Tag: Trauma

Trauma and Female Genital Cutting, Part 4: Psycho-sexual functioning

On By SahiyoIn Joanna Vergoth, sexual health, Trauma, Trauma Series1 Comment

(This article is Part 4 of a seven-part series on trauma related to Female Genital Cutting. To read the complete series, click here. These articles should NOT be used in lieu of seeking professional mental health and counseling services when needed.)

By Joanna Vergoth, LCSW, NCPsyA

When discussing psychosexual functioning following FGC, it is critical to acknowledge and recognize that many women who have undergone FGC will not experience sexual health problems. It is also important to note that many women with intact genitals do experience sexual difficulties. Female sexuality is a complex integration of biological, physiological, psychological, sociocultural and interpersonal factors that contribute to a combined experience of physical, emotional and relational satisfaction.

Nevertheless, symptoms of Post Traumatic Stress Disorder (PTSD) can interfere across the continuum of sexual behavior affecting desire, arousal, physical and/or psychological pleasure. The amygdala is the organ in the brain that alerts us to possible danger and responds to the danger by triggering the fear response along with the release of the stress hormones.  A state of negative hyperarousal persists for those who have been re-triggered by some person, place or memory associated to the original trauma while suffering from PTSD (see The Body and The Brain). Biopsycholsocial factors impacting sexual function

For some women affected by Female Genital Cutting (FGC), re-traumatizing triggers can be their initial (and ongoing) sexual experiences. Not only can the physical position (identical to that required for FGC) induce a flashback, but the already traumatized genital area can feel repeatedly violated with sexual activity, gynecological exams—or childbirth itself. [Note. in Sahiyo’s Exploratory Student on FGC in the Bohra community, 108 women reported that their FGC (khatna) had adversely affected their sex life – See Graph on the right]  Khatna sex lifeWhen these flashbacks occur the brain’s fear circuitry takes over and the hippocampus can no longer communicate effectively with the amygdala to allay its fears. This condition often leaves those affected feeling emotionally charged with generalized fear(s) that persist even after the traumatic event has passed. (See also ‘The Clitoral Hood – A Contested Site’) 

There are 3 primary psycho-sexual complications commonly associated with FGC:

  • painful intercourse (may be due to narrowing of vaginal canal; or excessive scarring, or clitoral neuromas, or infibulation or chronic infection);
  • difficulties reaching orgasm;
  • and, absence or reduction of sexual desire. 

Sexual difficulties can occur because for FGC survivors, positive sexual arousal mimics the physiological experience of fear. Once these hormonal and neuroanatomical associations have been forged through the intense experience of trauma and the associated PTSD symptoms, it can be difficult to uncouple them. PTSD SexIn these instances, arousal frequently signals impending threat rather than pleasure. Thus, the biology of PTSD primes an individual to associate arousal with trauma and this impairs the ability to contain the fear response—which in turn impedes sexual functioning and intimacy.

Due to repeated pain during sexual activity, women may develop anxiety responses to sex that restrict arousal and increase frustration—all of which can contribute to vaginal dryness, muscular spasm, painful intercourse and/or orgasmic failure. Women may actively avoid sexual activity to minimize feelings of physical arousal or vulnerability that could trigger flashbacks or intrusive memories. Others have reported that merely the fear of potential pain during intercourse and the frustration around delayed sexual arousal contributes to the lack of sexual desire. Recurring pain triggers memories adversely affected by the cutting. Chronic pain and distasteful memories reinforce each other and create a situation of mutual maintenance.

Emotional and/or physical pain during intercourse diminishes the enjoyment of both the woman and her partner. Complications such as these can contribute to feelings of worthlessness, inhibit social functioning and increase isolation. In fact, many women have expressed feelings of shame over being different and ‘less than’. Some may experience their circumcised genitals, now deemed ‘different’, as shaming. Others may feel responsible for the relationship distress that results and carry a burden of guilt for being unavailable to “provide” sex. They may perceive their anxiety and difficulty about permitting penetration as something they must overcome.

