The Impact of Migration on Attitudes to Female Genital Cutting and Experiences of Sexual Dysfunction Among Migrant Women with FGC

Anatomical Reconstruction following Female Genital Mutilation/Cutting

BACKGROUND

International migration from high-prevalence regions has increasingly confronted nonendemic countries with female genital mutilation/cutting (FGM/C), and Western-based health care providers have seen a greater demand for surgical reconstruction of female anatomic units. The authors introduce novel surgical techniques developed by the first author for clitoral and vulvovestibular reconstruction and examine operative outcomes.

METHODS

The authors performed a retrospective cohort study of operative outcomes of the omega domed flap, neurotizing and molding of the clitoral stump (NMCS procedure), and anterior obturator artery perforator flap for preputial, clitoral, and vulvovestibular reconstruction, respectively. Between 2014 and 2021, the authors treated patients with all types of FGM/C, and analyzed various data, including demographics, clitoral sensation, and symptoms such as dysmenorrhea, dysuria, dyspareunia, and anorgasmia. The authors aimed to examine the efficacy and safety of these techniques in improving clitoral sensation and reducing symptoms.

RESULTS

A total of 119 women (mean age, 31.0 ± 10.4 years) were included. The authors performed the omega domed flap (85%), the NMCS procedure (82%), or the anterior obturator artery perforator flap (36%), and had a 1-year follow-up period, which was attended by 94.1% of patients. Patients reported significant postoperative reduction of dysmenorrhea, dysuria, and dyspareunia, as well as significant improvement of clitoral sensation and ability to achieve orgasm ( P < 0.001). There was 1 major complication (loss of flap) reported. Secondary ambulatory interventions were performed in 10 patients (8.4%).

CONCLUSION

By allowing for safe and effective anatomic reconstruction of the female genitalia, the described surgical techniques represent a new stage of treatment possibilities for women with FGM/C.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Psychosocial and Sexual Aspects of Female Genital Circumcision in a Sample of Kurdish Women in the Kurdistan Region of Iraq

BACKGROUND AND AIM

Female genital circumcision (FGC), a prevalent practice in the Kurdistan Region of Iraq, has significant psychosocial and sexual implications for affected women. Therefore, this study aimed to investigate these impacts among circumcised and non-circumcised Kurdish women.

METHOD

This comparative study was conducted from January 2 to June 27, 2023, at the Al Mesalla for Human Rights Improvement organization in Erbil, Iraq. Purposive sampling was used to collect data using a comprehensive questionnaire. The questionnaire included demographic information, the Depression, Anxiety, and Stress Scale (DASS-21), the Rosenberg Self-Esteem Scale (RSE), and the New Sexual Satisfaction Scale-Short Form (NSSS-S). Statistical analysis was performed using SPSS version 26 (IBM Corp., Armonk, NY), with frequency and percentage used for categorical variables and mean and standard deviation for quantitative variables. Independent sample t-tests and Chi-square tests were conducted to compare groups. A p-value of less than 0.05 was considered statistically significant.

RESULTS

A total of 772 participants were enrolled in the study, including 382 circumcised and 390 non-circumcised women. The study found significant differences between the two groups in terms of depression, self-esteem, and sexual satisfaction. Circumcised women had higher mean scores for depression (12.19 ± 5.6 vs. 10.68 ± 5.3), lower mean scores for self-esteem (24.4 ± 12.1 vs. 30.3 ± 10.1), and lower mean scores for sexual satisfaction (52.4 ± 24.6 vs. 67.6 ± 20.4) compared to non-circumcised women (all p < 0.001).

CONCLUSIONS

The study demonstrated that FGC is associated with higher levels of depression, lower self-esteem, and lower sexual satisfaction among Kurdish women. It is recommended for policymakers and healthcare providers to develop targeted interventions to address the psychosocial and sexual health needs of circumcised women in the Kurdistan Region of Iraq.

