Female Genital Mutilation in Sierra Leone: A Systematic Review of Cultural Practices, Health Impacts, and Pathways to Eradication

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

My Comments

The authors, committed to addressing the complex issue of Female Genital Mutilation (FGM), should incorporate recent studies on FGM in Sierra Leone, emphasizing its prevalence and the growing recognition of FGM as a public health concern. Their dedication to this cause will be evident in how they highlight the intersection of FGM with intimate partner violence and early marriage, shedding light on its broader health and social implications. Additionally, their commitment to the role of education in reducing FGM practices and its critical importance in achieving sustainable development goals should be clearly articulated. The authors should also address issues associated with FGM in both high-income and low- and middle-income countries, demonstrating their comprehensive approach to the subject. To structure the introduction effectively, the authors should adopt the 'Funnel Approach.' This involves starting with a broad overview of FGM as a global issue, providing a comprehensive understanding for the readers. Then, the focus narrows to its specific prevalence and impacts in Sierra Leone, providing a more localized context. Finally, the introduction concludes with the study's objectives and rationale, providing a clear direction for the research. This approach ensures a logical flow and engages readers by progressively focusing on the study's core themes. [Line 26 – Line 129]

 

 

The authors' work is significant, yet they have not effectively conveyed the rationale for this study, which is critical for helping readers grasp its significance and necessity. A clear articulation of the rationale would enhance the reader's understanding by highlighting the cultural context, the pressing health impacts, and the urgent need for actionable strategies to confront this entrenched practice. [Line 114 – Line 125]

 

The authors must explicitly state this study's overall and specific objectives. Doing that will give readers a clear understanding of the study's scope and approach. [Line 125 – Line 129]

 

This study does not adequately discuss Figure 1 with the necessary clarity and conciseness. The authors should incorporate a thorough discussion in section 2.3 to highlight its relevance and ensure the study is understood correctly. [Line 150 – Line 158]

 

The Authors should include a short introduction description in the result section before including Table 1. [Line 198].

 

In Table 1, the Authors should summarize the contents in Table 1 to give a clear meaning of the table, as it is essential for this study. The Authors should briefly summarize the table's key data points or findings, emphasizing how they relate to the study's objectives or hypotheses. This summary could be added as a textual description preceding or following the table, ensuring readers grasp its significance within the study's framework. [Line 199 – Line 200]

 

In the discussion section, the Authors should emphasize the importance of addressing cultural nuances in interventions, as sustainable change requires collaboration with local communities and stakeholders. They should also analyze key health impacts and potential eradication pathways to provide actionable insights for policymakers and health advocates. [Line 287 – Line 332]

 

The Authors should summarize the limitations of the study. Could you include the study's strengths in this section, with the sub-theme: Strengths and Limitations of the study? [Line 333 -  Line 360]

 

The Authors should comprehensively summarise the conclusion to encapsulate the study's key findings and contributions. This will ensure readers fully understand the overarching significance and impact of the research.  [Line 361 -  Line 406]

 

Proofreading and editing are essential for improving your manuscript. Focus on maintaining consistent formatting, such as font type, size, margins, and adherence to the required style guide (e.g., APA, MLA, Chicago). Carefully check for grammar, punctuation, typographical errors, sentence structure, and verb tense consistency. Emphasize the importance of ensuring a logical flow in the writing, with smooth transitions between sections and paragraphs, to make you feel confident in your manuscript's coherence. Remove redundant information, simplify complex sentences, and clarify technical terms to enhance readability and professional presentation. A combination of grammar tools and manual review is recommended for thorough editing. [Line 2 – Line 524].

 

"The authors should thoroughly review the referencing and ensure the referencing style aligns consistently with the required guidelines. This includes verifying the accuracy of in-text citations and the reference list and checking for uniformity in formatting, such as author names, publication dates, and titles, to maintain a professional and cohesive presentation. [Line 420 – Line 520]

Comments on the Quality of English Language

Proofreading and editing are essential for improving your manuscript. Focus on maintaining consistent formatting, such as font type, size, margins, and adherence to the required style guide (e.g., APA, MLA, Chicago). Carefully check for grammar, punctuation, typographical errors, sentence structure, and verb tense consistency. Emphasize the importance of ensuring a logical flow in the writing, with smooth transitions between sections and paragraphs, to make you feel confident in your manuscript's coherence. Remove redundant information, simplify complex sentences, and clarify technical terms to enhance readability and professional presentation. A combination of grammar tools and manual review is recommended for thorough editing.

