The workshop aimed to support the workers in modifying their work, while the consultations assisted the eventual implementation. Feasibility was evaluated as per three aspects: (1) developing modifications of work, (2) implementing these modifications, and (3) changing physical behavior and self-reported fatigue, pain and energy. The three aspects were addressed through records completed by the workers, measurements of workers’ physical behavior and intensity during ‘control’ workdays  and ‘intervention’ workdays , and self-reported fatigue, pain and energy level following both types of workday. Five modifications to work were developed, and three of these five modifications were implemented. To some extent, physical behavior and intensity changed as intended during ‘intervention’ workdays compared to ‘control’ workdays. Workers were also less fatigued, had less pain, and had more energy after ‘intervention’ workdays. These results suggest that it is feasible to develop and implement modified work based on the Goldilocks Work Principle among industrial workers. However, we also identified several barriers to the implementation of such modifications.The Goldilocks Work Principle expresses that productive work should be redesigned to comprise physical behaviors of different intensities in a composition promoting workers’ health and fitness. This study is the first to assess the feasibility of redesigning work in an industrial setting according to the Goldilocks Work Principle. We recruited workers ( Industrial workers often have work tasks leading to considerable physical demands for several hours every workday . MeasureThis suggests that occupational physical activity (OPA) does not lead to the same health benefits as leisure time physical activity ; this haA promising approach for improving this situation is the Goldilocks Work Principle, saying that productive work should be redesigned to promote health and fitness by shifting workers’ physical behaviors towards a ‘just right’ distribution, including periods of sufficient intensity to promote fitness ,14. For Therefore, the aim of this study was to investigate the feasibility of (1) developing modifications to industrial work according to the Goldilocks Work Principle, (2) implementing these modifications; (3) changing workers’ physical behaviors towards a ‘just right’ distribution, including sufficient sitting to gain recovery and periods of a sufficiently high physical intensity to improve fitness; resulting in fatigue, pain and energy following work changing in a positive direction.The National Research Centre for the Working Environment has an institutional agreement with the Danish Data Protection Agency about procedures to treat confidential data , e.g., by securing data at a protected drive with limited access, and by anonymizing all individual data.The Danish National Committee on Biomedical Research Ethics  has evaluated a description of the study and concluded that, according to Danish law as defined in Committee Act § 2 and § 1, the intervention should not be further reported to the local ethics committee (Ref number: H-18041423).The reporting follows the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement extension to randomized controlled pilot and feasibility trials . Addition = 26) were recruited from a brewing company in Denmark. The study was announced at a quarterly meeting with both senior management and workers present. For logistical reasons we included workers exclusively from one department of the work production. This department was selected based on discussions with the management. The priority was to identify a department with interest in participation and with a potential to benefit from this type of intervention. The department consisted of three teams, with two teams weekly alternating between day and evening shifts, and one team exclusively doing night shifts. The main task in the department was to handle products  that were not suitable for processing by the company’s automated robotics system. We invited workers from the day and evening teams to participate in this study.Industrial workers , blood pressure and fat percentage, perceived physical exertion during work, and self-reported physical activity level during work and leisure.In step 3, the information from Step 1 and 2 provided a basis for assessing desirable changes in physical behavior which would lead towards a ‘just right’ distribution of behaviors, and to a sufficient occurrence of periods at high intensity.In step 4, we invited all workers in the department and the LWG to participate in the intervention, including being involved in the process of modifying their productive work and subsequently implement these modifications with the aim to achieve the intended goals. These steps are described in detail in In 2020, the World Health Organization (WHO) updated their guidelines on physical activity and sedentary behavior for adults to recommend between 150 and 300 min per week of physical activity at moderate intensity or 75 to 150 min at high intensity, while also reducing time in sedentary behavior ,20. BrieTo our knowledge, the ‘just right’ distribution of physical behaviors during work that would improve health and fitness is unknown. The evidence of physical variation being a protective factor against musculoskeletal disorders in working life, as suggested mainly for jobs characterized by continuous and/or repetitive operations, is weak . A systeIn order to assess the feasibility of changing physical behaviors based on the Goldilocks Work Principle, therefore, we decided on an operational definition of a ‘just right’ distribution of activities during a workday. We described it as follows: (1) to be characterized by one third of the time at work spent in each of these behaviors; sitting, standing and being active, and (2) to contain at least 10 min of high physical intensity, operationalized as activity associated with a heart rate equal to, or larger than 60% of the heart rate reserve (HRR). We considered these target behaviors to be feasible as part of the productive work, as well as sufficient for having a positive impact on workers’ health and cardiorespiratory fitness.All workers in the department  participated in a 16-week intervention . The development period consisted of an ongoing collaboration with the LWG to identify desirable changes to current work. Furthermore, two workshops were conducted, for the day and evening shift workers, respectively. The LWG were present at both workshops. We initiated the workshops by explaining the Goldilocks Work Principle and presenting a summary of their own baseline measurements. Then, the workers were split into groups, with a request to design modifications to their work. Each idea for modification was assessed by all workshop participants in terms of five criteria: (1) would it contribute to changing physical behavior and/or intensity towards a ‘just right’ distribution? (2) Is it a part of productive work? (3) Are there facilitating factors supporting implementation of this modification ? (4) Are there barriers to the implementation of this modification ? (5) How would the modification affect overall productivity? All modifications were scored in each category as either positive, neutral, or negative. Based on this assessment, the LWG selected the modifications considered to have the best potential to be successfully implemented. The workshop contents are detailed in The implementation period included two consultations (C1 and C2) conducted by the researchers with the purpose to assist the LWG in the implementation of modifications. In the consultations, the LWG used a checklist to evaluate whether each of the modifications was performed by the workers. If a modification had not been performed, the LWG initiated a discussion of the reasons why, and how to facilitate a future implementation.2])).At baseline cf. , we collAt the end of the two workshops, the participating workers’ opinions were collected using a questionnaire , which aAt follow up, we measured (1) to what extent the modifications had been implemented as planned, (2) to what extent workers’ physical behavior and intensity had changed as intended, and (3) to what extent the implemented modifications had led to short-term positive changes in workers’ health and wellbeing . The LWG informed workers when the follow up measurements would be performed, and encouraged workers to participate and wear sensors for recording physical behavior and intensity. Measurements were performed during a 4-day period with a randomized order of two ‘control’ workdays  and two ‘intervention’ workdays (modified tasks).To examine the workers’ compliance to each of the five modifications, they were asked (yes/no) on day 2 and 4 whether they had performed their work according to the plan . On answFurthermore, at the end of both ‘control’ and ‘intervention’ workdays, the worker noted the total number of work tasks performed during the day, as well as the number of alternations between tasks with different physical behaviors. Both variables reflect the frequency aspect of variation . This reWe used a protocol for measuring physical behavior and intensity similar to that in a previous study among childcare workers . An AX3 Physical behaviors were classified using the Acti4 software  into timIn order to classify the intensity of physical activity as low, moderate or high, we estimated the heart rate reserve (HRR), i.e., the difference between the maximal heart rate, estimated according to Tanaka et al. , and resDuring all measurement days, the workers noted in a diary at what time they, (1) woke up, (2) arrived at work, (3) left work, (4) went to sleep, and (5) if any of the wearable sensors were detached. On basis of the diaries, the continuous timeline of heart rate and physical behavior data was partitioned into periods of, (1) ‘control’ work, (2) ‘intervention’ work, (3) leisure time awake, and (4) sleep. Workers with data on both ‘control’ and ‘intervention’ workdays were included in further analyses, and their data on ‘control’ and ‘intervention’ work were summarized in terms of a mean value for ‘control’ and ‘intervention’ workdays.At the end of each ‘control’ or ‘intervention’ workday , workersDue to the small sample size and exploratory nature of this feasibility study, we used only descriptive statistics, and did not compare ‘control’ and ‘intervention’ workdays using more advanced statistical procedures. Group means with standard deviation (SD) between workers were used to summarize data on worker characteristics, physical behaviors, heart rate, and ratings in questions on fatigue, pain and energy. All categorical data are presented as N (number of workers), and percentages of the total population.Out of 26 eligible workers, we collected baseline data on 20 . All 14 n = 20) were predominantly male  moving boxes with bottles in a rapid pace and (2) labeling the boxes just moved. The intention of this modification was to increase time being physically active at a high intensity.Modification 2; ‘Sitting folding cardboard’. The task consisted in assembling a quarter pallet of bottles. This was originally done by folding a cardboard on top of a quarter pallet and placing