The need for and acceptability of a curriculum to train nursing and medical students in the sexual healthcare of clients with female genital mutilation/cutting in Tanzania

BACKGROUND

Female genital mutilation/cutting (FGM/C) is tied to one of the most conservative cultures in the Mediterranean and Sub-Saharan Africa. More than 200 million girls and women in 30 African, Asian and the middle Eastern countries have undergone FGM/C. However, healthcare professionals are not adequately trained to prevent and manage FGM/C-related complications including sexual health problems. This study aimed to assess the need and acceptability of a curriculum to train nursing and medical students in the sexual healthcare of clients with FGM/C in Tanzania.

METHODS

We used a descriptive and cross sectional study design to collect and analyse information from 271 medical and 137 nursing students in Tanzania. A Qualtrics online survey was used to obtain quantitative data on training interest, previous training received, and the curriculum delivery method. Open-ended questions were used to explore their insights on significance to obtain the necessary competencies to treat and prevent FGM/C. Descriptive statistics were used to analyze quantitative data while qualitative data were analyzed using a thematic approach.

RESULTS

Almost half of the participants reported they had little to no training in sexual healthcare for women with FGM/C (47%). In all, 82.4% reported the training to be acceptable. Following thematic analysis of open-ended questions, participants expressed a desire to improve their competencies to meet the current and future sexual and psychological health needs of women and girls who have undergone FGM/C.

CONCLUSION

It is a necessary and acceptable to develop a curriculum to train healthcare students to diagnose, treat and prevent sexual health complications related to FGM/C. In our study, designing a culturally sensitive curriculum and its delivery method, that includes practical sessions with simulated patients, was considered the most beneficial and favorable.

Our Body Our Health (Jirkeena, Caafimaadkeena): Somali Women's Narratives on Sexual Health

Women across the globe have been subject to female genital cutting (FGC), with the highest rates in Somalia. FGC can result in sexual concerns, especially sexual pain and lower pleasure. Due to ongoing civil war and climate disasters, there is a large number of Somali immigrants and refugees living in countries where healthcare providers may be unfamiliar with the impact of FGC. In this qualitative study, sixty Somali women between the ages 20 and 45 and living in the U.S. shared their perspectives on how FGC has affected their sexual lives, including how they have coped with any complications attributed to FGC. Participants were recruited through convenience sampling and interviewed by a bilingual community researcher in either Somali or English. Data were analyzed through a participatory analysis process by academic and community researchers. Themes included sexual desire, arousal, and pleasure; sexual satisfaction; sexual pain at first intercourse; coping with sexual pain at first intercourse; long-term sexual pain, coping with long-term sexual pain. Results are discussed with a focus on agency of the participants, role of partners, and implications for healthcare professionals.

Health Care Providers' Readiness to Adopt an Interactive 3D Web App in Consultations About Female Genital Mutilation/Cutting: Qualitative Evaluation of a Prototype

BACKGROUND

Comprehensive and appropriate health care provision to women and girls with female genital mutilation or cutting (FGM/C) is lacking. Use of visuals in health care provider (HCP) consultations facilitates the communication of health information and its comprehension by patients. A web app featuring a 3D visualization of the genitourinary anatomy was developed to support HCPs in conferring clinical information about FGM/C to patients.

OBJECTIVE

The aim of this study was to explore HCP perspectives on the use of visuals in discussion about FGM/C with their patients as well as to obtain their feedback on whether an interactive 3D web app showing the genitourinary anatomy would be helpful in patient consultations about FGM/C, identifying key features that are relevant to their clinical practice.

METHODS

We evaluated the web app through a semistructured interview protocol with seven HCPs from various disciplines experienced in care for women and girls with FGM/C in migration-destination settings. Interviews were audio- and video-recorded for transcription, and were then analyzed thematically for contextualized data regarding HCPs' willingness to use a 3D web app visualizing anatomy in FGM/C consultations with patients.

