exposure to trauma that will link between the stimulus and response. Researchers reported that prior sexual trauma is a major cause of genophobia 2,25.
The woman then conditioned intercourse with a painful memory that a woman is trying to forget. In Egypt, there is a culture belief that circumcision should be performed just before puberty. In this age, the girl is very anxious about her body, especially her sex organs, and so circumcision could cause a major trauma. Moreover, the girl becomes confused because of a mixed message on being beautiful and sexy, and instructions from their parents and false understanding of religious rules. These instructions insist that a young girl’s genitalia is the most precious part of her body that she should protect and prevent anyone from seeing or touching it. In many cases, the patient herself learns to avoid seeing or touching it. Therefore, when this girl is asked to undergo circumcision she becomes very anxious, irritable, and many times she develops panic attack. This bad experience can create feelings of disregard, avoidance, or even repugnance for any sexual behavior and could play an important role in the development of genophobia 26.
The present study found that there was a lower level of education and lower socioeconomic standard in circumcised women than in noncircumcised women. Similar results were found in a Field research on violence against women in Egypt by El Nadim Center for the Management and Rehabilitation of victims of violence 27. Being a resident of rural area was more prevalent in circumcised women than in noncircumcised women. This could be attributed to the fact that this culture is characterized by ignorance and very restrictive wrong religiosity 2 that stresses on sexual guilt and shame 28. Therefore, they commonly perform circumcision aiming to minimize sexual desire and to preserve virginity 1. Moreover, no information, or insufficient or wrong premarital sexual information was more prevalent among circumcised and uncircumcised women compared with good information. This result emphasized the value of providing correct sexual information to all girls before marriage.
Anxiety and depression scores were statistically significantly higher in circumcised than in noncircumcised women. Lower self-esteem was much prevalent among circumcised than among noncircumcised women. In addition, all sexual functions (libido, lubrication, orgasm, satisfaction, and pain) were better in noncircumcised than in circumcised women (Table 2). Previous studies illustrated that, depression 29, anxiety 24,30–32, and diminished self-esteem 26 are most common factors playing a role in the development of genophobia. Baasher 12 reported that the idea that the girl has to undergo surgical operation in this highly sensitive area is considered a serious threat to the child predisposing to anxiety and depression. Moreover, circumcision fixes an idea that her genitals are dirty, dangerous, or a source of irresistible threat and increase a sense of humiliation 1. All these negative ideas could play a vital role in the development low self-esteem, which later affect her sexual function.
Sex is a vital characteristic of the human life, and genophobia can have disturbing influences on those who experience it. Female circumcision increases a woman’s anxiety and depression and decreases her self-esteem. All these factors could play a vital role in the development of genophobia.
Conflicts of interest
There are no conflicts of interest.
1. Abdel-Azim S. Psychosocial and sexual aspects of female circumcision. Afr J Urol 2013; 19:141–142.
2. Masters WH, Johnson VE. Human sexual inadequacy. Boston, MA: Little, Brown; 1970.
3. American Psychiatric Association. Diagnostic and statistic manual of mental disorders, 4th ed.. Washington, DC: American Psychiatric Association Press; 2000.
4. Offir, Carole Wade. Sexual abuse and exploitation human sexuality. New York: Harcourt; 1983. 391–416.
5. Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, et al.. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc 2010; 85:618–629.
6. Sobański JA, Klasa K, Müldner-Nieckowski Ł, Dembińska E, Krzysztof R, Mielimaka M, Smiatek-Mazgaj B. Childhood sexual traumatic events and sexual life and relationship of a patient. Psychiatr Pol 2014; 48:573–597.
7. El-Zanaty Fatma, Way Ann. Demographic and Health Survey: Ministry of Health. Cairo, Egypt; 2008.
8. UNICEF report 2014. Female genital mutilation/cutting: data and trends. Population reference bureau update; 2014. Available at: http://www.prb.org/pdf14/fgm-wallchart2014.pdf
. [Accessed 4 May 2015].
9. Mukherjee A. Female genital mutilation in Egypt (compared to Burkina Faso). Scholarly Horizons: University of Minnesota. Morris Undergra Jour 2014; 1:1–25.
10. Tag-Eldin MA, Gadallah MA, Al-Tayeb MN, Abdel-Aty M, Mansour E, Sallem M. Prevalence of female genital cutting among Egyptian girls. Bull World Health Organ 2008; 86:269–274.
11. El Dareer A. Attitudes of Sudanese people to the practice of female circumcision. Int J Epidemiol 1983; 12:138–144.
12. Baasher TA. Psychological aspects of female circumcision, traditional practices affecting the health of women and children, Report of a seminar, 10–15 February 1979; Alexandria, Egypt: WHO-EMRO.
13. Abdullah M. A case-study of female genital mutilation in Egypt; 2014. Available at: http://www.e-ir.info/2014/02/09/a-case-study-of-female-genital-mutilation-in-egypt/
. [Accessed 9 February 2014].
14. El Dawla AS. The political and legal struggle over female genital mutilation in Egypt: five years since the ICPD. Reprod Health Matters 1999; 7:128–136.
15. Sadek A. Mini international neuropsychiatric interview (MINI): the Arabic translation, in Psychiatry Update. Institute of Psychiatry 2000; 2:23–31.
16. El-Gilany A, El-Wehady A, El-Wasify M. Updating and validation of the socioeconomic status scale for health research in Egypt. East Mediterr Health J 2012; 18:962–968.
17. Melikeh LK, Ismail ME. Wechsler preview adult intelligence scale. Arabic version, Cairo: Elnahda Elmasria; 1987.
18. Hamilton M. Guy W. Hamilton anxiety scale. ECDEU assessment manual for psychopharmacology rev. Rockville, MD: El Nahda El Masria; 1976. 193–198.
19. Fatim L. Hamilton anxiety scale (Arabic version). Cairo, Egypt: Anglo Egyptian Press; 1992.
20. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56–62.
21. Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press; 1965. 326.
22. Schmitt DP, Allik J. Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. J Pers Soc Psychol 2005; 89:623–642.
23. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al.. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26:191–208.
24. Anis TH, Gheit SA, Saied HS, Al kherbash SA. Validation in an Egyptian population. J Sex Med 2011; 8:3370–3378.
25. Kaplan HS. The new sex therapy. New York: Brunner/Mazel; 1974.
26. Lo Piccolo J, Stock WE. Treatment of sexual dysfunction. J Consult Clin Psychol 1986; 54:158–167.
27. El Nadim Center. Once again women speak out: results of a field research on violence against women in Egypt; 2009. El Nadim Center for the Management and Rehabilitation of victims of violence. Available at: http://alnadeem.org/en/node/101
. [Accessed 4 May 2015].
28. Mosher DL. Measurement of guilt in females by self-report inventories. J Consult Clin Psychol 1968; 32:690–695.
29. Kaplan HS. Disorders of sexual desire and other new concepts and techniques in sex therapy. New York: Brunner/MazeI; 1979.
30. Leif H. Handbook of sexual medicine. Chicago, IL: American Medical Association; 1982.
31. Katz RC, Jardine D. The relationship between worry, sexual aversion, and low sexual desire. J Sex Marital Ther 1999; 25:293–296.
32. van Minnen A, Kampman M. The interaction between anxiety and sexual functioning: a controlled study of sexual functioning in women with anxiety disorders. Sex Relation Ther 2000; 15:47–57.