bottles there in layers. The work task was modified by creating a new task consisting in folding cardboards supplying workers placing bottles on pallets. The new cardboard folding task could be performed sitting, and workers were encouraged to do so. The purpose of this modification was to increase time sitting.Modification 3; ‘Sitting labelling task’. This work task consisted in labeling bottles. This was originally done in a standing position with little movement. The work task was modified by making a chair available and encouraging the workers to sit while labeling the bottles. The purpose of this modification was to increase periods of sitting.Modification 4; ‘Sitting meeting task’. The task included planning and distributing tasks among workers. The meeting was conducted at the beginning of each workday, with participants standing next to a blackboard. This task was modified by placing out pallets for sitting and encouraging workers to use them while meeting. The purpose of this modification was to increase time with sitting.Modification 5; ‘Increase alternations between tasks’. The intention of this modification was to reorganize work so that workers alternated twice every workday between work tasks 1, 2 and 3 above, in their modified form, as opposed to the original rotation of only one alternation per day between the three tasks in their original form. The purpose of this modification was to increase variation in physical behavior and increase time being active.n = 14) were in general motivated to participate, felt they benefited from the content of the workshop, and felt that management supported the intervention. All questions and responses are available in Workers , while four workers answered on only one . Workers reported that they were able to perform the ‘active moving task’ (91%), ‘sitting meeting task’ (100%) and ‘increase alternations’ (82%) modifications as planned on the majority of the workdays . A consiThirteen workers answered regarding the number of alternations between work tasks during ‘control’ and ‘intervention’ workdays. Workers typically alternated once during ‘control’ workdays, increasing to three times on ‘intervention’ workdays . This shData on time spent sitting, standing and being active were available from nine workers who wore accelerometers on both ‘control’ and ‘intervention’ workdays . On ‘conData on time spent at low intensity, moderate intensity and high intensity were available from eight workers who wore heart rate sensors on both ‘control’ and ‘intervention’ workdays . On ‘conOnly one worker had more than 10 min of high-intensity activity on ‘intervention’ workdays, and this worker was already sufficiently active during ‘control’ workdays.On average, workers reported less fatigue in neck and shoulders , lower back  and legs and knees  following ‘intervention’ workdays compared to ‘control’ workdays . Also, wOn average, workers rated more perceived energy for walking , running  and doing sports , following ‘intervention’ workdays compared to ‘control’ workdays .The findings from this feasibility study suggest that it is, indeed, feasible to develop and implement modifications to productive work according to the Goldilocks Work Principle among industrial workers. When workers performed modified work, developed by themselves, their physical behavior changed towards the two stated goals for ‘intervention’ workdays, i.e., an equal proportion of time sitting, standing and being physically active, and at least 10 min in high intensity physical activity at ≥60%HRR. However, the changes did not fully reach these goals. Despite this, workers experienced less fatigue, less pain and a higher energy level following modified ‘intervention’ workdays compared to unmodified ‘control’ days.The workers developed five modifications of productive work at the workshops preceding implementation. Eventually, three of these were successfully implemented, which demonstrates the usefulness of the four steps procedure cf. . HoweverWorkers reported why they did not perform the two unsuccessful modifications, i.e., ‘sitting folding cardboard’ and ‘sitting labelling task’. Several workers stated that when they had performed ‘sitting folding cardboard’ for 1 to 1.5 h, that would sufficiently supply the work team’s demand for folded cardboard for the entire day, which would preclude other workers from performing that task. As for the ‘sitting labelling task’, some workers stated that the chair offered felt uncomfortable, and some stated that it placed excessive strain on the upper extremity and/or lower back. Therefore, many of the workers did not perform this modification as planned.Three of the modifications of productive work aimed at increasing time sitting. However, on average only a minor increase was observed, i.e., 8 more minutes of sitting during the whole workday. This could be due to the aforementioned failures expressed by many of the workers regarding the modifications ‘sitting folding cardboard’ and ‘sitting labelling task’. Thus, the increase in average time sitting was likely primarily due to workers performing the ‘sitting meeting task’ as planned.Although most of the workers increased their time being active on ‘intervention’ workdays compared to ‘control’ workdays, the average increase of only 9 min suggested that the modification that particularly aimed at a substantial increase in active time, i.e., ‘active moving task’, was not successful. This could be due to this task not being required much in production, which would lead to a limited time spent in this task, and thus being active, for all workers. Another explanation could be that workers did not increase their time being active while performing this modified task because they could perform the modification mainly standing, thus not being active.On average, the workers moved towards a ‘just right’ distribution of the three physical intensities; more time at low intensity (+18 min), less time with moderate intensity (−21 min), and more time at high intensity (+3 min) during ‘intervention’ workdays compared to ‘control’ workdays.Three workers went from spending almost no time with high intensity during ‘control’ workdays to accumulating about five minutes of high intensity during ‘intervention’ workdays. As a general result, the developed modifications were not successful in leading to sufficient time at a high intensity, defined a-priori to be at least 10 min during worktime per workday. However, even though achieving five minutes with high intensity did not reach this goal, accumulating five minutes during worktime every workday could contribute to reach the weekly recommendations of 75 min of high intensity physical activity for adults .We found a tendency towards workers being less fatigued, having less pain and reporting higher perceived energy level following ‘intervention’ workdays compared to ‘control’ workdays. The changes in physical behavior could have contributed to these positive changes. The workers were often standing for more than half of the workday, and even small increases in time sitting (+8 min) and some reduction of standing (−17 min) during ‘intervention’ workdays compared to ‘control’ workdays could have had effects ,10,23,44The present study suggests that it is feasible in an industrial setting to develop modifications to productive work, based on the Goldilocks Work Principle. Furthermore, the study shows that implementing such modifications can change workers’ physical behavior and the intensity of activity towards intended goals, even if the present study showed these changes to be far from what was desired for a ‘just right’ workday. Thus, a paramount issue in future projects is to improve the success, both of developing effective modifications that can, actually, lead to the intended changes, and of implementing those modifications successfully. This could lead to larger changes in physical behavior and intensity than those observed in the present study if, for example, additional tailoring of modifications would be possible, based on workers feedback. Furthermore, the sustainability of changes needs to be evaluated, even if they appear feasible in the short term. The Goldilocks Work Principle argues that task modifications which do not impact negatively on productivity should be sustainable, but this needs to be evaluated. Also, the ability of such sustainable changes in behavior to positively change workers’ well-being, health and fitness needs to be examined.Thus, in order to develop and implement modifications of productive industrial work based on the Goldilocks Work Principle, and examine their effects on workers’ health and fitness, larger scale controlled trials are encouraged. Effective modifications verified in a controlled trial design could offer a strategic and cost-effective way to promote industrial workers’ health and fitness, for the benefit of both workers, companies and society.A strength of this study was the participatory approach used to develop and implement modifications to productive work. We involved workers, management, work environment representatives, and health and safety managers within the company in this whole process.Another strength of this study was the use of wearable sensors to measure physical behaviors  and intensity of physical activity (in terms of %HRR) during ‘control’ and ‘intervention’ workdays.Some limitations should, however, be observed. First, the small sample size did not allow inferential statistics. Second, while we monitored alternations between work tasks on ‘intervention’ workdays compared to ‘control’ workdays, as a measure of the frequency aspect of variation, we did not explicitly evaluate the temporal pattern of physical behaviors, which is likely an important determinant of, e.g., fatigue and pain, even if the total duration of different behaviors is the same . Future The Goldilocks Work Principle is not intended to address all challenges to health among industrial workers. Thus, additional interventions  may be justified for these workers. In future intervention studies, the long-term effects of Goldilocks changes may be compared in terms of the cost-effectiveness of other organizational and individual initiatives aiming at promoting health.The present study suggests that it is feasible to involve workers and other stakeholders in developing and implementing modified work based on the Goldilocks Work Principle in an industrial setting. Physical behavior and the intensity of physical activity changed towards the intended ‘just right’ workday, with an equal distribution of physical behaviors , and sufficient time in high intensity to improve fitness. However, the modified work was still quite far from these target outcomes. We observed, however, that workers experienced less fatigue, less pain and had higher energy levels after the ‘intervention’ workdays compared to ‘control’ workdays. Thus, the present feasibility study provides useful knowledge for further development of ‘just right’ industrial work and, eventually, larger scale controlled trials assessing the effectiveness of modifications of productive work aiming at changing physical behavior and intensity and their efficacy in promoting health and fitness among the workers.