RESULTS

All but one of the seven participants expressed keen interest in using this web app and its 3D visuals of anatomy in FGM/C consultations with patients. Participants shared the common contexts for the use of visuals in health care for FGM/C and the concepts they are used to support, such as to help describe a patient's genitals after FGM/C and reinforce an understanding of clitoral anatomy, to illustrate the process of defibulation, or to explain the physiological effects of FGM/C. Participants also highlighted the benefit of using visuals that patients can relate to, expressing approval for the ability to customize the vulva by FGM/C subtype, skin tone, and complexity of the visual shown in the web app. Despite critiques that the visualization may serve to perpetuate idealistic standards for how a vulva should look, participants largely agreed on the web app's perceived usefulness to clinical practice and beyond.

CONCLUSIONS

Evaluation of the web app developed in this study identified that digital tools with 3D models of the genitourinary anatomy that are accessible, informative, and customizable to any specific patient are likely to aid HCPs in communicating clinical information about FGM/C in consultations. Universal access to the web app may be particularly useful for HCPs with less experience in FGM/C. The app also prompts options for applications such as for personal use, in medical education, in patient medical records, or in legal settings. Further qualitative research with patients is required to confirm that adoption of the web app by HCPs in a consultation setting will indeed benefit patient care for women and girls with FGM/C.

Exploring the Role of Traditional Women Society Membership Among West African Immigrant Women Who Have Experienced Female Genital Mutilation/Cutting

This study explores the complex nature of female genital mutilation/cutting (FGM/C) by juxtaposing the mental and sexual health of women who had undergone FGM/C as part of initiation/membership into a traditional women's society (TWS) with those who were also cut but not initiated into a TWS. While considerable differences emerged between TWS members and nonmembers, there was no evidence that TWS membership was protective against the physical and psychological trauma typically ascribed to FGM/C. In fact, the pattern of results would tend to suggest the opposite. Possible explanations for and implications of these findings are discussed.

Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation

BACKGROUND

Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results.

METHODS

The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin).

RESULTS

Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571).

CONCLUSIONS

A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.

(Un)usual suspects: Relational capacities and subjective transformations in polygynous and polyamorous practices in the Netherlands

Choice and autonomy are at the heart of classic feminist debates about structure and agency. This article revisits those debates with two contemporary cases of polygyny and polyamory. While scholars of non-monogamies often portray polyamory as potentially liberating, an alternative to the dominant patriarchal model of dyadic marriage, polygyny is generally considered oppressive to women due to its communal and heteropatriarchal structures. Based on in-depth interviews, this article complicates such binary understandings of progressive/oppressive non-monogamies by bringing them into dialogue with one another. Focusing on two narrated experiences of polyamory and polygyny in the Netherlands, I trace and investigate relational capacities and subjective transformations. This relational approach serves a political feminist project that seeks to safeguard both scepticism towards patriarchal systems and to remain sympathetic to everyday life’s messiness, moving beyond both cultural essentialism and cultural relativism.

New research on the global prevalence of female genital mutilation/cutting: Research, clinical, and policy implications

In this perspective, Kerrie Stevenson and Brenda Kelly discuss new research on the prevalence of female genital mutilation/cutting alongside clinical and policy implications.

"Damaged genitals"-Cut women's perceptions of the effect of female genital cutting on sexual function. A qualitative study from Sweden