Author Response

The authors, committed to addressing the complex issue of Female Genital Mutilation (FGM), should incorporate recent studies on FGM in Sierra Leone, emphasizing its prevalence and the growing recognition of FGM as a public health concern. Their dedication to this cause will be evident in how they highlight the intersection of FGM with intimate partner violence and early marriage, shedding light on its broader health and social implications. Additionally, their commitment to the role of education in reducing FGM practices and its critical importance in achieving sustainable development goals should be clearly articulated. Lot of thanks for your kind comments and suggestions, we have done a full revission of the paper, trying to apply all the reviewer's points for improvement.

 

The authors should also address issues associated with FGM in both high-income and low- and middle-income countries, demonstrating their comprehensive approach to the subject. To structure the introduction effectively, the authors should adopt the 'Funnel Approach.' This involves starting with a broad overview of FGM as a global issue, providing a comprehensive understanding for the readers. Then, the focus narrows to its specific prevalence and impacts in Sierra Leone, providing a more localized context. Finally, the introduction concludes with the study's objectives and rationale, providing a clear direction for the research. This approach ensures a logical flow and engages readers by progressively focusing on the study's core themes. [Line 26 – Line 129]- Lot of thanks for your kind comments and suggestions, we have done a full revission of the Introduction,making the changed and including all the reviewer's points for improvement.

 

 

The authors' work is significant, yet they have not effectively conveyed the rationale for this study, which is critical for helping readers grasp its significance and necessity. A clear articulation of the rationale would enhance the reader's understanding by highlighting the cultural context, the pressing health impacts, and the urgent need for actionable strategies to confront this entrenched practice. [Line 114 – Line 125] 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the Introduction, trying to explain clearlier the cultural context and the social pressure in the topic.

 

 

The authors must explicitly state this study's overall and specific objectives. Doing that will give readers a clear understanding of the study's scope and approach. [Line 125 – Line 129]- Lot of thanks for your comment, we have added the aims of the study.

 

This study does not adequately discuss Figure 1 with the necessary clarity and conciseness. The authors should incorporate a thorough discussion in section 2.3 to highlight its relevance and ensure the study is understood correctly. [Line 150 – Line 158]. 

Lot of thanks for your suggestions, we have done a review of this part, highlightong the Figure 1.

 

The Authors should include a short introduction description in the result section before including Table 1. [Line 198]. 

Lot of thanks for yourcomments, we have included a short description

 

 

In Table 1, the Authors should summarize the contents in Table 1 to give a clear meaning of the table, as it is essential for this study. The Authors should briefly summarize the table's key data points or findings, emphasizing how they relate to the study's objectives or hypotheses. This summary could be added as a textual description preceding or following the table, ensuring readers grasp its significance within the study's framework. [Line 199 – Line 200]. Lot of thanks again for your kind comment, we have summarized the contents in Table 1.

 

In the discussion section, the Authors should emphasize the importance of addressing cultural nuances in interventions, as sustainable change requires collaboration with local communities and stakeholders. They should also analyze key health impacts and potential eradication pathways to provide actionable insights for policymakers and health advocates. [Line 287 – Line 332]. Lot of thanks for your comment, we have changed the Discussion part in order to emphasize the relevance of the topic, and included proposal for policy makers 

 

The Authors should summarize the limitations of the study. Could you include the study's strengths in this section, with the sub-theme: Strengths and Limitations of the study? [Line 333 -  Line 360]. For sure, thanks again, we have done the summary of Limitations and included the Strenghts of the paper

 

The Authors should comprehensively summarise the conclusion to encapsulate the study's key findings and contributions. This will ensure readers fully understand the overarching significance and impact of the research.  [Line 361 -  Line 406] Lot of thanks again, we have summarize the conclusion.

Proofreading and editing are essential for improving your manuscript. Focus on maintaining consistent formatting, such as font type, size, margins, and adherence to the required style guide (e.g., APA, MLA, Chicago). Carefully check for grammar, punctuation, typographical errors, sentence structure, and verb tense consistency. Emphasize the importance of ensuring a logical flow in the writing, with smooth transitions between sections and paragraphs, to make you feel confident in your manuscript's coherence. Remove redundant information, simplify complex sentences, and clarify technical terms to enhance readability and professional presentation. A combination of grammar tools and manual review is recommended for thorough editing. [Line 2 – Line 524]. 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the paper

 

 

"The authors should thoroughly review the referencing and ensure the referencing style aligns consistently with the required guidelines. This includes verifying the accuracy of in-text citations and the reference list and checking for uniformity in formatting, such as author names, publication dates, and titles, to maintain a professional and cohesive presentation. [Line 420 – Line 520] 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the references int ext and the reference list, including several changes and new references.

