Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

What are the health needs of women with female genital mutilation going through menopause?

Female genital mutilation is widely recognised as a practice that causes grave, permanent damage to the genital anatomy and function. The literature has documented its impact on physical, sexual, emotional, and mental wellbeing, and this has informed the development of guidelines and recommendations for managing women with female genital mutilation. There has, though, been little, if any, focus on how women with female genital mutilation experience menopause. A literature search did not return any published research on the topic and there are currently no clinical guidelines for managing the menopause in women who have undergone female genital mutilation. This review calls attention to this gap by exploring the clinical implications that the loss of natural hormones has on the vulvovaginal tissues, as well as on urogenital and sexual function. Psychological aspects of the experience of women with female genital mutilation going through menopause are also explored, as well as common barriers they face in accessing adequate healthcare. Finally, we offer a set of recommendations for clinical practice, including the need to improve current care pathways, and potential directions for future research.

The feasibility, acceptability, appropriateness and impact of implementing person-centered communication for prevention of female genital mutilation in antenatal care settings in Guinea, Kenya and Somalia

BACKGROUND

There is limited evidence on how to engage health workers as advocates in preventing female genital mutilation (FGM). This study assesses the feasibility, acceptability, appropriateness and impact of a person-centered communication (PCC) approach for FGM prevention among antenatal care (ANC) providers in Guinea, Kenya and Somalia.

METHODS

Between August 2020 and September 2021, a cluster randomised trial was conducted in 180 ANC clinics in three countries testing an intervention on PCC for FGM prevention. A process evaluation was embedded, comprising in-depth interviews (IDIs) with 18 ANC providers and 18 ANC clients. A qualitative thematic analysis was conducted, guided by themes identified a priori and/or that emerged from the data.

RESULTS

ANC providers and clients agreed that the ANC context was a feasible, acceptable and appropriate entry point for FGM prevention counselling. ANC clients were satisfied with how FGM-related information was communicated by providers and viewed them as trusted and effective communicators. Respondents suggested training reinforcement, targeting other cadres of health workers and applying this approach at different service delivery points in health facilities and in the community to increase sustainability and impact.

CONCLUSION

These findings can inform the scale up this FGM prevention approach in high prevalence countries.

Knowledge, attitudes, and practice of female genital mutilation and cutting: an observational cross-sectional study in English primary care (FGM/C Study)

BACKGROUND

Female genital mutilation and cutting (FGM/C) describes procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Increasing migration means many communities living in the UK originate from countries where FGM/C is practised. Consequently, clinicians in the UK are increasingly exposed to women and children who have experienced FGM/C.

AIM

To explore the knowledge, attitudes, and practice of primary care GPs and practice nurses (PNs) regarding FGM/C.

DESIGN & SETTING

An observational cross-sectional study with GPs and PNs working in primary care in the West Midlands, UK.

METHOD

An online survey was circulated to GPs and PNs between September 2019 and December 2019.

RESULTS

A total of 137 survey responses were received. Study participants were predominantly female (81.8%) and GPs (59.9%), with a mean age of 47.3 years (standard deviation [SD] 9.1). The survey found 19.7% of responders reported seeing >1 patient with FGM/C in the past 12 months. It also found 91.3% of responders had received some form of FGM/C training; however, the format and frequency of training varied and 34.3% felt they had received inadequate training to manage treatment of FGM/C.

CONCLUSION

The results have suggested varying degrees of competence and confidence associated with recognising and managing patients with FGM/C in primary care in the West Midlands. Given that patients with FGM/C typically present in primary care, it is important that clinicians can provide appropriate support underpinned by up-to-date training.

U.S.-Based Obstetrician/Gynecologists' Experiences with Delivering Care to Women with Female Genital Cutting