Female genital cutting (FGC) is a traditional practice, commonly underpinned by cultural values regarding female sexuality, that involves the cutting of women's external genitalia, often entailing the removal of clitoral tissue and/or closing the vaginal orifice. As control of female sexual libido is a common rationale for FGC, international concern has been raised regarding its potential negative effect on female sexuality. Most studies attempting to measure the impact of FGC on women's sexual function are quantitative and employ predefined questionnaires such as the Female Sexual Function Index (FSFI). However, these have not been validated for cut women, or for all FGC-practicing countries or communities; nor do they capture cut women's perceptions and experiences of their sexuality. We propose that the subjective nature of sexuality calls for a qualitative approach in which cut women's own voices and reflections are investigated. In this paper, we seek to unravel how FGC-affected women themselves reflect upon and perceive the possible connection between FGC and their sexual function and intimate relationships. The study has a qualitative design and is based on 44 individual interviews with 25 women seeking clitoral reconstruction in Sweden. Its findings demonstrate that the women largely perceived the physical aspects of FGC, including the removal of clitoral tissue, to affect women's (including their own) sexual function negatively. They also recognized the psychological aspects of FGC as further challenging their sex lives and intimate relationships. The women desired acknowledgment of the physical consequences of FGC and of their sexual difficulties as "real" and not merely "psychological blocks".

Changing attitudes towards female genital mutilation. From conflicts of loyalty to reconciliation with self and the community: The role of emotion regulation

The practice of female genital mutilation (FGM) is a social norm embedded in the patriarchal system and is resistant to change due to its roots in the tradition of the practising communities. Despite this difficulty in change, some women succeed in changing their attitudes towards the practice. In trying to understand what makes these women change their attitudes, we identified in a previous study, the critical life events at which change occurs (turning point). These turning points were described with emotions and conflicting feelings based on which we hypothesised that emotion regulation and the resolution of conflicts of loyalty might be possible mechanisms that explain the change of attitudes by the women. In this article, we sought to investigate how the mechanisms interact and how they were at play to explain the change. We, therefore, triangulated our previous data, fifteen women interviewed twice, with the published life stories and public testimonies of 10 women with FGM, and interviews of six experts chosen for their complementary fields of expertise to discuss the emerging concepts and theory, generated by our study. The data were analysed using framework analysis and an element of the grounded theory approach (constant comparison). As a result of our theorisation process, we propose a model of change in five stages (Emotion suppression, The awakening, The clash, Re-appropriation of self, and Reconciliation). This describes the process of a woman’s journey from compliance with FGM and community norms to non-compliance. Our study reveals how the women whose stories were analysed, moved from being full members of their community at the cost of suppressing their emotions and denying their selves, to becoming their whole selves while symbolically remaining members of their communities through the forgiveness of their mothers.

Factors contributing to the perpetuation and eradication of female genital mutilation/cutting in sub-Saharan women living in Spain

OBJECTIVE

Female Genital Mutilation/Cutting (FGM/C) is one of the most widespread traditional practices harmful to the health of women and girls in the world. Its spread to the West highlights the need to establish preventive actions in European countries taking into account the affected population. That is why this study is aimed at finding out the elements that support the continuation of FGM/C and those that promote the change of attitudes and fight against FGM / C from the perspective of the sub-Saharan women themselves who reside in Spain.

DESIGN

Qualitative exploratory research that uses the method of life stories through an open interview.

PARTICIPANTS AND SETTING

The participants were 24 women living in the Region of Murcia (Spain) who come from sub-Saharan countries where FGM/C is commonly practised.

FINDINGS

Arguments supporting FGM/C, the lack of knowledge and family pressure are identified as factors that perpetuate the practice, whereas the motivating factors for the change in attitudes that make most of the interviewees oppose FGM/C are the awareness of the consequences on health and close negative experiences, growing awareness of their rights, supportive legislation and breaking the taboo related to this practice to question justifications for FGM / C and share experiences.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

Being aware of the arguments of both sides, women who defend FGM/C and those who oppose it, is a valuable source of information that obstetrics, midwifery and nursing professionals can use. The study provides the core elements that any healthcare education program should incorporate to prevent female genital mutilation/circumcision.

