Background Strategies aimed to address Female Genital Mutilation (FGM/C) have provided a necessary service to women affected by it, but have also had the unintended consequence of stigmatising affected communities and undermining efforts to positively engage with them. Addressing FGM/C is a complex issue, involving multiple stakeholders with differing and potentially conflicting perspectives.Calls for the greater application of systems thinking in public health have recognised soft systems methodology (SSM) as desirable due to its consideration of contextual factors and multiple perspectives.However, SSM has not previously been applied to the topic of addressing FGM/C.This study aims to apply systems thinking and SSM to build understanding of how the issue of FGM/C is addressed in Scotland, and to co-create with stakeholders recommendations for how the situation can be improved.

Methods We recruited 23 participants; from the 3rd sector (Community groups and Non-Governmental Organisations NGOs), as well as from the statutory sector (Health care, Social work, Police, Scottish Children’s Reporter Administration SCRA, and Education). We conducted 20 semi structured interviews to explore the roles, perspectives, priorities, and challenges of participants. We conducted 7 workshops to build shared understanding of the situation, and to use SSM models to structure stakeholder discussion to identify feasible and acceptable ways to improve the situation.

Results Our outcomes included firstly a ‘rich picture’ of the key issues in addressing FGM/C, including education and awareness raising, support and health care provision, child protection, case investigation and legal decision making.Secondly, identification of ten systems of purposeful activity which detailed key priorities of stakeholders, including making services more accessible to affected communities; building knowledge and understanding of FGM/C in services; and supporting creation of good policy on FGM/C. Challenges included stakeholders working in ‘silos’, and communities feeling that their voice was not heard. Collaboration across stakeholder groups and creation of a standardised framework for community engagement and service training were found to be the areas of greatest consensus for improvement. Thirdly, system maps demonstrating that both the challenges and the ways to improve the situation identified are interconnected and interdependent.

Conclusion This first application of SSM to FGM/C bridges the various institutions through which FGM/C is addressed in Scotland, approaching the situation as a ‘whole system’, and supporting a more integrated response to the issue. Implementing a greater collaboration between stakeholders, and standardisation of training and engagement on the issue are the areas of greatest leverage for improvement.