Female Genital Cutting: Clinical knowledge, Attitudes, and Practices from a Provider survey in the US

Pre-service education and continuous professional development on female genital mutilation/cutting for maternal health professionals in OECD countries: A scoping review

BACKGROUND

Female Genital Mutilation/Cutting can cause sequalae throughout pregnancy, childbirth, and the postpartum period. Due to changing patterns in migration flows, the practice evolved into a global phenomenon. Health professionals should ensure high quality of care during maternity service provision.

OBJECTIVE

This scoping review aimed to map available evidence on pre-service and continuous professional development education about Female Genital Mutilation/Cutting for maternal health professionals and identify developmental needs for topic inclusion into teaching.

METHODOLOGY

The review was conducted in accordance with the PRISMA-ScR guidelines. A protocol was developed and is publicly available (medRxiv 2022.08.16.22278598). Three databases (CINAHL, Embase, Medline) and other educational sources were searched. During the final stages of the review an ethical application was submitted and approved. Expert interviews were added to gain insights from practice.

RESULTS

The search identified 224 records. After title and abstract screening, 33 studies were selected for full-text review, resulting into the inclusion of 4 studies and 12 non-research educational sources. Scoping the topic revealed that Female Genital Mutilation/Cutting is often included ad-hoc or stand-alone during trainings and it remains unclear, who owes the responsibility. There is lack of knowledge about which competencies are needed for the different levels of health cadres, how competencies are achieved and outcomes measured.

CONCLUSION

More transparency into training on Female Genital Mutilation/Cutting and about how competency levels are achieved, maintained and evaluated is required. Further research and interdisciplinary collaboration could focus on the development of specific modules and lead to service improvement.

The Need for Standardized Nomenclature in Electronic Documentation of Female Genital Cutting in Health Records

To evaluate the quality of Electronic Health Record (EHR) documentation practices of Female Genital Cutting (FGC) by medical providers. A retrospective chart review study of 99 patient encounter notes within the University of Minnesota health system (inclusive of 40 hospitals and clinics) was conducted. Extracted data included but was not limited to patient demographics, reason for patient visit, ICD code used in note, and provider description of FGC anatomy. Data was entered into REDCAP and categorized according to descriptive statistics. Out of 99 encounters, 45% used the unspecified code for FGC. The most common reason for patient visits was sexual pain, though many notes contained several reasons for the visit regarding reproductive, urological, or sexual concerns. 56% of visits discussed deinfibulation. 11 different terms for FGC were used, with "female circumcision" being the most common. 14 different terms for deinfibulation were found within 64 notes. 42% of encounters included a description of introitus size in the anatomical description, and only 38% of these provided a metric measurement. This study found significant variation in the quality of FGC documentation practices. Medical providers often used the unspecified FGC code, subjective and/or seemingly inaccurate descriptions of FGC/anatomy, and several different terms for both FGC and deinfibulation. Clearly, more education is needed in clinical training programs to (1) identify FGC type, (2) use the corresponding ICD code, and (3) use specific, objective descriptions (including presence/absence of structures and infibulation status).

"All you Gain is Pain and Sorrow": Facilitators and Barriers to the Prevention of Female Genital Mutilation in High-income Countries

BACKGROUND

Female genital mutilation (FGM) is a harmful practice that has long-lasting negative impacts on the physical and psychological health of victims. Deemed a global concern, this practice persists in high-income countries (HIC) among certain migrant communities. Given the deleterious effects of the practice, we conducted an updated systematic review of the facilitators and barriers associated with the prevention of FGM in HIC.

METHOD

A systematic review of published qualitative studies of FGM in HIC was conducted from 2012 to 2022. The search resulted in 276 studies. Of these, the majority were from low- and middle-income countries (LMIC) and excluded. A total of 14 studies were deemed fit for inclusion and none were excluded during quality appraisal. Relevant data were extracted from the studies and thematically analyzed to identify prevalent themes.

RESULTS

A total of 12 themes were identified and the majority reflected barriers to the prevention of FGM including beliefs about female virtue, beliefs about social sanctions, and the preservation of culture, among others. Facilitators to the prevention of FGM were fewer and included memory and trauma from experiencing FGM, knowledge and awareness of the female anatomy, and legislative protection from FGM due to migration. A few themes, such as religious beliefs, acted as both facilitators and barriers.