Emotional Health Work of Women With Female Genital Cutting Prior to Reproductive Health Care Encounters

We used institutional ethnography to explore the social relations that shaped the reproductive health care experiences of women with female genital cutting. Interviews with eight women revealed that they engaged in discourse that opposed the practices of cutting female genitals as a human-rights violation. This discourse worked to protect those affected by the practices, but also stigmatized female genital cutting, making participants anticipate experiencing stigmatization during health care. Women's engagement in this discourse shaped their emotional health work to prepare for such encounters. This work included navigating feelings of worry, shame, and courage to understand what to expect during their own appointment; learning from family/friends' experiences; and seeking a clinic with the reputation of best care for women with female genital cutting. It is important to strive for more inclusive health care in which women do not have to engage in emotional health work to prepare for their clinical encounters.

Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study

INTRODUCTION

Chronic vulvar pain is a condition that affects many women during their lifetime, including women with Female Genital Mutilation/Cutting (FGM/C).

AIM

To study the prevalence and possible etiologies of chronic vulvar pain among women living with FGM/C.

METHODS

We conducted a retrospective review of consecutive medical files of 506 women who consulted our specialized clinic for women with FGM/C between April 1, 2010 and December 31, 2017. We collected sociodemographic and clinical data including information on the type of FGM/C and its complications. We focused on studying the prevalence, etiologies and characteristics of chronic vulvar pain.

MAIN OUTCOME MEASURES

Prevalence and etiologies of vulvar pain in women with FGM/C.

RESULTS

Chronic vulvar pain was present in 14 women (2.8%). Pain was unprovoked in one case (7.1%) and provoked in the 13 other cases (92.9%). In most of the cases, women presented vulvar pain related to scar complications such as clitoral or peri-clitoral adhesions or scar tissue (n = 3, 21.4%), bridle scars (n = 1, 7.1%), post-traumatic neuromas (n = 2, 14.3%) and vulvar cysts (n = 6, 42.9%), the latter being found more frequently in women with FGM/C type III. In 2 cases (14.3%) of chronic vulvar pain, no lesions other than FGM/C were visible at clinical examination. Among these 14 women, 12 suffered from superficial dyspareunia as well. The remaining ones had not had any sexual contact for several years. Dyspareunia was present in 126 women (24.9%), among which 75 patients (14.8%) suffered from superficial dyspareunia and 25 patients (4.9%) complained of deep dyspareunia. Fourteen women (2.8%) reported both superficial and deep dyspareunia. Twelve women (2.3%) reported dyspareunia with no specified localization documented in the medical charts. Dyspareunia was significantly more frequent among infibulated women compared to women with FGM/C different from type III (P = .014).

CONCLUSION

Chronic vulvar pain after FGM/C is probably associated with scar complications and FGM/C type III (infibulation). Dyspareunia is more frequent in women with FGM/C type III. Bazzoun Y, Aerts L, Abdulcadir J. Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study. Sex Med 2021;9:100425.

The benefits and disappointments following clitoral reconstruction after female genital cutting: A qualitative interview study from Sweden

Female genital cutting or mutilation refers to the cutting of girls' external genitalia. Due to migration from contexts where female genital cutting is common, it is estimated that around 38 000 cut women and girls live in Sweden. Clitoral reconstruction, a relatively new form of surgical healthcare offered to women with female genital cutting, was established in Sweden in 2014. This surgery aims at restoring clitoral function and anatomy, but there is yet a dearth of evidence demonstrating the effects of the surgery. The aim of this study was to explore how women undergoing clitoral reconstruction in Sweden between 2016 and 2019 experienced the surgical process and its aftereffects from a physical, sexual and psychosocial perspective. Eighteen women who had undergone clitoral reconstruction at a university hospital in Sweden agreed to participate in the study. The women were interviewed using semi-structured interviews, which were recorded, transcribed and analysed using thematic analysis. The results, based on self-categorization and labelling theory, demonstrated both benefits and disappointments following the surgery. Several women reported positive outcomes in terms of sexual, psychosocial and aesthetic terms. They experienced reduced genital pain, improvements in their sex lives, and a sense of feeling more empowered and at ease in their bodies. Yet, some women reported aesthetic, functional and process-related disappointment related to clitoral reconstruction. Nonetheless, the women expressed gratitude for the possibility of undergoing the surgery. In conclusion, the women reported that they experienced physical, sexual and psychosocial benefits of the surgery.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

Female Genital Mutilation/Cutting among Somali Women in the U.S. State of Arizona: Evidence of Treatment Access, Health Service Use and Care Experiences

BACKGROUND

Female genital mutilation/cutting (FGM/C) is associated with adverse sexual, reproductive and psychological sequelae. The aim of this study was to quantitatively explore factors related to satisfaction with FGM/C-related care in the US focusing on access to care, health service utilization, and women's experiences.