 

Comments on the Quality of English Language

Proofreading and editing are essential for improving your manuscript. Focus on maintaining consistent formatting, such as font type, size, margins, and adherence to the required style guide (e.g., APA, MLA, Chicago). Carefully check for grammar, punctuation, typographical errors, sentence structure, and verb tense consistency. Emphasize the importance of ensuring a logical flow in the writing, with smooth transitions between sections and paragraphs, to make you feel confident in your manuscript's coherence. Remove redundant information, simplify complex sentences, and clarify technical terms to enhance readability and professional presentation. A combination of grammar tools and manual review is recommended for thorough editing. Lot of thanks for your kind comment, we have done a full revission of paper, including the English style and vocabulary. 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the paper

 

Reviewer 2 Report

Comments and Suggestions for Authors

The theme of the manuscript is particularly pertinent and current, especially for gender studies. The objectives are well defined, the methodology is adjusted and the discussion of the data refers to the most relevant aspects.
Therefore, the manuscript has consistency and quality and should be published in Women. In any case, perhaps the manuscript would gain more clarity and robustness if, on the one hand, the reference to Bondo society were further developed and, on the other, the anthropological explanations of female genital mutilation were reinforced.

Author Response

The theme of the manuscript is particularly pertinent and current, especially for gender studies. The objectives are well defined, the methodology is adjusted and the discussion of the data refers to the most relevant aspects.
Therefore, the manuscript has consistency and quality and should be published in Women. In any case, perhaps the manuscript would gain more clarity and robustness if, on the one hand, the reference to Bondo society were further developed and, on the other, the anthropological explanations of female genital mutilation were reinforced. Lot of thanks for your kind words, we really appreciate. We have included more information about the Bondo society, based on the reviewer´s suggestion, 

Reviewer 3 Report

Comments and Suggestions for Authors

Female Genital Mutilation in Sierra Leone: A Systematic Review of Cultural Practices, Health Impacts, and Pathways to Eradication

 

Thank you for inviting me to review this manuscript. The manuscript addresses an important, sensitive topic. It provides an overview of the cultural and health dimensions of FGM in Sierra Leone. However, for a manuscript aiming to qualify as a systematic review in a peer-reviewed journal, there are important methodological, structural, and stylistic issues that must be addressed. I have provided below some comments and recommendations that I believe will help the authors to improve their manuscript.

 

Abstract:

What do you mean by “utilizing a multidisciplinary approach”? It is unclear. Are you referring to a research design? If so, please use a research design that is appropriate for conducting a systematic review.

 

Introduction

-          The subheading statement “1.1 Understanding Female Genital Mutilation (FGM) in Sierra Leone” doesn’t align well with the introduction section. You may need to delete it. Allow the introduction to stand independently.

 

-          “Obiora, 2020” is not in your reference list. Please confirm inclusion.

 

-          Some of your references are old. (Bjälkander et al., 2013; Bjälkander et al., 2012—over 12 years ago). Are you sure the prevalence and situation of FGM are still as they were in the past 12 years? Could you include recent empirical studies/data to support your points?

 

-          After your first definition of the term abbreviated “female genital mutilation (FGM).” I think you should consistently use the abbreviation “FGM” in the manuscript. Don’t mix in your write-up using in some sentences “FGM” and in others “female genital mutilation.” Be consistent. See line 67, page 2.

 

-          The statement “Current research often overlooks the mental health ramifications and the intersectionality of various contributing factors” at page 3. Is your manuscript focusing on mental health? Please confirm this, as you have identified mental health as a gap in your manuscript.

 

-          The statement” “studies that explore the long-term consequences of surviving FGM remain scarce, particularly in assessing psychological well-being and sexual health.” My question again is. Is your study a longitudinal study or a retrospective study? Did you review longitudinal or retrospective studies focusing on long-term consequences of surviving FGM? If so, please describe how you assessed the long-term consequences of surviving FGM in your manuscript.

 

-          Please undertake a thorough review of the Introduction section with close attention to the removal of repetitive points and redundant phrasing. The current version contains overlapping ideas and restatements that disrupt the logical flow and weaken the narrative. To enhance clarity and readability, I suggest you consider involving a trusted senior researcher, colleague, or professional English editor to critically review this section. Aim for coherence and fluency in transitioning from one paragraph to another. Furthermore, ensure each paragraph builds upon the previous one. As it stands, the flow and progression of ideas need an improvement to better engage readers and convey a compelling scholarly argument.

  

-          The introduction also presents a wide array of themes but does not specify a clearly focused research question or objective. I will suggest you include a sentence or paragraph with a clear research question or objective at the end of the introduction section (e.g., "This review seeks to assess...").