The psychological issues for younger women who have undergone FGC and are living in Westernized societies may be especially complex. These women (and their partners) are subjected to different discourses of sexuality that centralize erotic pleasure and frame orgasm as the endpoint of sex for women and men. Some women may struggle with what are deemed irretrievable losses. Feelings of aversion may extend beyond sex to physical closeness or even intimate relationships in general. In other situations, a woman may feel inferior to other women or less entitled to positive relationships, so that she may engage in an unsatisfactory or even damaging relationship which could further diminish her self-esteem. Another underlying belief behind FGC is that women’s genitals are impure, dirty or ugly if uncut. As a result of this perception, the female body is viewed as flawed—forcing women to modify their physical appearance to fit standards far removed from health, well-being and gender-equality objectives.

Unfortunately, the very nature of this subject often doesn’t allow for much insight, since FGC has always been shrouded in secrecy. Women may be reluctant to disclose because of the fear of being judged, since FGM/C is perceived by outsiders to be illegal, and abnormal. The belief that sexual matters are to be kept private also makes FGC-affected women inclined to keep quiet about their symptoms and suffer in silence or attribute their pain to other sources. However, healing from the trauma through talk therapy as well as open discussions about strategies for obtaining sexual pleasure after FGC can be critical for women to regain control of their sexual identity.

For more information about the Psychosexual Consequences affecting the Clitoris see Trauma and Female Genital Cutting, Part 5: The “C” Word…and I Don’t Mean Circumcision.

About Joanna Vergoth:

Joanna is a psychotherapist in private practice specializing in trauma. Throughout the past 15 years she has become a committed activist in the cause of FGC, first as Coordinator of the Midwest Network on Female Genital Cutting, forma logoand most recently with the creation of forma, a charity organization dedicated to providing comprehensive, culturally-sensitive clinical services to women affected by FGC, and also offering psychoeducational outreach, advocacy and awareness training to hospitals, social service agencies, universities and the community at large.

Feeling drained after talking about Khatna? Here are some resources that can help

On By SahiyoIn Priya Ahluwalia, ResearchLeave a comment

By Priya Ahluwalia

Priya is a 22-year-old clinical psychology student at Tata Institute of Social Sciences – Mumbai. She is passionate about mental health, photography and writing. She is currently conducting a research on the individual experience of Khatna and its effects. Read her other articles in this series – Khatna Research in Mumbai.

As human beings we are trained to react immediately, lessen the magnitude of pain when injured, manage our emotions when overwhelmed. We always initiate a response, however not all actions can be immediately responded to, especially when they are extremely distressing or traumatic. Often they are hidden away by our minds to prevent any major upheaval for us. However, even when hidden, they tend to seep through the cracks, leading to subtle effects such as difficulty falling asleep, distrustfulness, self doubt, among others. But sometimes, a small object, event or even a word can widen the crack, leading to a dam of emotions running out. This process is called re-traumatization. Perhaps the best description of the same would be an object, event or situation which leads to re-experiencing the emotions and physical symptoms that are associated with the initial episode of trauma.

It is essential to acknowledge that all individuals give a similar physical response to trauma, but the psychological response is never the same. For example, we are biologically programmed to give a physical response to pain, such as crying when injured. However, we are culturally conditioned to suppress the psychological pain caused by the injury, which is essentially the case with women who have undergone FGC/Khatna. Although the pain is suppressed, it cannot be avoided because it begins to manifest indirectly. For example, one of the participants, I interviewed for my research reported that although she does not remember anything from the day of her Khatna, she has been terrified of blades ever since then. This is a clear example of unaddressed psychological distress. Thus, irrespective of whether the response to trauma is immediate, delayed, drastic or subtle, all individuals must gain access to resources for assistance.