METHODS

A community-based survey of 879 Ethnic Somali and Somali Bantu women using snowball sampling was conducted in Arizona. Bivariate, multivariable and ordered logistics analyses assessed the relationship between the aforementioned factors measured along six dimensions: non-discrimination, physical, economic, informational, health system accessibility and individual-level health service use factors.

FINDINGS

Most participants possessed FGM/C (77.4%), namely Type III (40.2%). FGM/C related health service use was low (14.3%). Perceived discrimination was associated with reduced satisfaction in care (OR = 0.22; CI 0.13-0.37). For FGM/C-specific variables, only recollection of adverse physical or psychological events at the time of circumcision predicted service use (OR = 3.09; CI 1.67-5.68). Somali Bantu (OR = 0.10; CI 0.02-0.44) and highly acculturated women (OR = 0.39; CI 0.17-0.86) had lower odds of service use.

CONCLUSIONS

Achieving respectful care and outreach to women affected by FGM/C has contextual complexity. However, the clinical implications and insights provided may have broader impacts on advancing health equity for FGM/C-affected women.

How to ensure policies and interventions rely on strong supporting facts to improve women's health: The case of female genital cutting, using Rosling's Factfulness approach

Rosling et al’s book Factfulness aims to inspire people to use strong supporting facts in their decision‐making, with 10 rules of thumb to fight dramatic instincts. In this paper, the Factfulness framework is applied to female genital cutting (FGC), in order to identify possible biases and promote evidence‐based thinking in studies on FGC, clinical guidelines on management of FGC, and interventions aimed at abolishing FGC. The Factfulness framework helps to acknowledge that FGC is not a uniform practice and helps address that variability. This framework also highlights the importance of multidisciplinarity to understand causalities of the FGC issue, which the authors argue is essential. This paper highlights the fact that FGC is a dynamic practice, with changes in the practice that are ongoing, and that those changes are different in different contexts. The “zero tolerance” discourses on FGC fail to acknowledge this. Factfulness encourages us to be more critical of methodologies used in the area of FGC, for example when estimating girls at risk of FGC in migration contexts. Factfulness provides the tools to calculate risks rather than judgments based on fear. This may help limit stigmatization of women with FGC and to allocate resources to health problems of migrant women based on real risks. The framework also calls for more research and production of less biased facts in the field of FGC, in order to improve interventions aimed at abolishing FGC, and clinical guidelines for the treatment of FGC. Factfulness is a useful and structured foundation for reflection over constructs, biases and disputes surrounding FGC, and can help improve the quality of future evidence‐based interventions and education that address the actual needs of women with FGC and girls at risk of FGC.

Challenges of Managing Skin Diseases in Refugees and Migrants

"Currently, an estimated 70.8 million individuals worldwide are forcibly displaced due to war, violence, and persecution. Barriers to providing dermatologic care include the large number of affected people, their movement within and across international borders, security issues, and limited access to dermatology expertise and formularies. Screening protocols for skin diseases and sexually transmitted infections differ worldwide, raising the need for shared guidelines to assess migrants' health. This article reviews the literature of skin and sexually transmitted infections in migrants and displaced persons, highlighting the impact of social determinants on skin health and challenges faced in providing care."

In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology

BACKGROUND

Myths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs.

AIM

To construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice.

METHODS

We retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education.

OUTCOMES

The main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing.