After publication in volume 140, issue 6, page 769–776 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2021 and This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been corrected.Open Access funding enabled and organized by Projekt DEAL.Funder Name: Universitätsklinikum RWTH Aachen (8915).


It has been noted that Japanese children sleep the least in the world, and this has become a major social issue. This study examined the pathways linked to sleep habits (SH) among children and adolescents. A questionnaire-based survey was conducted in March 2019 on children and their parents at all 63 public elementary and 29 public junior high schools in Setagaya-ku, Tokyo. For the analysis, 22,385 pairs of children–parent responses  with no missing data were used. This survey collected data on SH, physical activity (PA), screen time (ST) for the child, and lifestyle and neighborhood social capital (NSC) for the parents. Moreover, the pathways linking ‘NSC’ → ‘parental lifestyle’ → ‘child’s PA/ST’ →‘child’s SH’ were examined through structural equation modeling. The results indicated that children’s SH were affected by their PA and ST and influenced by the lifestyle of their parents and the NSC that surrounds them. Thus, we concluded that it is necessary to provide direct interventions and take additional measures with regard to parent lifestyle and their NSC to solve persistent sleep problems in children. The ‘era of sleep difficulty’ has arrived for humankind. The fact that the World Health Organization’s (WHO) Regional Office for the European Centre for Environment and Health held an expert meeting on sleep disorders in Bonn, Germany, in January 2004 confirms this . MoreoveThe shorter sleep duration among Japanese people is a serious problem, and children are no exception. According to the Japan School Health Society , sleep dIn this situation, a national campaign to promote early bedtime, early wake-up, and breakfast in Japan is underway. However, various survey results show that the campaign and other efforts during this period have not succeeded in significantly improving children’s lifestyles. Thus, it is necessary to examine the reasons behind children’s sleep problems comprehensively.According to Bronfenbrenner’s Model , a childThese previous studies were advantageous to our research. However, while they demonstrated individual associations, none have been examined simultaneously. Structurally, the relationships among social capital and parental lifestyle, PA, and ST of children are also yet to be examined. Structural equation modeling (SEM) has become a standard tool in many scientific disciplines for investigating the plausibility of theoretical models that might explain the interrelations among a set of variables .Therefore, using SEM, this study examined how the SH of Japanese children and adolescents is influenced by surrounding environmental factors including NSC, parental lifestyle, and their own lifestyle behavior . Based on the Japan School Health Society , this stThe study’s design was approved by the ethics committee of the Nippon Sport Science University . Participants were informed of the purpose and contents of the survey, informed about their right to withdraw from the study at any time, and were provided with complete assurance regarding the confidentiality of their data. Returning completed questionnaires meant that participants had given their informed consent.The survey was conducted in Setagaya-ku, Tokyo. The focus group included parents and their children enrolled in the third grade or above at all public elementary schools (63 schools) and all public junior high schools (29 schools), as of March 2019. For the analysis, 22,385 pairs of child–parent responses  with no missing data were used.2 . Additionally, according to the Basic Resident Register, as of June 2019, the population  and the number of households  were the highest among Tokyo’s 23 wards. The population composition ratio of this area is 11.8% for those aged 0–14 years, 68.1% for 15-to-64-year-olds, and 20.1% for those over 64 years of age.Setagaya Ward, the target area of this study, is located at the southwestern end of Tokyo’s 23 wards , 15 km from the city center. It has an area of 58.05 kmAs previously mentioned, no studies have simultaneously and structurally examined the relationships among social capital and parental lifestyle, PA, and ST of children. SEM has become a standard tool in many scientific disciplines for investigating the plausibility of theoretical models that might explain the interrelations among a set of variables . In thisMcCloskey and Pei  found thHypothesis 1.NSC has a direct effect on parental lifestyle.Several studies have previously reported that parents’ lifestyle habits influence those of their children. For example, Schoeppe et al.  found a Hypothesis 2.Parental lifestyle has a direct effect on children’s PA.Hypothesis 3.Parental lifestyle has a direct effect on children’s ST.PA has been reported to be effective in improving sleep problems. Stone et al.  found thHypothesis 4.PA has a direct effect on children’s SH.Hypothesis 5.ST has a direct effect on children’s SH.We created a self-administered questionnaire and asked the children and their parents to respond to the survey anonymously. The questionnaires were delivered and collected by the Setagaya Ward Board of Education from each school and homeroom teacher.The questionnaire for the children focused on ‘falling asleep’, ‘nocturnal awakening’, and ‘awakening’, based on research that has pointed out that sleep problems are an important indicator of SH ,24. The The questionnaire for parents focused on bedtime and wake-up times on weekdays, EX habits during the year , and the frequency of reading books (RB) per month . Nocturnal sleep duration was calculated from bedtime and wake-up time records. In addition, five questions were asked about NSC. Among these, three items  were developed by Nawa et al. , with reIn this study, the following three points were mainly analyzed based on the obtained data.The first was the examination of the lifestyle characteristics of the subjects. In this examination, we calculated the mean ± standard deviation (SD) or the distribution of the answers to each question according to sex and grade level, then compared the findings with those from previous studies and examined the characteristics of the participating children’s lifestyles.The second was the examination of the validity of latent variables. For this examination, confirmatory factor analysis (CFA) was used. The responses to the observation variable of ‘NSC’ were scored as ‘yes’ (5 point), ‘somewhat yes’ (4 points), ‘neither’ (3 points), ‘somewhat no’ (2 points), and ‘no’ (1 points). Similarly, in parental lifestyle, the response to the observation variable ‘parent’s bedtime’ , the observation variable ‘parent’s wake-up time’ , the observation variable ‘EX habits’ , and the observation variable ‘RB habits’  were scored. Furthermore, in children’s lifestyle, the response to the observation variables ‘before class’, ‘after lunch’, ‘after school’ , the observation variable ‘EX time in a week’ (continuous variable), and the observation variables ‘video game’, ‘TV/video/DVD’, ‘smartphone’, ‘table/PC’ (continuous variable) were used. Finally, in children’s SH, the observation variables ‘falling asleep’, ‘nocturnal awakening’, and ‘awakening’  were scored. The observation variable ‘bedtime’ and ‘wake-up time’ were scored in the same categories as the above ‘parent’s bedtime’ and ‘parent’s wake-up time’.The third was to verify the hypothetical model. In this examination, we verified the hypothetical model shown in The maximum likelihood method was used to estimate the parameters, and the goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were used. We also used the Akaike information criterion (AIC) and chi-square (CMIN) to compare the models in the simultaneous multiple-group SEM and comprehensively determined the suitability of the models; for example, GFI and AGFI were 0.9 or above, RMSEA was 0.8 or below . These aNext, the validity of each latent variable was examined by CFA . The estAfter the above procedure, the hypothetical model in this study was examined by SEM . As FiguFurthermore, the results of the examination of sex differences in this model are presented in From the above facts, for both sex and school grade differences in this model, the goodness-of-fit indices for CIM were better than ECM , and theThe nocturnal sleep duration of children in the present study  was extrIn this study, after confirming the validity of each latent variable by CFA , it was Wright et al.  reportedThe American Academy of Pediatrics  recommenRegarding the ties of local communities in Japan, neighborhood relationships decreased from 52.8% in 1975 to 10.7% in 2007, and neighborhoods that cooperated daily were reported to be 65.7% . These rIn addition, the incidence of poverty among children has become a social problem in Japan. According to a report by the OECD , the relAs described above, in the present study, NSC was found to influence children’s SH through parental lifestyle and children’s PA/ST. Therefore, for improving the SHs of children over many years, direct interventions and measures to improve parents’ lifestyles and the NSC surrounding them would be effective. We consider this an important study finding. This can be understood along the lines of Bronfenbrenner’s model, which states that the development of individual children is influenced by