Background: There has been an increase of women living in the United States who have experienced female genital cutting (FGC). However, limited research exists evaluating the experiences of obstetrician/gynecologists delivering care to this patient population. This study aimed to assess the overall experiences, including barriers and facilitators, of U.S.-based obstetrician/gynecologists (OBGYNs) with delivering care to patients with female genital cutting at a single academic health center in the United States. Materials and Methods: This is a qualitative study of OBGYNs at a large, U.S., urban, academic health center. OBGYNs participated in a one-on-one semistructured interview. Thematic analysis using a grounded theory approach was conducted to identify predominating themes regarding the overall experiences, barriers, and facilitators to delivering care to patients with FGC. Results: Analysis of 15 study interviews revealed 4 main themes impacting the ability of OBGYNs to deliver care to patients with FGC: (1) limited educational training on FGC, (2) challenges with identifying that a patient had FGC and with using the World Health Organization classification system, (3) questions regarding "normative" anatomy and reinfibulation after vaginal procedures, and (4) navigating affective responses of patient and self when FGC is encountered. Conclusion: The above findings have practical implications, showing that the limited educational experience and lack of a clear policy on how to manage the care of women with FGC lead to variation and even limitations in how care is delivered to these women. We encourage OBGYN professional societies to consider creating education and policy to aid clinicians in caring for patients with FGC.

Torture Survivors and Asylum: Legal, Medical, and Psychological Perspectives

Torture occurs worldwide. Survivors seeking asylum are detained and must complete a complicated legal process to prove a "well-founded fear of persecution" if returned to their home countries. Forensic evaluations guided by the United Nations Istanbul Protocol increase asylum grant rates. Medical evaluation emphasizes skin examination, which can provide strong evidence of torture. Female genital mutilation and cutting, a basis for asylum, is classified according to the World Health Organization. Many resettled refugees and foreign-born immigrants at urban health care facilities have been tortured, but few report it to physicians due to factors affecting both survivors and physicians. Specific torture methods can cause characteristic long-term sequelae. Painful somatic disorders of mind-body interaction and psychological disorders are common. Practices derived from cultural factors and traumatized individuals' feedback enhance management of survivors. Individual and group psychotherapy provide modest proven benefit, but assessment is limited. Physicians and psychotherapists should coordinate care.

Factors associated with general practitioners' routines and comfortability with assessing female genital cutting: a cross-sectional survey

BACKGROUND

Female genital cutting (FGC) may cause a series of health problems that require specialized healthcare. General practitioners (GPs) are gatekeepers to specialized healthcare services in Norway. To refer girls and women subjected to FGC to appropriate services, GPs need to assess whether the health problems reported by these patients are related to FGC. However, we do not know to what degree GPs assess FGC as a potential cause of the patients' health problems. We also know little about the GPs' patterns of training and knowledge of FGC and their effect on the GPs' assessment of FGC as a potential cause of health problems.

METHOD

We employed a cross-sectional online survey among GPs in Norway to examine: 1) patterns of received training on FGC, self-assessed knowledge, and experiences with patients with FGC-related problems and 2) the association between these three factors and the GPs' assessment of FGC as a potential cause of patients' health problems. A total of 222 GPs completed the survey. Data were analysed using binary logistic regression, where we also adjusted for sociodemographic characteristics.

RESULTS

Two-third of the participants had received training on FGC, but only over half received training on FGC-related health problems. Over 75% of the participants stated a need for more knowledge of FGC typology and Norwegian legislation. While the majority of the participants assessed their knowledge of FGC medical codes as inadequate, this was not the case for knowledge of the cultural aspects of FGC. Female GPs were more likely to have experience with patients with FGC-related health problems than male GPs. Among GPs with experience, 46% linked health problems to FGC in patients unaware of the connection between FGC and such health problems. GPs were more likely to assess FGC as a potential cause of health problems when they had experience with patients having FGC-related problems and when they assessed their knowledge of FGC typology and FGC-related medical codes as adequate.

CONCLUSION

To improve their assessment of FGC as a potential cause of patients' health problems, GPs should receive comprehensive training on FGC, with particular emphasis on typology, health problems, and medical codes.

[175 years of anesthesia and narcosis-Towards a "human right to unconsciousness"]

