The Female Genital Mutilation (FGM) – migration matrix: The case of the Arab League Region

Prognostic factors of poor surgical outcome after clitoral reconstruction in women with female genital mutilation/cutting

BACKGROUND

Complications of surgical clitoral reconstruction for female genital mutilation/cutting (FGM/C) are a rare occurrence, but there has been reports of patients experiencing chronic pain or clitoral burial.

AIM

This study aims to assess which factors are predictive of the occurrence of surgical complications in women who had surgical reconstruction for FGM/C (type 1, 2, or 3).

METHODS

This monocentric retrospective study was conducted among patients who underwent clitoral reconstruction after FGM/C from January 2016 to March 2020. Demographic and clinical data were abstracted from the medical records.

OUTCOMES

The primary outcome was the occurrence of chronic pain (defined as occurrence or persistence of any clitoral pain >3 months after surgery), and the secondary outcome was the occurrence of clitoral burial.

RESULTS

A total of 87 women were included in the analysis. Univariate analysis indicated significantly higher rates of a history of physical abuse in the group of women who experienced chronic pain after surgery (4 [100%] vs 2 [37.1%], P = .049). Patients with clitoral burial were significantly younger than the rest of the sample in univariate analysis (median [IQR], 29.6 years [24.6-30.2] vs 33.8 [28.2-37.9]; P = .049).

CLINICAL IMPLICATIONS

Surgical treatment of women who underwent FGM/C should include the entire history of the patient and especially a record of experiencing physical abuse.

STRENGTHS AND LIMITATIONS

The study stands out for its originality, the extensive sample size gathered over nearly 4 years, the surgical clitoral reconstructions conducted by an experienced surgeon, and the minimal amount of missing data. However, because the occurrence of these complications was rare, the number of patients in the subgroups was extremely low, preventing a valid multivariate analysis to be conducted.

CONCLUSION

The study suggests that women with a history of physical abuse could be at greater risk for chronic pain after surgery and that younger women tend to experience more clitoral burial.

Female genital cutting (FGC) type: proposing a multifaceted, interactive method for FGC self-assessment

BACKGROUND

Self-reporting female genital cutting (FGC) status and types by patients and clinicians is often inconsistent and inaccurate, particularly in community settings where clinically verifiable genital exams are not feasible or culturally appropriate.

AIM

In this study we sought to discern whether integrating multiple dimensions of participant engagement through self-reflection, visual imagery, and iterative discourse informed the determination of FGC status by a panel of health and cultural experts using World Health Organization (WHO) typology.

METHODS

Using community-based participatory research, we recruited 50 Somali women from the Minneapolis-St. Paul, MN, metropolitan area through convenience and snowball sampling to participate in semi-structured interviews. Participants were asked to discuss their recollection of their original circumcision-including the procedure itself and their assessment of the type of circumcision they experienced. Anatomical drawings of uncircumcised and circumcised vulvas were shown to participants to assist them in identifying their FGC type. A panel of health and cultural experts reviewed and independently assessed participant FGC type. Interrater reliability and degree of concordance between participants and panel were determined.

OUTCOMES

Outcomes included the following: (1) development of WHO-informed, anatomically accurate visual depictions of vulvas representing FGC typology, (2) development of an iterative, self-reflective process by which participants self-described their own FGC status aided by visual depictions of vulvas, (3) application of WHO FGC typology by a panel of health and cultural experts, and (4) determination of the degree of concordance between participants and panel in the classification of FGC type.

RESULTS

High interrater reliability (kappa = 0.64) and concordance (80%) between panel and participants were achieved.

CLINICAL TRANSLATION

Incorporation of FGC visual imagery combined with women's empowered use of their own self-described FGC status would optimize clinical care, patient education, and informed decision making between patients and their providers when considering medical and/or surgical interventions, particularly among women possessing limited health and anatomic literacy.

STRENGTHS AND LIMITATIONS

Strengths of this study include the incorporation of anatomically accurate visual representations of FGC types; the iterative, educational process by which participants qualitatively self-described their FGC status; and the high interrater reliability and concordance achieved between panel and participants. Study limitations include the inability to conduct clinical genital exams (due to the community-based methodology used), recall bias, and small sample size (n = 50).

CONCLUSION

We propose a new patient-informed educational method for integrating anatomically accurate visual imagery and iterative self-reflective discourse to investigate sensitive topics and guide clinicians in providing patient-centered, culturally informed care for patients with FGC.

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.

Advancing the measurement of knowledge, attitudes and practices of health workers who care for women and girls who have undergone female genital mutilation/ cutting (FGM/C): A qualitative exploration of expert opinion

BACKGROUND

Female genital mutilation or cutting (FGM/C) is a social norm driven practice associated with numerous adverse health complications. Existing assessment tools for health workers are limited by lack of a clear framework for what constitutes the critical knowledge, attitudes, and practices that impact FGM/C prevention and care. The aim of this study was to explore expert opinion of the knowledge, attitudes, and practices for FGM/C-related prevention and care that can be used to inform the development of future KAP measurement tools.