their parents, and the NSC around them is shaped by the social context determined by interactions over time . This stThis study had at least three limitations, and we would like to direct the focus of future studies towards addressing them. First, all data in this study were collected using a self-reported questionnaire, as this is an effective way to collect data from large sample sizes. However, a more detailed examination based on objective data is required. Second, factors other than NSC, which affect the lifestyle of children and their parents, were not examined. In this regard, a model verification that accounts for economic, cultural, and time capital should provide future directions. Third, we were not able to examine the relationship between the SH of children and health problems. In Japan, after the high economic growth period, people have been worried about ‘physical disorders’ among children. This issue was also indicated in the report on citizens and NGOs regarding the Rights of the Child . LikewisThis study examined the pathways linked to SH among children and adolescents, regardless of sex and/or school stage, enrolled in the third grade or above at all public elementary and public junior high schools in Setagaya-ku, Tokyo. In total, 22,385 pairs of child–parent responses were used. The results confirmed that the NSC surrounding parental pathways had links to children’s SH through parental lifestyle and children’s PA and/or ST. Thus, we concluded that it is necessary to provide direct interventions and take additional measures to protect parents’ lifestyle and their NSC, to solve persistent sleep problems in children.


How did this happen? What are the consequences of framing and foreseeing the pandemic in these modes? Focusing on historical and contemporary disease responses, primarily in Britain, I explore the emergence of statistical modelling as a ‘crisis technology’, a reductive mechanism for making rapid decisions or judgments under uncertain biological constraint. I consider how Covid-19 might be configured or assembled otherwise, constituted as a more heterogeneous object of knowledge, a different and more encompassing moment of truth – not simply as a measured telos directing us to a new normal. Drawing on earlier critical engagements with the AIDS pandemic, inquiries into how to have ‘theory’ and ‘promiscuity’ in a crisis, I seek to open up a space for greater ecological, sociological, and cultural complexity in the biopolitics of modelling, thereby attempting to validate a role for critique in the Covid-19 crisis.During the past forty years, statistical modelling and simulation have come to frame perceptions of epidemic disease and to determine public health interventions that might limit or suppress the transmission of the causative agent. The influence of such formulaic disease modelling has pervaded public health policy and practice during the Covid-19 pandemic. The critical vocabulary of epidemiology, and now popular debate, thus includes R He was concerned that many humans could summon up nothing but fatigue and inertia in response to such horrors. ‘I know that for a long time already,’ he told readers of American Vogue, ‘we humans have been ill at ease in our skins, have been unsure of the future, which is not a normal state for supposedly civilized men’  in Europe from the seventeenth century onwards. Its everyday clinical significance gradually declined, though lingering in the vague parlance of ‘critical’ condition and ‘critical’ care. Meanwhile, the concept of crisis has come increasingly to frame the body politic, denoting a ‘moment of judgment and diagnosis, as well as the prescription for a therapy’ (la crisi) consists precisely in the fact that the old is dying and the new cannot be born; in the interregnum a great variety of morbid symptoms (fenomeni morbosi) appear.’3 Unlike other organic analogies, such as reproductive and life cycles, a crisis is anticipatory, progressive and dynamic. Thus, the concept of crisis, To the ancient Greeks, the word ‘crisis’ meant discrimination or decision. In the Hippocratic corpus, a crisis was the moment in a disease or fever when its course is determined, a turning point tending either to recovery or death. It implied that a verdict or judgment had been reached. Accordingly, therapy’ : 370. Botherapy’ : 275–2764 When epidemic diseases such as cholera swept across Europe and North America in this period, such health crises, magnified across a population, prompted the development of statistical maps and charts in efforts to render them coherent and actionable , and ‘flattening the curve’ and epidemic ‘waves’ – how did this come to be, and what is the function of framing and foreseeing the crisis in this mode? These are issues that concern me here.‘In this moment of crisis’, conservative historian François-René tionable . Outbreasic] best equivalent of the instruments with which the physicist speeds up the processes of matter in order to make them more “visible”.’ The crisis becomes a sort of functional focal point in a structural and organic skeleton. The Berkeley historian was reflecting on the proliferation of crisis talk during the Cold War, much of it involving nuclear flashpoints or youth rebellion or Western civilization or population growth, not emerging infectious diseases. Few in the Global North perceived any crises in the economy or public health in that turbulent era. Even so, ‘notions of crisis cropped up everywhere … in the past two decades’, Starn observed (p. 14). ‘Crisis interpretations have displaced older interpretative scaffoldings’ . I have reservations about submitting to the wisdom of lived experience  – the ‘mad-cow’ crisis – of the 1990s. Since 1985, farmers in southern England had been reporting strange behavior in their cattle, with many beasts losing weight, staggering, falling down and dying. Postmortem examination showed surprisingly spongy brains, resembling those from sheep that died from scrapie and from humans who succumbed to kuru or Creutzfeldt-Jakob Disease (CJD). All of these diseases are infectious, and uniformly fatal, though at the time the causes were still enigmatic: some medical scientists attributed them to a ‘slow virus’, alluding to the presumed agent’s long incubation period, while others suspected a misshapen transmissible protein, called a prion. The BSE epizootic had been propagated through industrial feeding of contaminated meat and bone meal to herbivore cattle. By 1990, tens of thousands of the national herd were afflicted; at the end of the decade, almost two hundred thousand had perished. Within a few years, it was reported that scores of Britons were developing a new variant of CJD, the likely consequence of abnormal prion exposure through beef consumption . Roy Andination’ . They sh0 value below one … became the dominant rhetorical tool in scientific and political debate around the management of risk’ . Yet Ferguson and his colleagues warned that ‘no public health intervention with such disruptive effects on society has previously been attempted for such a long duration of time’ (p. 16). Soon after reading the report, Prime Minister Boris Johnson began awkwardly to change tack, lurching toward mechanisms to suppress the virus. The model proved a decisive, even critical, arbiter. When Britain ‘locked down’ on March 23, there had been, cumulatively, 798 confirmed cases of Covid-19 and eight deaths. By the end of April, more than 160,000 Britons had tested positive and at least 21,000 had died from the coronavirus, but the curve slowly was flattening. Perhaps rashly, Johnson then decided to ease restrictions , specifying transmission rates between them. ‘The model’s reliance on a simplified picture of social interactions limits its extensibility,’ they concluded. When alternative network and individual-based models, so much more adept at capturing heterogeneity, are available, ‘why are we still using models developed 15-20 years ago?’ .14 The cmplexity . To compmplexity , 2020b. mplexity : 484. AcLancet, The principle of deploying abstract models to shape decision making in a crisis elicited more general criticism. Some condemned reliance on modelling and displacement of ‘old-fashioned’ epidemic control techniques such as surveillance and testing, contact tracing, and isolation of confirmed cases – even though the epidemic in Britain had long ago outpaced the capacity to roll out such procedures. The editor of the anticipated potentials, affecting actions, publics and policies in-the-now’  of security’, developed during the past two centuries in response to ‘epidemics and the medical campaigns that try to halt epidemic or endemic phenomena’. The securitizing apparatus is constituted through calculation and analysis and regulation, transforming the normal into a statistical distribution around a norm, conjuring a milieu in which other mechanisms of biopower, whether juridico-legal or disciplinary, might exert effects on a population. In Foucault’s schema, security is a way of making ‘the old armatures of law and discipline’ (p. 10) function in organizing a collective, not just in punishing or transforming a singular body or subject. Evidently, security responses to Covid-19 have involved centrifugal expansion of juridical processes, which punish and exclude, as well as disciplinary strategies, which codify what is forbidden and permitted in daily life, drilling and correcting populations (dispositifs predicated on simple contamination, bruiting the danger of contact without