RESULTS

We present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users.

CLINICAL TRANSLATION

Our kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population.

STRENGTHS & LIMITATIONS

The strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only.

CONCLUSION

Our kit can be studied in anatomy, biology, and sex education, as well as in clinical practice. Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging-Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590-1602.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study

Background

Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya.

Methods

We drew on qualitative data collected from purposively selected women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12.

Results

Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals’ and health facilities’ capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare.

Conclusion

Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate

INTRODUCTION

Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance.

AIM

In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure.

METHODS

A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR.

MAIN OUTCOME MEASURE

The main outcome measure includes benefits, risks, and ethical analysis of CR.

RESULTS

While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date.

CLINICAL IMPLICATIONS

CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices.

STRENGTH & LIMITATIONS

This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun.

CONCLUSION

We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.

Review of Web-Based Toolkits for Health Care Practitioners Working With Women and Girls Affected by or at Risk of Female Genital Mutilation/Cutting

Increased migration has given rise to more advocacy efforts against female genital mutilation or cutting (FGM/C), legislation that criminalizes the practice, and guidance to the health sector for managing care of affected groups. More women and girls who have been cut or who are at risk of FGM/C are migrating from regions where it is common to countries where it is not and interacting with health professionals and other community practitioners in these host countries. Despite numerous studies on the negative health impacts of FGM/C, little is known about toolkits on FGM/C that providers can use in their prevention and response efforts. We sought to explore the nature of Internet-based products referenced as toolkits and materials characteristic of toolkits aimed at different service providers who may interact with women and girls affected by FGM/C. Through an online search, we identified 45 toolkits and collected data about each one. We found that the toolkits targeted different audiences and offered a diverse set of information and resources. The majority of toolkits were aimed at health professionals and provided factual and epidemiological-focused content, yet many did not include research evidence, skills development application, or approaches for implementing the toolkit in practice. This review is the first completed in the area of FGM/C to show a rich diversity of online materials. Future toolkits can be improved with the provision of evidence-based information and practical skills development for use by health professionals in implementing best practices in working with women and girls affected by FGM/C.

The Impact of Circular Migration on FGM/C: Transnational Communities in Spain and the Gambia

Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that migrates with people and has become a global phenomenon. Understanding how the diaspora resignifies and can change the tradition will allow us to measure the impact of transnational relations on information flows and decision making in a multisite space. The objective is to analyze the influence of migration on the practice of FGM/C with a participatory and circular methodology, focused on Gambian communities both in Spain and in The Gambia. The study shows the trends on how acculturation processes entail cultural change, both in Africa as well as in diaspora.

Paradoxes of awareness raising in development: gender and sexual morality in anti-FGC campaigning in Egypt

This paper discusses cultural translations of international campaigns against Female Genital Cutting (FGC) through a critical ethnographic study. It analyses development initiatives as cultural practices and signifying processes. The vernacularisation of these campaigns leads to certain paradoxes: while the abandonment of FGC is encouraged, nationalist-modernist processes of Othering and dominant gender and sexual moralities are also reinforced. These paradoxes reveal how certain aspects of transnational development discourse are easily transmitted while others are subverted. Individual rights discourse fades to the background in favour of putting emphasis on common social concerns and shared gender-conservative norms. FGC as an external bodily practice and a means to control sexual behaviour is rejected in favour of internal moral self-disciplining. Secondly, the transnational fight against FGC is translated into a fight for marriage. The practice is condemned for causing sexual dissatisfaction and friction within the marital bond. Local development workers aim to connect to women's life worlds through reference to dominant social anxieties - family unity, social cohesion and gender-conservative sexuality norms but, importantly, fail to address women's lived experience and knowledge. When international scripts and hegemonic social norms are foregrounded, a body affirmative discussion of female lived sexuality and actual sexual coping strategies is precluded.