METHODS

We conducted 32 semi-structured individual interviews with global clinical and research experts on FGM/C from 30 countries including participants from Africa, Australia/ New Zealand, Europe, the Middle East, and North America. Interview questions explored areas of knowledge, attitudes, and practices that influence FGM/C-related prevention and care activities. We used the directed content analysis methodology for the qualitative data analysis.

RESULTS

We identified six categories of knowledge, six of practice, and seven of attitudes that contribute to FGM/C-related prevention and care. Areas of knowledge included: general knowledge about FGM/C; who is at risk for experiencing FGM/C; support for FGM/C; female genital anatomy/ physiology; health complications of FGM/C; management of health complications of FGM/C; ethical and legal considerations for the treatment and prevention of FGM/C, and patient-health worker communication. Areas of practice included: clinical procedures and protocols; management of complications; defibulation; other surgical procedures for FGM/C; pediatric care (including prevention); and patient-centered care. Participants described health worker attitudes that may affect how prevention and care activities are delivered and/or received including attitudes toward: the perceived benefits of FGM/C; harms of FGM/C; ethical considerations related to FGM/C medicalization, prevention, and treatment; providing care for FGM/C-affected clients; women and girls who have experienced FGM/C; communities that practice FGM/C; and affective response to FGM/C. We also present participant perspectives on the ways in which knowledge, attitudes, and practice interact impacting the type and quality of care provided to those affected by FGM/C.

CONCLUSIONS

This study identified specific areas of knowledge, attitudes, and practices in FGM/C prevention and care that are important to include in future evaluation metrics. Future KAP tools should be theoretically informed using the framework we present, and assessed for validity and reliability using psychometrically rigorous methods. Developers of KAP tools should consider the hypothesized relationships between knowledge, attitudes, and practices.

Female genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in Austria

INTRODUCTION

Practical experience in the care of women with female genital mutilation/cutting (FGM/C) is uncommon in Austria. However, affected women require specialized gynecological and obstetric care. In our region, there is currently neither an official counseling center nor specially trained medical personnel to address the special needs of women after FGM/C. The aim of this study was to determine the potential need for obstetric care for women who have undergone FGM/C in our region.

METHODS

We retrospectively reviewed women presenting for delivery at the LKH University Hospital Graz from 1.1.2010 until 31.12.2020 regarding the place of birth and/or the nationality of the mother to filter out women from a country with known FGM/C prevalence according to the UNICEF Global Database. Data on the documentation of FGM/C as well as demographic maternal data and peripartal parameters were gathered. Periods before and after the European refugee crisis in 2015 were compared.

RESULTS

During the study period, a total of 35,628 deliveries took place at our hospital. 856 (2.4%) deliveries of 539 women were included due to nationality or birthplace in a country with known FGM/C prevalence. We found only 17/539 (3.2%) documented FGM/C cases. The estimated FGM/C prevalence among those patients was, however, 208/539 (38,6%). Women affected by FGM/C in our collective were most frequently from Nigeria, Egypt, Iraq, Ghana, and Somalia. No statistically significant increase in deliveries during the study period in the overall study cohort was observed, with the exception of deliveries of Somali women (p = 0.000).

DISCUSSION

The discrepancy between documented and expected FGM/C rates (3,2% vs. 38,6%) in our collective suggests that most cases of FGM/C go undetected among women delivering in Austria. These data show the great need for special training for obstetricians and targeted contact points for affected women.

A scoping review of FGM in humanitarian settings: an overlooked phenomenon with lifelong consequences

Background

Female genital mutilation (FGM) is widely recognized as a human rights violation. Little is known about FGM rates and practices in humanitarian settings, and about the impact of crisis on the drivers and consequences of FGM. This scoping review set out to investigate the current research landscape on FGM in humanitarian settings.

Methods

We conducted a search of electronic databases and gray literature published between 1990 and 2021. This was coupled with backward citation tracking on eligible studies and reviews. We analyzed studies that met our eligibility criteria using thematic analysis.

Results

We found 13 peer-reviewed and four grey literature articles. Most studies were published in the last decade between 2010 and 2021, signaling growing attention to the issue. Five of the 17 articles provided estimates of incidence based on primary data collection amongst crisis-affected populations, ten focused on drivers, ten on consequences and five on interventions. The limited studies that have examined FGM in humanitarian settings indicate that the impact of crisis on FGM is multifaceted and context-specific, depending in part on interactions with host and other displaced communities and their social norms and practices. There is evidence that the acquisition and transfer of harmful social norms may take place during migration flows, but also that social norms underlying FGM may weaken in contexts of displacement, causing the practice to decrease. The incidence of FGM may also remain unchanged, but the type of FGM practiced may shift from more harmfully perceived forms to less radical forms. We found that drivers of FGM may be exacerbated, attenuated, or unchanged by crisis and displacement. Overall, there was predominant focus on medical consequences of FGM, and limited research on the social, economic, and psychological consequences of the practice. There was also a dearth of research into intervention effectiveness.

Conclusions

Despite an increase in research on FGM in humanitarian settings, there is still a notable dearth of studies investigating the impact of emergencies on FGM and the factors that propel it. More research and documentation of evidence are needed to inform interventions and policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00479-5.