 

- I can see you stated, "This review aims to contribute to the broader discourse on FGM by providing insights into the specific context of Sierra Leone." … to offer recommendations for policymakers, practitioners, and researchers on strengthening efforts to eliminate FGM, fostering a future where no girl or woman has to endure this harmful practice.” Could you please clarify what your review aims to assess? Before stating how your review will contribute to a broader discourse and policy framework, it is important to clarify this for readers' understanding.

 

2. Materials and Methods  

-          “This research paper will use a qualitative approach…”. This phrase contradicts the PRISMA-based systematic review process, which should be rigorous, replicable, and transparent. Please consider using an appropriate research design for a systematic review study.

 

-          Why include BMC as your research source? Is BMC a research database? Please confirm, and if not, delete appropriately.

 

-          Is searching PubMed not also searching MEDLINE? Didn’t you have access to MEDLINE while using PubMed search? Please explain why both are included. Please confirm their differences and remove or retain appropriately.

 

-          You mention the review covered the years 2000 to 2025, but your key reviewed paper begins from 2012 to 2025. Why is the period from 2000 to 2025 included in the review? Please explain the differences and correct appropriately.

 

-          “Van Baak et al., 2025” is not in your reference list. Please confirm and include.

 

-          More so, your methodology section lacks the following:

• No search string is provided. Include Search Strategy—include the key words, phrases, and concepts searched.  
• Inclusion/exclusion criteria are not clearly defined beyond language and year.
• Screening, data extraction, and synthesis methods are not clearly stated and addressed.

 

-          Since you are using the “Recommended Reference Unit for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021) as contained in your manuscript, I will suggest you consult this guideline for the necessities to be included in your methodology section. Furthermore, include the following:

 

-          Improve your flow diagram with full explanations (number of duplicates, titles/abstracts excluded, reasons for exclusion). The figure you provided lacks reasons for exclusion.

 

-          Include a data extraction and analysis procedure sub-heading and explain

 

-          Your figure 1: PRISMA Flowchart should also be given brief explanations.

 

3. Table 1 and Use of Sources

In your Table 1: FGM PRISMA table. The structure is inconsistent across studies. Studies summarize methods and results unevenly. Furthermore, not all included studies are directly focused on FGM (e.g., IPV or SRHR studies with weak FGM linkage). Please revisit this table to improve on it. I will suggest a standardized table with columns for:

-          Author/year

-          Study setting/site/location

-          Research objective

-          Study design (You may include sample size, focus respondents/participants.)

-          Key findings

-          Quality rating (justify each score using the Newcastle-Ottawa Scale (NOS) you mentioned).

 

4. Your manuscript contains some inconsistent terminology and instances of misuse that require correction. For example:

- Page 4, Line 147: “relevant inspection”—unclear” term.

- Page 4, Line 150: “2.3 “Examples” --- likely meant “Search Strategy” or “Search Process.” Please check and correct appropriately.

 

-          Again, please revise your manuscript for clarity and professional tone. Consider proofreading by a native English speaker or using an academic editor.

 

5. Results and Discussion

• The Results section reads more like an annotated bibliography than a synthesized narrative. Please improve by synthesizing points with intersectionality reflected.
• Pages 9–11 (e.g., Sections 3.1–3.8): Each subsection summarizes findings but lacks comparative synthesis or identification of cross-study themes. Please improve this, too. You may identify themes across studies, e.g., psychological consequences, socio-cultural justifications, or intervention types, or follow what you have identified but use more “compare and contrast” language.

 

6. Again, although a modified Newcastle–Ottawa Scale is mentioned (Page 4, Lines 160–163), no actual quality assessment table or rationale is provided for individual study scores (e.g., why “high” or “medium”?). Please provide a justification or scoring rubric in table format, or alternatively, in supplementary material.

 

7. The Discussion section misses opportunities to engage with theoretical frameworks (e.g., feminist theory, social norms theory, health belief model). I suggest you briefly discuss how key findings relate to a conceptual or theoretical lens to enhance the analytical depth of your manuscript.

 

8. Minor comments to also correct

-          Line 43 - Reference to “Bitong, 2005; Kallon & Dundes, 2010…” is outdated. Consider adding more recent ethnographic evidence.

 

-          Line 138 - Sentence: “how this practice works in this area…” is informal and unclear. Please replace it with more academic phrasing.

 

-          Line 334 - Sentence: “making challenging to make uniform solutions” is grammatically incorrect. Please rephrase for clarity.

 

-          Line 386–390 - Include appropriate references for mental health care interventions in low-income or post-conflict settings for more robust discussion.

 

9. References

Some citations lack DOIs or URLs (e.g., [8], [10], [18]). Standardize according to journal referencing style.

 

 

Comments on the Quality of English Language

Please revise your manuscript for clarity and professional tone. Consider proofreading by a native English speaker or using an academic editor.