CONCLUSION

Findings highlight the importance of shared cultural and social threads among FGM practicing communities in HIC. Interventions can use these findings to guide the development of sociocultural strategies centered on community-level prevention and reduction of FGM in HIC.

What African immigrant service providers can teach us about the needs of African immigrant survivors of FGM/C

Health and social service providers who immigrated from regions with high Female Genital Mutilation/Cutting (FGM/C) prevalence rates can provide unique insights on serving women with FGM/C experience. Specifically, we investigated African immigrant service providers' knowledge, experience, attitudes about FGM/C, and their recommendations on how to provide services to immigrants from sub-Saharan Africa who have experienced FGM/C. Derived from a larger study, interviews of 10 African service providers were selectively analyzed with a particular attention to cultural insights that could inform the framework in Western destination countries on how to serve women and girls with FGM/C experience.

Female genital mutilation in high-income countries: knowledge and experience among health professionals

BACKGROUND

Female genital mutilation (FGM) is a cultural practice with numerous negative health consequences. Due to migration from countries where FGM is prevalent into high-income countries, there is increased awareness within non-practising communities, with emphasis on FGM's illegal nature and the negative impacts on women. It is therefore vital for health professionals to be knowledgeable to provide adequate patient care.

AIM

This review aimed to synthesise literature to report the understanding and experiences of health professionals caring for females affected by FGM in high-income countries.

METHODS

A systematic search was conducted on three databases: Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Inclusion and exclusion criteria were applied to select the papers. Findings from included papers were synthesised using thematic synthesis.

FINDINGS

Eight articles met the criteria. Four themes were generated: FGM knowledge, training, attitudes and caring for FGM patients.

CONCLUSION

Health professionals' knowledge and experiences of FGM tend to be varied. This review highlights the need of training for health professionals in high-income countries to strengthen their FGM knowledge.

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.

Reproductive health care appointments: How the institutional organization of obstetric/gynecological work shapes the experiences of women with female genital cutting in Toronto, Canada

We investigated the social relations shaping the reproductive health care experiences of women with female genital cutting (FGC) in Toronto, Canada. Using Institutional Ethnography, we interviewed eight women with FGC and seven obstetrician/gynecologists (OB/GYN). We found a disjuncture between women's needs during appointments that extended beyond the reproductive body and range of care that doctors were able to provide. Women engaged in emotional healthwork during appointments by explaining FGC to doctors, reading doctors' body language, and getting through vulvar/vaginal examinations. Women reported that if they had emotional reactions during appointments, they were often referred to a mental health specialist, a referral on which they did not act. OB/GYNs described their specialty as "surgical"-training centered around treating reproductive abnormalities and not mental health issues. Therefore, the disjuncture between women's needs and OB/GYNs' institutional training highlights the difficulties inherent when bodies of "difference" encounter the reproductive health care system.

Exploring Beliefs and Attitudes Toward Female Genital Mutilation/Cutting Among Healthcare Providers in New York City

Given the increase of African immigrants from countries with high female genital cutting (FGC) prevalence, this study explored U.S. healthcare providers' beliefs and attitudes regarding FGC. A total of 31 professionals who have provided services to FGC-experienced women in New York City were interviewed; data were analyzed using grounded theory. Results indicated that, although a majority of respondents emphasized maintaining a nonjudgmental and open-minded attitude toward clients' experiences, some only focused on the negative aspects of FGC. Also, multifaceted efforts by providers to understand the cultural meanings of FGC and resolve their own cultural dissonance were identified. The implications for practice were discussed.

Educating Nursing Students About Female Genital Cutting/Mutilation Using a Standardized Patient in a Virtual Dramatization Simulation

INTRODUCTION

Female genital cutting/mutilation (FGC/M) is a ritual to remove any or all of the external female genitalia. Educational strategies regarding the teaching of FGC/M for nursing students are scarce. The focus of this article is to describe the development, implementation, and evaluation of a virtual, FGC/M-related dramatization simulation with a standardized patient (SP).

METHODS

This educational intervention used an East African immigrant woman as the SP with 35 undergraduate nursing students in two nursing schools in the Midwest United States.

RESULTS

Participants appraised the simulation as an effective way to teach and learn about FGC/M. Debriefing was a key part of the simulation.

DISCUSSION

Students felt the simulation was novel and engaging for a highly sensitive topic. The SP thought the virtual setting made it more comfortable for her to reveal sensitive facts. The researchers confirmed that the simulation required extensive time commitment to develop, critique, and implement.