Therefore, while delving into a topic such as Khatna, which is emotionally charged and traumatic, it is the researcher’s responsibility to ensure that the effect of re-traumatization is minimized. As cliché as it sounds, listening is perhaps the best therapeutic tool to minimize re-traumatization. Case studies have shown that when victims of trauma are unheard they are more likely to indulge in self-destructive behaviour. Besides listening, providing an open and safe environment, choices, lists of resources and being available post the interview are also known to help. However, it is essential that a sense of independence be encouraged. Therefore survivors must be trained to look out for signs on their own and have a some set of immediate resources be available for themselves.

Some of the signs to look out for:

  1. Sudden and recurring thoughts of an unpleasant event, that may be difficult to control.
  2. Change in sleeping habits: an increase or decrease in the need for sleep, as compared to before the interview with the researcher.
  3. Change in eating habits: an increase or decrease in appetite as compared to before the interview with the researcher.
  4. Difficulty paying attention to an activity at hand, inability to remember information.
  5. Easily irritated.
  6. Not interested in participating in activities which were earlier enjoyable.
  7. Frequent crying spells.
  8. Using negative statements (“I am bad”) while addressing oneself.
  9. Having extremely negative view of the world (“everyone in the world is bad”).
  10. Regular thoughts of death or harming oneself.
  11. Distrust and suspiciousness of those around oneself.
  12. Sense of powerlessness
  13. Increased feeling of fear

Things to do:

  1. Seek out a trusted confidante and talk to them, it will allow you an emotional release as well as provide the support to overcome the current distress you feel.
  2. Arrange your day in a way that allows for at least 1 or 2 activities, such as painting or dancing among others, which give you positive emotions such as happiness. These activities could last from anywhere between 30 minutes to an hour, preferably not consecutively organised.
  3. Seek out support in organizations – research has shown that women who choose to speak out about their trauma by joining organizations working against the trauma that they survived are more adept with dealing with their emotions as they are able to gather wider support of individuals with similar experiences.
  4. Perform physical activity which would allow your body to release positive hormones which would assist in overcoming some of the negative emotions you may currently feel.
  5. Progressive Muscle Relaxation:

Progressive muscle relaxation is a two-step process in which you systematically tense and relax different muscle groups in the body. With regular practice, it gives you an intimate familiarity with what tension—as well as complete relaxation—feels like in different parts of the body. This can help you to you react to the first signs of the muscular tension that accompanies stress. And as your body relaxes, so will your mind.

Steps involved:

  • Start at your feet and work your way up to your face, trying to only tense those muscles intended.
  • Loosen clothing, take off your shoes, and get comfortable.
  • Take a few minutes to breathe in and out in slow, deep breaths.
  • When you’re ready, shift your attention to your right foot. Take a moment to focus on the way it feels.
  • Slowly tense the muscles in your right foot, squeezing as tightly as you can. Hold for a count of 10.
  • Relax your foot. Focus on the tension flowing away and how your foot feels as it becomes limp and loose.
  • Stay in this relaxed state for a moment, breathing deeply and slowly.
  • Shift your attention to your left foot. Follow the same sequence of muscle tension and release.
  • Move slowly up through your body, contracting and relaxing the different muscle groups.
  • It may take some practice at first, but try not to tense muscles other than those intended.

6. Mindfulness Meditation:

Rather than worrying about the future or dwelling on the past, mindfulness meditation switches the focus to what’s happening right now, enabling you to be fully engaged in the present moment and thereby reduce our anxiety.

Steps involved:

  • Sit on a straight-backed chair or cross-legged on the floor.
  • Focus on an aspect of your breathing, such as the sensation of air flowing into your nostrils and out of your mouth, or your belly rising and falling.
  • Once you’ve narrowed your concentration in this way, begin to widen your focus. Become aware of sounds, sensations, and thoughts.
  • Embrace and consider each thought or sensation without judging it good or bad. If your mind starts to race, return your focus to your breathing. Then expand your awareness again.