Author Response

Thank you for inviting me to review this manuscript. The manuscript addresses an important, sensitive topic. It provides an overview of the cultural and health dimensions of FGM in Sierra Leone. However, for a manuscript aiming to qualify as a systematic review in a peer-reviewed journal, there are important methodological, structural, and stylistic issues that must be addressed. I have provided below some comments and recommendations that I believe will help the authors to improve their manuscript. Lot of thanks for your kind comments and suggestions, we have done a full revission of the paper, trying to apply all the reviewer's points for improvement.

 

Abstract:

What do you mean by “utilizing a multidisciplinary approach”? It is unclear. Are you referring to a research design? If so, please use a research design that is appropriate for conducting a systematic review. 

Lot of thanks for your kind comments and suggestions, we have deleted the sentence.

 

 

Introduction

-          The subheading statement “1.1 Understanding Female Genital Mutilation (FGM) in Sierra Leone” doesn’t align well with the introduction section. You may need to delete it. Allow the introduction to stand independently. 

Lot of thanks for your kind comments and suggestions, we have deleted the sentence

 

-          “Obiora, 2020” is not in your reference list. Please confirm inclusion. 

Lot of thanks for your kind comments and suggestions, we have included the reference.

 

 

-          Some of your references are old. (Bjälkander et al., 2013; Bjälkander et al., 2012—over 12 years ago). Are you sure the prevalence and situation of FGM are still as they were in the past 12 years? Could you include recent empirical studies/data to support your points? 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the references list and added new and more actual references.

 

-          After your first definition of the term abbreviated “female genital mutilation (FGM).” I think you should consistently use the abbreviation “FGM” in the manuscript. Don’t mix in your write-up using in some sentences “FGM” and in others “female genital mutilation.” Be consistent. See line 67, page 2.

Lot of thanks for your kind comments and suggestions, we have changed all the mentions to FGM

 

-          The statement “Current research often overlooks the mental health ramifications and the intersectionality of various contributing factors” at page 3. Is your manuscript focusing on mental health? Please confirm this, as you have identified mental health as a gap in your manuscript. 

Lot of thanks for your kind comments and suggestions, mental health impact of FGM is one of the aims of our paper. 

 

 

-          The statement” “studies that explore the long-term consequences of surviving FGM remain scarce, particularly in assessing psychological well-being and sexual health.” My question again is. Is your study a longitudinal study or a retrospective study? Did you review longitudinal or retrospective studies focusing on long-term consequences of surviving FGM? If so, please describe how you assessed the long-term consequences of surviving FGM in your manuscript. 

Lot of thanks for your kind comment, we have reviewed and compiled the main results and conclusions of the mentioned studies. Using these results, we have concluded the sentence.

 

 

-          Please undertake a thorough review of the Introduction section with close attention to the removal of repetitive points and redundant phrasing. The current version contains overlapping ideas and restatements that disrupt the logical flow and weaken the narrative. To enhance clarity and readability, I suggest you consider involving a trusted senior researcher, colleague, or professional English editor to critically review this section. Aim for coherence and fluency in transitioning from one paragraph to another. Furthermore, ensure each paragraph builds upon the previous one. As it stands, the flow and progression of ideas need an improvement to better engage readers and convey a compelling scholarly argument. 

Lot of thanks for your kind comments and suggestions, we have done a full revission of the Introduction part of the paper

 

  

-          The introduction also presents a wide array of themes but does not specify a clearly focused research question or objective. I will suggest you include a sentence or paragraph with a clear research question or objective at the end of the introduction section (e.g., "This review seeks to assess..."). 

Lot of thanks for your kind comments and suggestions, we have included the focus of the study

 

 

- I can see you stated, "This review aims to contribute to the broader discourse on FGM by providing insights into the specific context of Sierra Leone." … to offer recommendations for policymakers, practitioners, and researchers on strengthening efforts to eliminate FGM, fostering a future where no girl or woman has to endure this harmful practice.” Could you please clarify what your review aims to assess? Before stating how your review will contribute to a broader discourse and policy framework, it is important to clarify this for readers' understanding. Lot of thanks for your comment, we have added: 

"Ultimately, this review aims to contribute to the broader discourse on FGM in the specific context of Sierra. Despite the breadth of existing literature on FGM in Sierra Leone, significant limitations still persist. Consequently, this study aims to review and critically assess the existing scientific research on FGM in Sierra Leone. By analyzing both the quantity and quality of available studies, this review seeks to establish a comprehensive theoretical framework that captures the cultural, social, and mental health dimensions sustaining the practice. The ultimate objective is to inform and support the development of evidence-based, culturally sensitive interventions that address the psychological needs of affected populations."