Sexual health counselling targeting girls and young women with female genital cutting in Sweden: mind-body dualism affecting social and health care professionals' perspectives

Female genital mutilation (FGM), also referred to as female genital cutting (FGC), has become the subject of an intense debate exposing tensions between varying cultural values about bodies and sexuality. These issues are brought to the fore in settings where professionals provide sexual counselling to young circumcised women and girls in Western, multicultural societies. This article is based on interviews and focus group discussions with professionals in social and healthcare services. The aim of this study was to examine how professionals reflect upon and talk about sexuality and the promotion of sexual wellbeing in young circumcised women and girls. Policy documents guide their obligations, yet they are also influenced by culture-specific notions about bodies and sexuality and what can be called “the FGM standard tale”. The study found that professionals showed great commitment to helping the girls and young women in the best possible way. Their basic starting point, however, was characterised by a reductionist focus on the genitalia’s role in sexuality, thus neglecting other important dimensions in lived sexuality. In some cases, such an attitude may negatively affect an individual’s body image and sexual self-esteem. Future policy making in the field of sexual health among girls and young women with FGC would benefit from taking a broader holistic approach to sexuality. Professionals need to find ways of working that promote sexual wellbeing in girls, and must avoid messages that evoke body shame or feelings of loss of sexual capacity among those affected by FGC.

Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews

Background

In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.

Objectives

To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).

Review methods

The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.

Results

Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.

Limitations

Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.

Conclusions

The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.

Future work

Future research should evaluate the most-effective models of training and of service delivery.

Study registration

This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Blurred transitions of female genital cutting in a Norwegian Somali community

While diaspora communities have become more critical of Female Genital Cutting (FGC), there are also trends of continuity. To explore the interplay between continuity and change, I designed a study among Somali migrants in Norway. A team of six Somali research assistants collected data from 72 male and female research participants between 16 and 57 years of age through in-depth interviews and focus group discussions. The aim of the study was to gather knowledge that could improve interventions among migrant populations. The study findings indicate that the experience of FGC as a practice in transition implies that people have to maneuver between different and partly contradictory social norms. The paper first discusses the contradiction between a strong negative attitude toward FGC and very low engagement. The lack of engagement is explained by the increased privatization of FGC and insecurities due to the transition and disempowerment with regard to challenging the FGC practices of relatives based in countries of origin. Second, the paper explores the contradiction between perceptions of FGC as a disappearing practice and the recognition of trends of continuation. Trends of continuation include those related to perceptions of risk during travel to countries of origin, resistance to defibulation, support for sunna circumcision and insecurities regarding the significance of FGC for marriageability. Thus, despite an almost universally negative attitude toward FGC in the form of infibulation, ongoing changes can, to some extent, hamper further change. This suggests that to ensure further progress in the abandonment of the practice, these complex and interconnected expectations must be addressed.

Missing from the debate? A qualitative study exploring the role of communities within interventions to address female genital mutilation in Europe

INTRODUCTION

Public attention on female genital mutilation (FGM) in diaspora communities is increasing in Europe, as health and social welfare implications become better understood. This study explored the role of potentially affected communities within interventions to address FGM in Europe, examining current practices, promising interventions and remaining gaps.

METHODS

A qualitative study design incorporated 18 individual key informant interviews and five semistructured group interviews with policy-makers, service providers and community representatives. Data were analysed thematically, guided by the Scottish Government '4Ps' framework for addressing violence against women and girls, that is, prevention, protection, provision of services and participation.

RESULTS

Participants emphasised both the importance of community participation and the lack of consistent engagement by policy-makers and practitioners. All indicated that communities had a key role, though most interventions focused on awareness-raising rather than community empowerment, behaviour change or influence on the design, delivery and/or evaluation of interventions.

CONCLUSIONS

Despite clear consensus around the need to engage, support and empower potentially affected communities and several examples of meaningful community participation in addressing FGM (eg, REPLACE, REPLACE 2, Ketenaapak, Tackling FGM Initiative), the role of communities remains inconsistent and further engagement efforts are necessary.