context, would seem to generate more coercive or repressive force fields of biopower, commanding, for example, lockdown, curfew and border closure, measures involving the suspension of rights. Whereas modelling more sensitive to ecological and sociological configuration – to complex and particularistic assemblage – would appear to necessitate and to enable disciplinary measures, reaching more deeply into the social body, changing conduct and the sense of the self, reforming customs and habits, and adapting a population to the new normal.15 The different premises and parameters for modelling the crisis, for reducing R0, can thus produce distinct subjectivities and collectivities – sometimes a diverging, and then again sometimes a composite, politics of life.Such disparate visions of contamination and configuration evoke different politics of life. What sorts of population or herd may be brought into being through operation of a crisis technology like modelling? The statistical model or simulation surely exemplifies what ulations . Models theory in an epidemic. According to To engage the problematics of apprehending a pandemic surely requires critical inquiry, in the sense that ‘critique’ and ‘critical’ derive from the same root as crisis. Passing judgment on the merits of something is what we must do in a crisis. Impure Science, 16 It was critique as One could translate that struggle into another question in another era: How can we have critical theory in the Covid-19 pandemic? That is, how might Covid-19 be refigured or assembled otherwise? Can critique reconstitute the crisis as a more encompassing and ambient subject of knowledge, affording room to maneuver? Can it socialize or de-herd or ecologize or even queer our models? This is, of course, a reiteration of Treichler’s quest to undertake critical theory in relation to the AIDS epidemic. She was making a plea for ‘the careful examination of language and culture that enables us, as members of intersecting social constellations, to think carefully about ideas in the midst of a crisis’ : 1. She 17 So, too, does Covid-19, more or less. Silence equals death, as we used to say. Recall ACT UP – the AIDS Coalition to Unleash Power, which was inspiring Crimp’s reflections on how to have promiscuity in an epidemic. Or, just get busy with the abstraction of a pandemic, as Camus once proffered. Perhaps, then, we could start with some critical promiscuity.Treichler’s question of theory was a deliberate echo of


Female genital mutilation (FGM) is conceptualized as an interpersonal act,commonly initiated by mothers. This study investigates relational dynamics amongadult women who experienced FGM in childhood and have since migrated to theUnited Kingdom. A qualitative research design was employed, usingsemi-structured interviews and interpretative phenomenological analysis (IPA)with nine women. Three superordinate themes emerged: (a) “The ‘who to blame?’conflict: Preserving goodness in parents”; (b) “Better or worse? Positioning theself in relation to others”; and (c) “Regaining power: Righting the wrongs.”Implications for understanding the relational consequences of FGM and thediscontinuation of its intergenerational transmission are considered. FGM touches the lives of an estimated 200 million women and girls worldwide. The praThe sociocultural context surrounding the practice varies considerably acrossregions, including the age at which it is performed, from newborns to teenagers.It may be performed covertly or celebrated as part of a wider initiationceremony. Cutting the genitalia may represent a “rite of passage” into womanhood,believeThe ancient tradition of “female circumcision” was transformed linguisticallyinto “Female Genital Mutilation” (FGM) by Notwithstanding its international recognition and role in the safeguarding ofwomen and girls at risk, “FGM” discourse also has the potential to perpetuatestigmatization, disempowerment, alienation, and persecution of women ,particuFGM is an interpersonal act that occurs within families and perpetuates throughintergenerational transmission, most commonly organized by mothers for theirdaughters . There iSome women report a sense of betrayal by their families and communities .So-callFurthermore, the well-documented health consequences of FGM are inextricable fromthe relational lives of women. Studies of sexual dysfunction show that couplesreport low sexual satisfaction, frequent pain and discomfort, and some womenview sex as a duty to the husband rather than a pleasurable or desirableexperience . The subFew studies to date have investigated women’s experiences of FGM in a relationalframework. In a mixed-methods study, Predictably, the mother–daughter relationship has been identified as a meaningfularea of study regarding FGM. Migrant women were interviewed in a grounded theory study that produced a modelof psychosocial consequences of FGM . Again, Finally, a thematic analysis of interviews with migrant women by Despite the interpersonal nature of the phenomenon, there remains a paucity ofresearch into relational consequences in the FGM literature. This study aimed toaddress this gap by employing a qualitative methodology to explore thesubjective intricacies of relational dynamics in a small number of adult migrantwomen in the United Kingdom who experienced FGM in childhood. It aimed toachieve a greater understanding of women’s relationships with their mothers,partners, and other important figures in their lives, in relation to theirFGM.The study used a qualitative research design, utilizing interpretativephenomenological analysis (IPA) and semi-structured interview methodology. IPAdraws upon three philosophical stances of inquiry: phenomenology or the study ofexperience; hermeneutics, that is, the theory of interpretation; and idiography,which is the focus on the particular . This alAdult women (18 years or older);Experience of FGM in childhood ;Able to understand the study remit and give informed consent.Participants were recruited from two sites. The first was a specialist FGM clinicsituated within a U.K. National Health Service (NHS) gynecology department inLondon, offering diagnostic services, deinfibulation procedures, and specialistcare for pregnant and nonpregnant women with FGM. The second was a charityorganization in Reading that supports women with FGM through group meetings,education, and awareness events and campaigns.Convenience sampling was used to recruit women who met the inclusion criteriaat the two sites. The study was advertised through verbal invitation by theservice leads on an opt-in basis. A total of nine women participated in thestudy; five from the NHS clinic and four from the charity group. Some womendeclined on the basis of being unwilling to be audio recorded or not feelingready to talk about their experience; however, it was not possible tosystematically record data on refusals due to the recruitment method usedand practical constraints of the settings. The sample size was consideredoptimal for the IPA methodology: large enough to identify themes andillustrate variation, and small enough to preserve the richness and depth ofidiosyncratic lived experiences .A brief demographic questionnaire was administered to gather basicinformation about participants at the start of each interview to situate thesample in their personal and familial contexts.A semi-structured interview schedule was developed in line with IPAprinciples in being open-ended, expansive, and aimed at capturing subjectiveexperience while using prompts flexibly to steer the topic toward theresearch aims. Participants were asked about their experience of FGM andwere invited to talk about how they thought about it in relation toimportant people in their lives. Interviews were conducted face-to-face bythe primary researcher . An interpretation service was offered for those who needed, orpreferred, to speak in their native language. All participants opted tospeak in English. Interviews were audio recorded and ranged between 25–60min in duration.A bracketing interview was conducted prior to participant interviews, whichaimed to identify prior assumptions, biases, and expectations of theresearcher in engaging with the research subject to minimize the impact ofpersonal prejudices on the procedure and results. Each participant interviewwas followed by a reflexive discussion between the researchers to reflect onthe process of interviewing, consider participant well-being, explore anysafeguarding concerns, and discuss any adjustments necessary to facilitatethe telling of rich, elaborate narratives. All interviews were considered ofadequate quality for inclusion.Ethical approval was granted by Queen’s Square Ethics Committee. Participantwell-being was prioritized at all stages of research in line with the BritishPsychological Society code of human research ethics .ParticiBoth researchers were experienced in qualitative data analysis. Analysis wasinformed by Nine women who met the inclusion criteria agreed to take part in the study. All participants had migrated from their countries of origin and had lived asworking residents in the United Kingdom for a considerable length of time andall had good or excellent English language ability. All were either married ordivorced. All but one were mothers or soon-to-be mothers; three women werepregnant at the time of interview. There was a range in FGM type reported andtwo women were unsure or there was a level of unclarity. Of the four women withType III, all had undergone deinfibulation (opening) procedures in the UnitedKingdom. There was a wide range in estimated age at the time of FGM and also inwhether or not the event was remembered. Each participant was randomly allocateda pseudonym that will be used throughout the article to preserve anonymity.Verbatim quotes will be used to illustrate themes.Three superordinate themes emerged through the data analysis alongside 12subordinate themes displayed in All participants presented in their narratives an apparent need to locate blamefor their FGM. FGM was strongly condemned and perceived as a deliberate,relational act with an originator, a decision-maker, and colluding bystanders.At the forefront of blame were the parents as the ones responsible for makingdecisions for their children. However, the situation becomes complex and blameshifts between those who are known  andthose who are unknown  who are less readilyabsolved.My Dad always lets my Mum have it her way but yeah . . . um . . .that one wasn’t a good one, I think my Dad should have stopped her.Some participants expressed anger toward their parents for organizing theirFGM or for failing to protect or prepare them. Particularly guilty weremothers; fathers were less present in narratives in comparison, although attimes they were blamed for not exerting their authority and protecting themfrom the mother or grandmother:That changed through the years, yeah that has changed because um . .. I have realised that my mum felt so bad of what I went throughpersonally . . . because when I was a teenager she will call—shewill see me go through a painful life, like having pain all the timeand she regret a lot . . . she regret because she said I didn’t knowbetter . . . I didn’t know better . . . otherwise I would not havedone that. Grandmothers were also absolved of their involvement, which was influenced bymost of them being deceased and thereby were forgiven. Attitudes changedover time with maturity and the influence of critical life events, such asbecoming a parent oneself, asking parents questions, or receiving an apologyor expression of regret:The nature of the intentions behind the parental decision was deemedimportant. Relief was found in the belief that parents had good intentions,rather than acting maliciously. Initial confusion, anger, and feelings ofbetrayal often turned to acceptance and forgiveness, with greater sympathyfor their parents’ fallibility, lack of education, and societalpressure.I never thought that my Mum actually done something bad . . . butwhen she . . . apologised for it and she was talking about it . . .after the phone call I had to sit down and think about it, and I waslike . . . wait, was it bad? Like what’s wrong with me now? I feltlike there was something wrong with me [laughs]. Aisha alludes to a possible function of preserving the parents as good tosimultaneously preserve the self as good, particularly in the context ofstrong identification and close relationships with mothers.The nurse itself—herself, sorry . . . um . . . you should beeducated. Why are you doing this? Why are you getting money to hurtpeople instead of making sure people are safe? Those kind ofquestions will go in my mind, thinking . . . and then I was gettingangry as I talk and saying like . . . I don’t know . . . yeah.The “cutters” who performed the FGM were frequently mentioned but were almostalways unknown, sometimes unseen due to the girls being blindfolded. Theywere dehumanized and described as brutal, faceless aggressors. Theirqualifications were important; either they were unqualified and thereforeillegitimate, dangerous, and irresponsible, or they were educatedprofessionals such as nurses or midwives and should have known better thanto hurt children for whom they ought to be caring:Cutters were not absolved of blame and it may have been preferable toparticipants to direct anger and aggression here rather than toward theparents and wider family.I don’t know. I—I know she didn’t want it. So I can’t actually blameher a lot. Although as I—as I said it was like a social norm. Kindof I wanted it as well, so I won’t actually blame her. First of all,she doesn’t want it, and it’s a social thing that you want to getbelong to a certain group, so I can’t blame her. I can’t blamemyself, it’s just . . . one of those things that . . . if educationwas there, if you were educated . . . Most women described a wholly nonconsensual FGM experience, particularlythose at a younger age. Some, however, recalled insisting that their parentslet them have FGM, or going there willingly. This was not an informed choicebut a desire to be like everybody else and join in an exciting ceremony suchas in the “Bondo” society of Sierra Leone. There was a tendency amongparticipants to apportion blame to themselves for their FGM directly or fortheir inability to cope with the consequences or the impact on others. Thereseemed to be a tension between taking some blame away from parents but notwanting to take all of the blame due to the negative impact to the self.Blame could be directed outward instead:A lot of these people it’s not their fault, they’ve got nothing to dowith it, but it’s what tradition and society has succumbed them todo, and that’s what happened. Women described powerful social forces to which their parents were subjected.Religion was protected from blame but wider “culture” and ancestral“tradition” were held strongly accountable for parental impotence regardingFGM. Parents were perceived as doing the same as everyone else, trying to doright by their families in the context of FGM being the social norm:There was an inevitability and inescapability to FGM in this powerfulcultural context, with individual resistance feeling futile.Intergenerational and community pressure were thought to be strong, andthere was a desire in some to locate the ultimate originator of thepractice. There was also recognition of how culture has changed over thecourse of their lifetimes, particularly with regard to education about thehealth consequences of FGM, evoking a hopefulness for change in culturalnorms.Women continually positioned themselves in relation to important people in theirlives. This seemed to reflect a confronting of the question, “Am I lucky forsurviving my ordeal or unlucky for being afflicted in the first place?”Negotiating this dilemma seemed to have implications for one’s sense ofself-worth and belonging in social systems.The husbands of participants were described in strongly favorable terms: assupportive, understanding, and loving. These qualities were contrasted withthe way women described themselves, as though they were failing in theirrole as wife. Stories of sexual inadequacy were commonplace, with womenexclusively locating the problems within themselves by way of pain anddiscomfort, coldness and avoidance, lack of desire, and absence of pleasureand enjoyment. Transparent communication about FGM being the reason for thissituation protected them against husbands feeling rejected or unloved andmaintaining marital harmony. Husbands were credited with being patient,dedicating extra effort to enable her to achieve pleasure and remainingfaithful rather than leaving her for an “uncut” woman. Women said they feltgrateful and lucky to have such good husbands and told stories of other menwhom they said could be pressurizing, forceful, and unfaithful.I was lucky, I got someone who was very understanding so . . . it allcomes down to him that he is able to cope with it. If that isactually affecting my relationship with my husband, if he left mebecause of that, then I’ll have gone back and said Mum, see . . .This quote suggests that this husband is credited not only with goodqualities, but also with protecting his wife against a more severeinterpersonal impact and confrontation with the mother.I must say I have been lucky in the sense that I didn’t have most ofthe complications that women do have and suffer with. Women evaluated the impact of FGM on their lives by way of comparison withother women. Frequently told were horror stories of death, tragedy, and moresevere complications than their own. Relief was found in feeling “lucky” incomparison with other women and having escaped something much worse:The practice in Sierra Leone is not that bad as the other like someother countries where they cut and they sew and all of that. This seemed to be a way to bolster self-worth. Women made individualcomparisons, particularly with sisters and friends, and compared theircountry with the practices of other countries:Actually . . . I think three and two . . . one is better than that.One is actually they just take the clitoris, but it won’t cause youany harm or . . . difficulty of giving birth or also you see moreinfection because of they take out everything. It’s very hard.Different FGM types were also evaluated by comparisons. This woman describedfeeling her Type III was worse than her Type I counterparts:And um, it’s very painful really I mean . . . I feel like . . .