 

2. Materials and Methods  

-          “This research paper will use a qualitative approach…”. This phrase contradicts the PRISMA-based systematic review process, which should be rigorous, replicable, and transparent. Please consider using an appropriate research design for a systematic review study. Lot of thanks for your comment, we have deleted the sentence and included "This study adopts a systematic review methodology in accordance with the PRISMA 2020 guidelines (Page et al., 2021)."

 

-          Why include BMC as your research source? Is BMC a research database? Please confirm, and if not, delete appropriately. Lot of thanks for your comment, we have added the sentence: "BMC was excluded from the final analysis as it is a publishing platform rather than a database"

 

-          Is searching PubMed not also searching MEDLINE? Didn’t you have access to MEDLINE while using PubMed search? Please explain why both are included. Please confirm their differences and remove or retain appropriately. 

Lot of thanks for your comment, we have added the sentence: "PubMed (including MEDLINE)"

 

-          You mention the review covered the years 2000 to 2025, but your key reviewed paper begins from 2012 to 2025. Why is the period from 2000 to 2025 included in the review? Please explain the differences and correct appropriately. 

Lot of thanks for your comment, we have added the sentence: "Although the search initially covered literature from 2000, the final sample includes only studies published between 2012 and 2025, as earlier works did not meet the methodological inclusion criteria."

 

-          “Van Baak et al., 2025” is not in your reference list. Please confirm and include. Lot of thanks for your comment, we have added the reference

 

-          More so, your methodology section lacks the following:

• No search string is provided. Include Search Strategy—include the key words, phrases, and concepts searched.  
• Inclusion/exclusion criteria are not clearly defined beyond language and year.
• Screening, data extraction, and synthesis methods are not clearly stated and addressed.

Lot of thanks for your comment, we have changed the Method part, using the reviewer´s comments.

-          Since you are using the “Recommended Reference Unit for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021) as contained in your manuscript, I will suggest you consult this guideline for the necessities to be included in your methodology section. Furthermore, include the following:

 

-          Improve your flow diagram with full explanations (number of duplicates, titles/abstracts excluded, reasons for exclusion). The figure you provided lacks reasons for exclusion.

 

-          Include a data extraction and analysis procedure sub-heading and explain

 

-          Your figure 1: PRISMA Flowchart should also be given brief explanations.

Lot of thanks for your comment, we have changed this part, using the reviewer´s comments

3. Table 1 and Use of Sources

In your Table 1: FGM PRISMA table. The structure is inconsistent across studies. Studies summarize methods and results unevenly. Furthermore, not all included studies are directly focused on FGM (e.g., IPV or SRHR studies with weak FGM linkage). Please revisit this table to improve on it. I will suggest a standardized table with columns for:

-          Author/year

-          Study setting/site/location

-          Research objective

-          Study design (You may include sample size, focus respondents/participants.)

-          Key findings

-          Quality rating (justify each score using the Newcastle-Ottawa Scale (NOS) you mentioned).

Lot of thanks for your comment, we have changed this part, using the reviewer´s comments

4. Your manuscript contains some inconsistent terminology and instances of misuse that require correction. For example:

- Page 4, Line 147: “relevant inspection”—unclear” term.

- Page 4, Line 150: “2.3 “Examples” --- likely meant “Search Strategy” or “Search Process.” Please check and correct appropriately.

Lot of thanks for your comment, we have changed this part, using the reviewer´s comments

-          Again, please revise your manuscript for clarity and professional tone. Consider proofreading by a native English speaker or using an academic editor.

Lot of thanks for your comment, we have done a full revision of the paper

5. Results and Discussion

• The Results section reads more like an annotated bibliography than a synthesized narrative. Please improve by synthesizing points with intersectionality reflected. Lot of thanks for your comment, we have changed this part, using the reviewer´s comments
• Pages 9–11 (e.g., Sections 3.1–3.8): Each subsection summarizes findings but lacks comparative synthesis or identification of cross-study themes. Please improve this, too. You may identify themes across studies, e.g., psychological consequences, socio-cultural justifications, or intervention types, or follow what you have identified but use more “compare and contrast” language. Lot of thanks for your comment, we have changed this part, using the reviewer´s comments

 

6. Again, although a modified Newcastle–Ottawa Scale is mentioned (Page 4, Lines 160–163), no actual quality assessment table or rationale is provided for individual study scores (e.g., why “high” or “medium”?). Please provide a justification or scoring rubric in table format, or alternatively, in supplementary material. Lot of thanks for your comment, we have added the marks into the table

 

7. The Discussion section misses opportunities to engage with theoretical frameworks (e.g., feminist theory, social norms theory, health belief model). I suggest you briefly discuss how key findings relate to a conceptual or theoretical lens to enhance the analytical depth of your manuscript. Lot of thanks for your comment, we have changed this part and included several theoretical models, using the reviewer´s comments

 

8. Minor comments to also correct

-          Line 43 - Reference to “Bitong, 2005; Kallon & Dundes, 2010…” is outdated. Consider adding more recent ethnographic evidence. Lot of thanks for your comment, we have changed this reference and used a recenter one

 

-          Line 138 - Sentence: “how this practice works in this area…” is informal and unclear. Please replace it with more academic phrasing. Lot of thanks for your comment, we have changed this sentence.