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.

Nursing students' knowledge gained about female genital cutting/mutilation through dramatization simulation with a standardized patient: A quasi-experimental study

BACKGROUND

Female genital cutting is a culture bound ritual involving excision of the female genitalia. Little is known about nursing students' knowledge and perceptions of female genital cutting and no studies using simulation to teach this topic exist.

OBJECTIVE

The aim of this study was to examine the impact of a dramatization simulation on nursing students' knowledge about and perceptions of female genital cutting.

DESIGN

A quasi-experimental pretest posttest study with a convenience sample.

SETTING

Two Bachelor of Nursing schools in Northeast Ohio, United States.

PARTICIPANTS

35 third year undergraduate students.

METHODS

Students were divided into an intervention group (n = 14) and a wait list control group (n = 21). The intervention group took a pre-test, did a reading assignment and then attended a virtual, dramatization simulation session with a standardized patient; a Muslim woman with a personal history of female genital cutting. They took the posttest within the next week. The control group took the pretest, did the reading assignment, and then took the posttest, followed by the simulation. The survey instrument used for pretest and posttest was the Knowledge, Perceptions, and Practice Questionnaire on Female Genital Cutting for Healthcare Professionals in the United States. Debriefing was a critical part of the simulation.

RESULTS

The knowledge of female genital cutting of the nursing students in the intervention group increased more than that of the students in the control group (change score 3.57 and 2.05 respectively). Students' perceptions of female genital cutting were not significantly changed by intervention type.

CONCLUSION

This study was the first of its kind to measure nursing students' knowledge and perceptions about female genital cutting before and after a dramatization simulation. A standardized patient dramatization simulation including focused debriefing may be an effective education strategy to teach nursing students about female genital cutting.

Female genital mutilation and cutting in the Arab League and diaspora: A systematic review of preventive interventions

OBJECTIVES

Female Genital Mutilation and Cutting (FGM/C) is an act of gender-based violence (GBV) and a global public health issue with well-documented adverse outcomes. With the rise in global migration, there is an increasing prevalence of FGM/C among Arab diaspora living in the West and Global South. What remains unclear is how to reduce the practice. This study was designed to identify interventions exerting an effect on reducing the practice of FGM/C.

METHODS

A systematic review of peer-reviewed articles was conducted on interventions targeting individuals and/or the broader community to prevent FGM/C within the Arab League and its diaspora, up to December 2021. Databases searched included PubMed, Medline, Web of Science, PsycINFO, EMBASE, CINAHL, BIOSIS, ASSIA and Scopus. Quality assessment used the Mixed Methods Appraisal Tool (MMAT) 2018.

RESULTS

Twelve of 896 studies met the inclusion criteria. Eight interventions relied entirely on education with short-term gains but unchanged practices. Three interventions used social marketing and mixed media. Only one study took a multi-sectoral approach.

CONCLUSIONS

At a macro level, opportunities to reduce or to end the practice of FGM/C exist through legislation, policy, a public health approach grounded in gender equality and human rights. Using multi-sectoral actions that consider the social context and challenge social norms at macro, meso and micro levels appears more effective than individual-level interventions. Promoting advocacy and developing supportive environments to reduce GBV, enhance gender equality and empower communities is crucial for interventions to succeed and achieve the Sustainable Development Goal target of FGM/C abandonment by 2030.

Commentary: What should referral pathways have to improve healthcare experiences of women with female genital mutilation in Australia?

BACKGROUND

We examined the evidence derived from healthcare professionals' interfacing with women with female genital mutilation (FGM) to comprehend the referral pathways available to these women in Australia.

MAIN BODY

Clinicians encountered FGM-related complications that included ruptured bladder and total urinary incontinence. Midwives and paediatricians indicated a lack of referral pathways for FGM, but used their discretion to refer such cases to social work departments, obstetric/gynaecological units, child protection service providers, psychological counsellors and surgeons. The continuum of care for women with FGM is characterised by inadequate and lack of clear referral pathways. This underscores the need to develop and strengthen referral pathways in response to physical, birthing and psychological complications of women with FGM to improve their care experiences in Australia.

SHORT CONCLUSION

Capacity building initiatives on FGM-prevention and care for trainees and practising health providers and community involvement in high burden areas/populations should be implemented to promote uptake and utilization of the referral services. Provision of infrastructural support, including clinical management tools, job aids, posters, referral algorithms and electronic patient records with "drop-down menus" for referral sites for health complications of FGM to reinforce the providers' efforts are critical.

The comparison of sexual function in women with or without experience of female genital circumcision: A case-control study in a Kurdish region of Iran

Studies on the sexual consequences of female genital circumcision are controversial. In this article, we intend to compare the sexual function in women with or without experience of circumcision in the Kurdish region of Mahabad in Iran. In this case-control study 550 women completed the demographic and Female Sexual Function Index (FSFI) questionnaires. Female genital circumcision was associated with reduction of lubrication and sexual satisfaction as well as increasing dyspareunia compared to the uncircumcised women. However, there was no significant difference between two groups regarding to arousal, desire and orgasm of women.