[sigh] I’m not normal like other ladies . . . that’s why I ask . . .if they can do anything about it, they can do they can repair the .. . this damage, I know it’s very . . . I’m old [laugh] but I feellike I want to live like normal people. I want to live, I want tofeel. I want to feel like other people feelings. Najma seems to say that she, unlike others, has had “everything” taken fromher. Feeling worse off or unlucky in comparison with others seemed to evokea painful sense of inferiority or shame. Women who felt unlucky also held asense of being damaged or abnormal. Migrating to the United Kingdom wasthought to impact on comparison tendencies as the environment changed to onewhere FGM is no longer considered the norm:I felt different in terms of . . . getting married, I was so scaredto get married, thinking . . . what is gunna happen when I getmarried? What the person gunna say? They gunna say what happened toyou and you know . . . I was so scared . . . for me to even thinkabout to get married or have uh . . . sex with someone, alwaysthinking there’s something wrong down there and they will find outand they will tell me like things . . . Women provided insight into a need to belong in one’s community: to feelsameness, connected, and secure in one’s in-group. Exclusion was considereda worse outcome than physical pain, which was a frequently reported reasonfor the perpetuation of FGM within societies where it is considered the normand “uncut” girls are ostracized and shamed. This situation reversed for thesample after migration to a nonpracticing country. FGM was treated by someas a shameful secret, hidden from view, and there was a fear of rejection,judgment, or attack for being different. This fear related most strongly tofriendship groups and potential partners:Another participant believed that her divorces were directly linked to hersexual failings caused by FGM, and that she subsequently suffered with anintense fear and anticipation of repeated abandonment in relationships.They sort of did it as a form of loyalty to their parents, to honourthe last thing that they wanted from their grandkids before theydie. So they sort of like they did that so I don’t know if becausethat burden wasn’t on them anymore, to like please anybody or theirparents, so they didn’t just go there anymore. Women’s narratives emphasized the importance of responsibilities associatedwith their position in their family structure and hierarchy. Althoughinevitably culturally and individually varied, women presented a set ofassumptions about family roles. For instance, older sisters took care ofyounger sisters, boys protected girls, and fathers were largely absentalthough they held authoritative positions. Children belonged to theirparents. It was not acceptable to act against one’s parents. This, ofcourse, also applied to one’s grandparents, raising the question of who runsfamilies, parents or grandparents? These implicitly understood social rulesnot only seemed to help make sense of relational dynamics, but also raisedconfusion when expected roles were not fulfilled—for example, whenprotectors were not protecting, or when authority figures were impotent.Idil considers the impact of grandparents’ wishes on her parents’ decisionto allow FGM and how positions changed once the grandparents passed away:The women strongly condemned FGM, regarding it as a moral issue in which they hadbeen wronged; a wrong that needed to be put right somehow. Some gave lengthy,descriptive accounts of their FGM experience, vividly portraying theirpowerlessness in the face of serious danger and disablement. Women depictedthemselves as survivors, having endured unconscionable pain without medical aid,reflecting a view of themselves as strong, while mourning for their lostchildhood innocence. Acts of resistance took many forms and there was a strikingfocus on creating something good from suffering, rather than seeking revenge orperpetuating wrongdoing.Um . . . I’m glad I know now, because in the life if I’ve got child,I will never put through my child ever or like . . . somehow it wasa sign for me to having this . . . so at least . . . if any myfamily or anyone else, I could literally stop . . . I could at leastsave someone . . . you know what I mean? Women described a situation in which they were unprotected from the dangersof FGM in childhood. Some talked of entering into their “initiationceremony” blind, blissfully ignorant, and how this was felt to beexploitation by a system of knowing adults. The people whom they expected toprotect them from harm—parents, grandparents, nurses, community elders, andfriends—failed to do so. Women described how, as they grew up, they assumedthe role of protector themselves. They all exhibited a fiercely protectivestance toward their own children (or future children) and voiced a strongdesire to “save” younger members of their family and the younger generationof girls more widely. Taking an authoritative position, engaging in activismand campaigning, and shielding their own daughters from FGM, they became thewished-for parents and protectors, and disrupted the intergenerationaltransmission of powerlessness:I wish I didn’t know. But in . . . somehow I wish I didn’t know andsomehow I . . . it’s better to know . . . if I got married to thisperson or we have any kind of relation . . . he would . . . he willleave me . . . and I will go back to the same circle asking why andwhy. Some women had vivid memories of their FGM experience and described attemptsto suppress and forget. Others were too young to remember and learning abouttheir FGM in adulthood was a significant event, often difficult to process.There was a conflict of knowing; on one hand, it was helpful to understandbut, on the other hand, considered a painful burden. This woman believedthat continued avoidance of knowing would result in a continued pattern ofabandonment in her romantic relationships:I think we just need more education, just to educate people. It willchange. ’Cause once you empower the young ones . . . Avoidant defenses were commonly described to prevent knowing . At the same time, many women showed a clear pursuit of knowledgeabout FGM. There was a desire to be educated about the association betweenFGM and symptomology. Once educated, women put great faith in the power ofeducation to stop the practice of FGM and help others:There was a belief that if only their parents had been educated about theharms of FGM they could have been spared. This idea of knowledge as powercould also be conceptualized as an act of resistance against the secrecy andblinding experienced as a child.brainwashing” . Some women described howthe societal silencing of FGM discourse could cause disconnection inrelationships with husbands, siblings, parents, and friends, and breakingthe silence was both frightening and freeing. For some, speaking out aboutFGM risked real physical danger, and migration allowed increased freedom.Numerous modes of expression were found in support groups, psychotherapy,public speaking, and sending family members news stories or pieces ofresearch. Talking about FGM could be painful but was generally considered helpful:It helps a lot, it ease that tension you know it ease that pain, itease that burden that you feel now, because before people don’t talkabout it, you feel shy to even talk about it, to say I’ve beenthrough it, you know, even though . . . we know . . . that it’s onlynow that FGM came in the open that people feel happy to talk aboutit. Before because even when you go through that, in there, it’s ataboo. They say to you, you do not ever talk about this when youcome out. So you never ever talk about it. You’re a child. Obviouslyif they say that to you what would you do? You keep quiet, you know.So it’s only now people feel free, people are happy to talk abouttheir experience, share their experience and things like that to behonest, which I’m glad about to be honest. I’m really, really gladabout that, ’cause you know you just feel all bottled up, you’ve gotthat heavy thing in your heart, you can’t talk about it, you can’t .. . but now you can talk about it anywhere, I don’t care where Italk about it. The taboo surrounding FGM had a strong presence in narratives. Taboo wasdescribed as an oppressing force embedded in culture and strictly, evenviolently, enforced through manipulation, coercion, and“This theme was mirrored in the research interview process; at follow-up, manyparticipants described finding the interview therapeutic, saying it was notusual for them to have a space to freely express personal feelings abouttaboo topics such as FGM and sexuality, and that they felt strongly aboutbeing able to give something to help others through telling theirstories.Yeah because I really want everything natural, I don’t want the gasand air or anything . . . like I wanna . . . experience—this soundsa bit weird but, the pain I don’t know [laughs], like I wanna havemy child naturally so that I can talk to her about like . . . Idon’t want . . . ’cause I’ve seen it cause . . . and in some . . .cases I’ve seen some female when . . . they’ve been asked to pushand stuff . . . like they don’t know what’s going on, they have tobe told like, the midwives that are looking at them telling them OKyou’re in this much pain, I wanna know what’s going on, don’t wantanybody to tell me, I think maybe I’m a control freak a bit init—Iwanna be in control of my feelings [laughs], I wanna experience thepain like that . . . um so yeah . . . no . . . I’m gunna go for it.A fundamental difference between purposeful and purposeless pain emerged inwomen’s accounts. FGM for some incurred lifelong physical and emotionalpain, and was considered by many to be devoid of purpose; the justificationsavailable were deemed unacceptable. In contrast, women found great purposein the pains of childbirth and motherhood, which represented womanhood andnaturalness that were deemed very important:Childbirth stories like Aisha’s seem to reflect a mastery of a previous stateof powerlessness. Similarly, deinfibulation was perceived as a purposefulchoice, painful at