 

Trauma and Female Genital Cutting, Part 3: The Body and the Brain

On By SahiyoIn Joanna Vergoth, Mental Health, Trauma, Trauma SeriesLeave a comment

(This article is Part 3 of a seven-part series on trauma related to Female Genital Cutting. To read the complete series, click here. These articles should NOT be used in lieu of seeking professional mental health and counseling services when needed.)

By Joanna Vergoth, LCSW, NCPsyA

Trauma overwhelms us and disrupts our normal functioning, impacting both the brain and body, both of which interact with one another to regulate our biological states of arousal. When traumatized, we lose access to our social communication skills and displace our ability to relate/connect/interact with three basic defensive reactions: namely, we react by fighting, fleeing, or freezing (this numbing response happens when death feels imminent or escape seems impossible).   

In order to understand and appreciate our survival responses, it’s important to have a basic understanding of how our brain functions during a traumatic experience, such as undergoing Female Genital Cutting or FGC.

Our brains are structured into three main parts:

image1The human brain, which focused on survival in its primitive stages, has evolved over the millennia to develop three main parts, which all continue to function today. The earliest brain to develop was the reptilian brain, responsible for survival instincts. This was followed by the mammalian brain (Limbic system), with instincts for feelings and memory. The Cortex, the thinking part of our brain, was the final addition.

The Reptilian brain:

The reptilian brain, which includes the brain stem, is concerned with physical survival and maintenance of the body. It controls our movement and automatic functions, breathing, heart rate, circulation, hunger, reproduction and social dominance— “Will it eat me or can I eat it?” In addition to real threats, stress can also result from the fact that this ancient brain cannot differentiate between reality and imagination. Reactions of the reptilian brain are largely unconscious, automatic, and highly resistant to change.  Can you remember waking up from a nightmare, sweating and fearful—this is an example of the body reacting to an imagined threat as if it were a real one.

The Limbic System:

Also referred to as the mammalian brain, this is the second brain that evolved and is the center for emotional responsiveness, memory formation and integration, and the mechanisms to keep ourselves safe (flight, fight or freeze). It is also involved with controlling hormones and temperature. Like the reptilian brain, it operates primarily on image5a subconscious level and without a sense of time.

The basic structures of Limbic system include:  thalamus, amygdala, hippocampus and hypothalamus  

The Neocortex:

The neocortex is that part of the cerebral cortex that is the modern, most newly (“neo”) evolved part. It enables executive decision-making, thinking, planning, speech and writing and is responsible for voluntary movement.

But…image6

Almost all of the brain’s work activity is conducted at the unconscious level, completely without our knowledge. While we like to think that we are thinking, functioning people, making logical choices, in fact our neocortex is only responsible for 5-15 % of our choices.  When the processing is done and there is a decision to make or a physical act to perform, that very small job is executed by the conscious mind.

How the brain responds to Trauma

The fight or flight response system — also known as the acute stress response — is an automatic reaction to something frightening, either physically or mentally. 

This response is facilitated by the two branches of the autonomic nervous system (ANS) called the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) which work in harmony with each other, connecting the brain with various organs and muscle groups, in order to coordinate the response.

Following the perception of threat, received from the thalamus, the amygdala immediately responds to the signal of danger and the sympathetic nervous system  (SNS) is activated by the release of stress hormones that prepare the body to fight or escape.

It is the SNS which tells the heart to beat faster, the muscles to tense, the eyes to dilate and the mucous membranes to dry up—all so you can fight harder, run faster, see better and breathe easier under stressful circumstances.  As we prepare to fight for our lives, depending on our nature and the situation we are in, we may have an overwhelming need to “get out of here” or become very angry and aggressive (See ‘I underwent female genital cutting in a hospital in Rajasthan’ on Sahiyo’s blog). Usually, the effects of these hormones wear off only minutes after the threat is withdrawn or successfully dealt with.