 

-          Line 334 - Sentence: “making challenging to make uniform solutions” is grammatically incorrect. Please rephrase for clarity. 

Lot of thanks for your comment, we have changed this sentence.

 

 

-          Line 386–390 - Include appropriate references for mental health care interventions in low-income or post-conflict settings for more robust discussion. 

Lot of thanks for your comment, we have included more references

 

 

9. References

Some citations lack DOIs or URLs (e.g., [8], [10], [18]). Standardize according to journal referencing style.

Lot of thanks for your comment, we have reviewed all the references list

 

 

Comments on the Quality of English Language

Please revise your manuscript for clarity and professional tone. Consider proofreading by a native English speaker or using an academic editor. Lot of thanks for your kind comment, we have done a full revission of paper, including the English style and vocabulary.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Title: Female Genital Mutilation in Sierra Leone: A Systematic Review of Cultural Practices, Health Impacts, and Pathways to Eradication

Thank you again for the opportunity to re-review this manuscript. The authors have strengthened the manuscript. However, there are still areas requiring clarification, language improvements, and minor corrections to enhance the clarity and scholarly rigor of the manuscript. Below are specific comments for improvement:

 

1. Abstract (Lines 10–22):
   The abstract could briefly mention the number of studies included in the review and the key gap identified (lack of psychological impact studies).
   I will suggest you add: “A total of eight peer-reviewed empirical studies were included in the final synthesis.”

 

2. Introduction

The World Health Organization (WHO, 2022) classifies FGM into four categories:

• Type I: Partial or complete excision of the clitoral glans.
• Type II: Excision of the clitoral glans and partial removal of the labia minora.
• Type III (infibulation): Removal of all external genitalia followed by suturing of the vulva, leaving only a small orifice for urinary and menstrual flow.
• Type IV: All other harmful procedures, including pricking, piercing, incising, scraping, and cauterization.

In your introduction, tweak the above write up into a prose format and remove the bullet points. It does not look good that way in the introduction section.

3. Grammar/clarity improvements

• Page 2, Line 43:
  “FGM is influenced by complex social, cultural, and economic dynamic.”
  "dynamic" should be plural.
  I will suggest you revise to read: “…complex social, cultural, and economic dynamics.”
• Page 9, Line 340:
  “must be addressed to inform meaningful intervention strategies.”
  Please adjust this to read: “must be addressed to ensure effective intervention strategies.”
  
  

4. Content clarification

• Page 6, Line 220:
  You Figure 1 appears to scatter as I cannot find the linking lines between the included and the excluded sides of the diagram (I mean the left-and the right-hand side of the diagram. Probably it is scattered, you have to do something about it, to avoid confusion.
• Table 1 is labelled “FGM PRISMA table,” but the table title is too generic.
  I will suggest you revised to: “Table 1: Summary of Reviewed Studies on FGM in Sierra

 

5. Missing information

• Page 9, Line 343:
  “The review identifies a critical gap in understanding the long-term psychological and sexual health consequences of FGM.”
  My suggestion is that: A few studies on mental health (e.g., Connor et al., 2021; Knipscheer et al., 2015) are referenced in the bibliography but not well integrated here. Consider citing these studies explicitly in this section to show limited but existing literature.

6. Discussion

I think this is very important. You discussion of section still lacks adequate engagement with previous and existing literature as expected in a discussion section. I could not find any aspects stating that this present or current study agrees or disagrees, supports or contrasts previous findings. I then ask myself, what is new in your work? Please improve on this section. Bring in previous studies to show areas of agreements and/or disagreements through engagement. I know that this is a review study, but discussion must be made as a discussion. That is why it is call a discussion section.  

Additionally, I am still thinking if there is any need to separate your discussion section into 4.1, 4.2, 4.3 and 4.4 as you have done. Why not combine or join everything together and provide a lengthy discussion section. However, I will allow you to decide on this - either to join together or sub-divide. My may concern here is that you should engage the findings with previous and existing studies showing areas of agreements and /or contrasts.

