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.
Methods
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.
Study design
This was a cross-sectional comparative study that was conducted for a duration of 1 year.
Target population
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.
Study tools
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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.
Statistical analysis
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).
Results
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.
Table 1: The socioeconomic data of the studied sample
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.
Table 2: The results of psychometric tests in circumcised and noncircumcised women Table 3: The levels of anxiety, depression, and degree of self-esteem among circumcised and noncircumcised women
Discussion
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.
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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.
Conclusion
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.
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