However, when we’re terrified and feel like there is no chance for our survival or escape, the “freeze” response, activated via the parasympathetic nervous system, can occur. The same  hormones or naturally occurring pain killers that the body produces to help it relax (endorphins are the ‘feel good’ hormones) are also released into the bloodstream, in enormous amounts, when the freeze response is triggered. This can happen to people in car accidents, to sexual assault survivors and to people who are robbed at gunpoint. Sometimes these individuals pass out, or mentally remove themselves from their bodies and don’t feel the pain of the attack, and sometimes have no conscious or explicit memory of the incident afterwards. Many survivors of female genital cutting have reported fainting after being cut. Other survivors have reported blocking out their experiences of being cut (See ‘I don’t remember my khatna. But it feels like a violation’). Our bodies can also hold on to these past traumas which may be reflected not only in our body language and posture but can be the source of vague somatic complaints (headaches, back pain, abdominal discomfort, etc.) that have no organic source. FGC survivors who were cut at very young ages can be plagued with ambiguous symptoms such as these.

Neuroscientists have identified two different types of memory: explicit and implicit. The hippocampus, the seat of explicit memory, is not developed until 18 months. However, the implicit memory system, involving limbic processes, is available from birth. Many of our emotional memories are laid down before we have words or explicit recall, yet they influence our lives without our awareness. Although a traumatized person may not explicitly remember the traumatic event(s), the memory is held in the body: ‘‘What the mind forgets, the body remembers in the form of fear, pain, or physical illness’’ (Cozolino, 2006, p. 131; Van der Kolk, 1994).

The brain and PTSD

For those affected by Post Traumatic Stress Disorder — especially those who had no chance to fight back successfully or escape — the body and the brain have been blocked from responding normally and the trauma does not end.

Dr. Bessel van der Kolk (2001), a major clinician and researcher in the field of trauma notes that individuals with PTSD ‘‘are very sensitively tuned to pick up threat and respond to minor stimuli as if their life were in danger”.

What Dr Bessel is referring to is the fact that for those with PTSD, the trauma has not been able to come to a conclusion and remains unfinished. When stressors are present or familiar triggers (such as a person, place, or scent) are activated, the person can feel threatened and those fight-or-flight reactions stay turned-on, prompting the amygdala to be in a state of perpetual overactivation — in effect, hijacking the thinking process. Some FGC survivors in the Bohra community have experienced versions of such responses. For example, one young woman interviewed in the documentary A Pinch of Skin mentioned that her traumatic memories of being cut are triggered when she sees her cutter in the neighbourhood, and she ‘never wants to see that lady again’.  

When the amygdala is overactive and in control it registers only emotional and sensory information so that when the hippocampus tries to record the event sequentially it is compromised by these hormonal releases and only fragmented flashes of memory and emotional distress are remembered. This, too, is common in the way many FGC survivors remember their experience of being cut.

Why this happens

Trauma impairs the integrative functioning in the brain and neural networks get stuck in paths related to processing and encoding fear. The limbic system stores our emotional memories and replicates the response we had to the earliest time we experienced a similar situation: if we are in a state of distress we will revisit a memory of distress and that will cause more somatic sensations of distress.

PTSD reflects a condition in which the body’s natural mechanisms for recovery have failed, resulting in a prolonged state of negative stress arousal—causing increased heart rate and blood pressure, restricted flow of blood to the genitals and digestive systems—in effect making it hard to process information, eat, sleep, salivate or be sexually aroused.

For more information about the Psychosexual Consequences of trauma, see Trauma and Female Genital Cutting, Part 4: Psychosexual Consequences.

About Joanna Vergoth:

Joanna is a psychotherapist in private practice specializing in trauma. Throughout the past forma logo15 years she has become a committed activist in the cause of FGC, first as Coordinator of the Midwest Network on Female Genital Cutting, and most recently with the creation of forma, a charity organization dedicated to providing comprehensive, culturally-sensitive clinical services to women affected by FGC, and also offering psychoeducational outreach, advocacy and awareness training to hospitals, social service agencies, universities and the community at large.