first but representing openness and liberation.Motherhood was depicted as an opportunity to be a creator, an educator, andto be responsible for one’s child, and a new beginning with the chance to dothings differently from one’s own parents.This study used IPA methodology to explore the relational dynamics of women whoexperienced FGM in childhood and migrated to the United Kingdom. Three superordinatethemes emerged: capturing a conflicted interpersonal blaming process, a positioningof the self in relation to others, and a regaining of power from a previous state ofpowerlessness. The findings will be discussed in light of existing theoretical andempirical literature. Limitations of the study and real-world implications forpolicy and practice will be considered.Women were greatly concerned with attributing blame for their FGM but faced atension between the need to blame and the need to preserve one’s parents asgood. Parents were largely absolved of blame through justifying and sympathizingwith their impotence; however, cutters and wider culture remained guilty andsome self-blame was reported. This is a similar finding to the blaming processseen in Blame is an inherently social process; it attributes badness to another personand makes judgments on their intentions and moral character . It makeWhereas FGM is classified as child maltreatment by international definitions, such coAttributing the majority of blame to “culture” or “tradition” appeared to easethis tension for participants. If blame poisons relationships, it may be saferto direct it toward faceless objects or systems. Nonetheless, blaming “culture”is not without interpersonal consequence. Shunning or denigrating an aspect ofone’s culture may pose a threat to one’s identity and sense of belonging,particularly in the context of settlement into a Western culture, and increasethe need to redress self-worth by comparison with others. Participantscontinually positioned themselves as better or worse in relation to others. Theyreflected upon their need for belonging and connectedness, and the consequentialpain of exclusion, rejection, inferiority, and abandonment when this was notmet. The psychological need to belong is ubiquitous and part of the essence ofhumanity e.g., . It depiInterpersonal relationships also contributed to women’s sense of good fortune or“luck.” On one hand, women reported feeling lucky compared with others. Feelinglucky may be a characteristic of survivorhood, serving to defend againstvictimhood and its associated inadequacy and vulnerability. Whereas victimhoodevokes powerlessness, survivorhood can evoke a prosocial sense of duty to helpothers less fortunate, as seen in participants’ engagement in activism andhelping younger members of their family.On the other hand, women could feel unlucky, different, or inferior. Fear ofrejection, particularly by men, was offset by gratitude and indebtedness towardtheir husbands, who supported and stayed with them, despite a range of perceivedsexual inadequacies. Here, women described being lucky in their unluckiness.This relational imbalance may perpetuate a patriarchal power dynamic in whichwomen are emotionally, and/or otherwise, dependent on husbands due to aperception of being “damaged.” A psychoanalytic view put forth by Women strove to regain power in adulthood, and relational dynamics changed asthey grew up and took on different roles in their family structure. Far frompresenting as victims, women not only survived experiences of extremedisempowerment, but also they later thrived in coping with pain and adversity,helping others, speaking out despite powerful barriers of silencing and secrecy,and campaigning and advocating social change, thereby challenging a reductionistnarrative of adversity leading to only psychopathological outcomes. That is notto deny the potential traumatization in this population but to acknowledge theways in which adversity can also engender significant strength. Some womengained a sense of mastery over powerlessness through the childbirth event, mostlikely due to its similarities with the FGM experience—for example, repeat cuts,extreme pain, feeling helpless at the mercy of professionals, and a period ofhealing and recovery—a way of repairing wounds in the present that cannot bechanged in the past and finding meaning in otherwise “purposeless”suffering.Women reported disrupting the intergenerational transmission of FGM by protectingtheir daughters and the younger generation at large. They resolved to do thingsdifferently from their ancestors and took upon themselves the responsibility todo for their children what they wished their own parents could have done forthem: to protect, educate, and exert authority. Indeed, Women may have felt able to regain power because they were able to face the painof their experiences: to bear the burden of knowing, rather than sustainavoidance or dissociation. Migrating to the United Kingdom may have made it moredifficult to avoid the issue. This study adds depth to understanding the relational dynamics of women who haveexperienced FGM. It took a holistic, rather than pathologizing, orientation andfocused on subjectivity of experience. This contributes to an ethos ofunderstanding before explaining complex phenomena  that canThis study contends that psychological well-being is socially situated andcommunity-based interventions may need to be considered for women who areafflicted by social isolation, feeling different or damaged, feeling silencedand unable to access help, or experiencing strain in marital relationships.For those who seek psychotherapeutic intervention, the current findings mayprovide clinicians with a sense of the complexity of issues associated with FGMand help them avoid taking a stereotyped view of women as victims, which canperpetuate systemic disempowerment. Studies exploring practitioners’ attitudestoward working with women with FGM report a significant gap in knowledge,understanding, and confidence in this area . OnehelWomen identified that the typology of FGM (Type I to IV) could contribute totheir tendency toward “better or worse” comparisons, and clinics ought toconsider the support offered around diagnostic labels and recognize that medicalterms are not neutral. Future research could further investigate women’sexperiences of typological labeling, with reference to the broader issue of“mutilation” discourse and its personal and societal impact.The findings have additional implications for understanding why some womenchoose, and feel able, to successfully disrupt the intergenerationaltransmission of FGM. Women identified a need for safety and agency to expresstheir views and act more freely. Many had been supported to make meaningfulcontact with their pain rather than dissociating, which enabled them to seekknowledge and educate others. This highlights the importance of survivor-ledtraining and education programs. Further research may elucidate the relationshipbetween dissociation and discontinuing FGM, explore how migration and educationimpact on attitudes, dissect the reasons why some women cease to continue thepractice, and help others to overcome powerful barriers to discontinuation whilemaintaining an important sense of cultural and familial belonging.The findings of the current study must be considered in conjunction with acareful examination of the sample characteristics that limit generalizability.All participants were good English speakers, well-educated, and long-settledmigrants working in the United Kingdom. Invitations for non-English speakers toparticipate with interpreters were not taken up, so this group was notrepresented. There will inevitably be stories that are silenced by fear of therepercussions. In addition, participants were recruited through an NHS clinicand a charity group that campaigns against FGM, and this is likely to produce abias in terms of the stories presented. It is quite possible that those withpositive or neutral attitudes toward FGM would describe different relationaldynamics. The “pro-FGM” group is more difficult to access in the United Kingdomdue to the legal implications of professing to have practiced or intending topractice FGM on one’s children and fear of judgment from professionals. Thisgroup is therefore underrepresented in FGM research, including in the currentstudy.Data on refusal and drop-out rate were not systematically studied but would behelpful in future research to further understand sample biases. The more“disempowered” and “traumatized” groups identified by The current study provides insight into the relational dynamics of adult women whohave experienced FGM in childhood and since migrated to the United Kingdom. An IPAof women’s narratives identified a conflicted blaming process in which the need toblame someone acted in tension with the need to preserve one’s parents as good.Women also engaged in a process of comparison with others as better or worse off,which helped them negotiate a sense of identity and belonging, particularly salientin the context of migration. Finally, the women regained powerful roles in theirlives from a previous place of powerlessness and held a strong sense of duty toprotect the next generation of girls. The findings hold valuable implications forclinical practice and policy. Findings should be interpreted in the context ofimportant sampling biases and future research is recommended to investigate barriersfor more marginalized or silenced women to share their stories on FGM as a part oftheir personal and interpersonal lives.