The Ether Day, a key moment in the history of mankind, commemorates its 175th anniversary on 16 October 2021. On that day the dentist William T. G. Morton successfully gave the first public ether anesthesia in Boston. From then on it was possible to save people from pain with justifiable risk and at the same time to protect them from psychological damage by inducing unconsciousness. The German philosopher Peter Sloterdijk, one of the most renowned and effective philosophers of our times, deduced that from then on humans, to some extent, had a right to unconsciousness when in psychophysical distress. This postulate unfolded from his concept of "anthropotechnics" developed around 1997, meaning the idea of treating human nature as an object of possible improvements. According to Sloterdijk, in favorable cases a synthesis of man and technology can result in a significant improvement of human capabilities in the sense of "enhancement", i.e. an increase, an improvement or even an expansion of intellectual, physical or psychological possibilities, as it were in a transgression of the human (so-called transhumanism). Man should go into vertical tension, i.e. strive for higher aims and exploit his inherent potential, he should not dwell in the horizontal. This is not meant as an appeal but as an imperative: "You must change your life!". In this context modern anesthesia may prove helpful: be operated on by others in order to undergo an enhancement. Or, in its most extreme form, the operation in the "auto-operational curved space", a person can even operate on himself as has been dramatically demonstrated by Rogozov, a young Russian physician and trainee surgeon who successfully performed a self-appendectomy under local anesthesia at the Novolazarevskaya Antarctic Station in 1961; however, the implementation of this idea is a long way off. On the one hand, many countries lack qualified personnel in sufficiently large numbers to perform even vital operations with patients under anesthesia. On the other hand, over the decades it has become clear that anesthesia is obviously beneficial for mankind in that it offers relief from pain and psychological stress but that it can also often show its dark side: substance abuse, use of anesthetics in torture and in executions. In addition, the role of anesthetics in resuscitation, palliative care, and allaying executions is unclear or controversial. Finally, the necessary formal legal steps to acknowledge a "human right to unconsciousness" have not yet been implemented.

Barriers and facilitators to the access to specialized female genital cutting healthcare services: Experiences of Somali and Sudanese women in Norway

BACKGROUND

Girls and women subjected to female genital cutting (FGC) risk experiencing obstetrical, gynecological, sexual, and psychological health problems. Therefore, Norway has established low-threshold specialized healthcare services where girls and women with FGC-related health problems can directly seek medical attention. Nevertheless, we lack data about access to these services, especially for non-maternity-related purposes. In this article, we explore experiences of seeking medical attention for health problems that are potentially FGC-related, aiming to identify factors that hinder or facilitate access to FGC-specialized services.

METHODS

We conducted a qualitative study in three Norwegian cities employing semi-structured repeat interviews with 26 girls and women subjected to FGC, participant observation, and three validation focus group discussions with 17 additional participants. We thematically analyzed the data and approached access as a dynamic process of interactions between individuals and the healthcare system that lasts from an initial perception of need until reception of healthcare appropriate to that need.

FINDINGS

We identified several barriers to healthcare, including 1) uncertainty about FGC as a cause of experienced health problems, 2) unfamiliarity with FGC-specialized services, 3) lack of assessment by general practitioners of FGC as a potential cause of health problems, and 4) negative interactions with healthcare providers. In contrast, factors facilitating healthcare included: 1) receiving information on FGC-related health problems and FGC-specialized services from a non-profit immigrant organization, 2) referral to gynecologists with good knowledge of FGC, and 3) positive interactions with healthcare providers.

CONCLUSION

Assessing whether FGC is the cause for experienced health problems requires diagnostic competency and should not be left entirely to the patients. We recommend that Norwegian policymakers acknowledge the central role of GPs in the clinical management of patients with FGC-related health problems and provide them with comprehensive training on FGC.

Identifying evidence for five realist reviews in primary health care: A comparison of search methods

The approach to identifying evidence for inclusion in realist reviews differs from that used in 'traditional' systematic reviews. Guidance suggests that realist reviews should be inclusive of diverse data from a range of sources, gathered in iterative searching cycles. Saturation is prioritised over exhaustiveness. Supplementary techniques such as citation snowballing are emphasised as potentially important sources of evidence. This paper describes the processes used to identify evidence in a selection of realist reviews focused on primary health care settings and examines the origin and type of evidence selected for inclusion. Data from five realist reviews were extracted from (a) reviewers' reference management libraries and (b) records kept by review teams. Although all reviews focused on primary health care, they used data from a wide range of document types and research designs, drawing on learning from multiple perspectives and settings, and sourced the documents containing this data in a variety of ways. Systematic searching of academic databases played an important role, supplementary search techniques such as snowballing were used to identify a significant proportion of documents included in the reviews. Our analysis demonstrates the diverse data sources used within realist reviews and the need for flexible, responsive efforts to identify relevant documents. Reviewers and information specialists should devise approaches to data gathering that reflect the individual needs of realist review projects and report these transparently.