 

Author Response

Thank you again for the opportunity to re-review this manuscript. The authors have strengthened the manuscript. However, there are still areas requiring clarification, language improvements, and minor corrections to enhance the clarity and scholarly rigor of the manuscript. Thank you very much for your comments and proposals. We have included more information using the requirements of the reviewer, about the background, the framework, and the discussion. We hope it will be more detailed and with deeper and wider implications.

 

Below are specific comments for improvement:

 

 

 

Abstract (Lines 10–22):

The abstract could briefly mention the number of studies included in the review and the key gap identified (lack of psychological impact studies). Thank you very much for your suggestion. We have included a few words about the issue. 

I will suggest you add: “A total of eight peer-reviewed empirical studies were included in the final synthesis.” Thank you very much for your suggestion. We have included the sentence 

 

 

Introduction

The World Health Organization (WHO, 2022) classifies FGM into four categories:

 

Type I: Partial or complete excision of the clitoral glans.

Type II: Excision of the clitoral glans and partial removal of the labia minora.

Type III (infibulation): Removal of all external genitalia followed by suturing of the vulva, leaving only a small orifice for urinary and menstrual flow.

Type IV: All other harmful procedures, including pricking, piercing, incising, scraping, and cauterization.

In your introduction, tweak the above write up into a prose format and remove the bullet points. It does not look good that way in the introduction section. Thank you very much for your suggestion. We have included the definition in the way the reviewer has written. 

 

Grammar/clarity improvements

Page 2, Line 43:

“FGM is influenced by complex social, cultural, and economic dynamic.” "dynamic" should be plural. Thank you very much for your suggestion. We have changed the word 

I will suggest you revise to read: “…complex social, cultural, and economic dynamics.” Thank you very much for your suggestion. We have changed the sentence

Page 9, Line 340: “must be addressed to inform meaningful intervention strategies.” Please adjust this to read: “must be addressed to ensure effective intervention strategies.” Thank you very much for your suggestion. We have changed the sentence

 

Content clarification

Page 6, Line 220:

You Figure 1 appears to scatter as I cannot find the linking lines between the included and the excluded sides of the diagram (I mean the left-and the right-hand side of the diagram. Probably it is scattered, you have to do something about it, to avoid confusion.

Table 1 is labelled “FGM PRISMA table,” but the table title is too generic. I will suggest you revised to: “Table 1: Summary of Reviewed Studies on FGM in Sierra. Thank you very much for your suggestion. We have changed the name of the table

 

Missing information

Page 9, Line 343:

“The review identifies a critical gap in understanding the long-term psychological and sexual health consequences of FGM.”

My suggestion is that: A few studies on mental health (e.g., Connor et al., 2021; Knipscheer et al., 2015) are referenced in the bibliography but not well integrated here. Consider citing these studies explicitly in this section to show limited but existing literature. Thank you very much for your suggestion. We have changed the sentence

Discussion

I think this is very important. You discussion of section still lacks adequate engagement with previous and existing literature as expected in a discussion section. I could not find any aspects stating that this present or current study agrees or disagrees, supports or contrasts previous findings. I then ask myself, what is new in your work? Please improve on this section. Bring in previous studies to show areas of agreements and/or disagreements through engagement. I know that this is a review study, but discussion must be made as a discussion. That is why it is call a discussion section.  Thank you very much for your suggestion. We have changed the Discussion part

 

Additionally, I am still thinking if there is any need to separate your discussion section into 4.1, 4.2, 4.3 and 4.4 as you have done. Why not combine or join everything together and provide a lengthy discussion section. However, I will allow you to decide on this - either to join together or sub-divide. My may concern here is that you should engage the findings with previous and existing studies showing areas of agreements and /or contrasts. Thank you very much for your suggestion. We have changed the discussion part. In our opinion, it´s clearer the explanation with the points, because it remarks the main areas and objectives of our study. Anyway, we have done the change as the reviewer has written and we will trust in the opinion of the editor about the best way for publishing. 

 

 

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

The authors should please proofread the entire manuscript for further improvement on its grammatical structure. Language editing is very essential. Please also re-read the discussion section to improve grammar. Thank you.

Comments on the Quality of English Language

The authors should please proofread the entire manuscript for further improvement on its grammatical structure. Language editing is very essential. Please also re-read the discussion section to improve grammar. Thank you again. 

Author Response

The authors should please proofread the entire manuscript for further improvement on its grammatical structure. Language editing is very essential. Please also re-read the discussion section to improve grammar. Thank you. Lot of thanks for your kind and clear comments and suggestions to improve our paper. We have done a full revision of the text, especially a language editing, using the proposal of the reviewer. More than this, we have reviewed the references, in format and in list. Thanks again