Dismantling Inequities in Adolescent and Young Adult Health through a Sexual and Reproductive Health Justice Approach

This article provides an overview of the social determinants of adolescents and young adults' (AYAs') sexual and reproductive health (SRH), from a global health perspective. The status of AYAs' SRH constitutes leading health indicators across nations and globally, and reveals the well-being of this population. Throughout the article, AYAs' SRH is approached from a health equity perspective, which includes SRH health rights and reproductive justice. Using this health equity lens, salient topics are presented: sexual abuse/assault among AYAs; immigrant and refugee populations; child, early, and forced marriage; human trafficking; and female genital mutilation. The article also discusses access to SRH services and comprehensive education. Practical implications and resources are offered for healthcare providers for their daily encounters with AYAs, as well as for community, institutional level, and advocacy action. Healthcare providers are well positioned to advance AYAs SRH through mitigating inequities and in so doing, they are assuring the health of the population and future generations.

Awareness, clinical experience and knowledge of female genital mutilation/cutting among female pelvic medicine and reconstructive surgeons in the United States

OBJECTIVES

To promote the recognition and care of patients with female genital mutilation/cutting (FGM/C), we aimed to evaluate the awareness, clinical experience and knowledge of FGM/C among female pelvic medicine and reconstructive surgery (FPMRS) specialists. FGM/C is a cultural practice whereby there is removal of external female genitalia for non-therapeutic reasons. Despite the high prevalence of urogynecologic complications, there is a paucity of literature discussing FGM/C from the lens of urologists and urogynecologists.

METHODS

By cross-sectional design, we distributed a 27-item survey via email to members of the Society of Urodynamics, Female Pelvic Medicine and Reconstructive Surgery. We collected variables pertaining to previous FGM/C education, clinical confidence, cultural and medical knowledge, and desire for future education.

RESULTS

A total of 54 US-based, mostly urologists and FPMRS specialists, completed the survey. All providers had heard of FGM/C; however only 13% received formal education during medical training. Over 50% had encountered a patient with FGM/C in clinical practice. Only 19% and 13% felt completely confident recognizing and discussing FGM/C, respectively. Seventy percent believed religious doctrine informed FGM/C practice and 24% correctly identified FGM/C type on clinical representation. Finally, only 17% of respondents were aware of FGM/C guidelines, and providers expressed a desire for increased availability of multimodal resources.

CONCLUSIONS

Education regarding FGM/C remains sparse and variable for US FPMRS specialists. Cultural and clinical knowledge is also lacking, which is a detriment to patient care. In order to strengthen awareness and knowledge, we must develop high-quality FGM/C educational resources for urologists and gynecologists.

Assessing the reliability and validity of attitudes and confidence scales for the care of women and girls affected by female genital mutilation/cutting

Background

Approximately 545,000 women and girls in the USA have undergone Female Genital Mutilation/ Cutting (FGM/C) or have mothers from a country where FGM/C is practiced. Women and girls living with FGM/C in the USA may experience stigma and bias due to their FGM/C, immigration, racial, and language status. Health care provider attitudes toward FGM/C and confidence for related clinical care may affect the quality of care, yet there are no validated instruments to measure these constructs.

Methods

We developed the instruments via review of the FGM/C literature, the development of scale items, expert review, and pre-testing. We validated the instruments using a convenience sample of providers in Arizona and Maryland. We used exploratory factor analysis (EFA) to confirm factor structures, and compared scores between known groups to assess validity.

Results

The EFA revealed a two-factor solution for attitudes, including subscales for Negative Attitudes and Empathetic Attitudes toward FGM/C and those who practice with Cronbach’s alphas of 0.814 and 0.628 respectively. The EFA for confidence revealed a two-factor solution including Confidence in Clinical FGM/C Care and Confidence in Critical Communication Skills for FGM/C Care with Cronbach’s alphas of 0.857 and 0.694 respectively.

Conclusions

Health care provider attitudes and confidence toward FGM/C care may affect quality of care and health outcomes for women and girls. Our study describes the rigorous psychometric analysis to create reliable and valid instruments to assess health care provider attitudes and confidence for the care of women and girls who have experienced FGM/C.

Trial registration

ClinicalTrials.gov, NCT03249649. Registered on 15 August 2017. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11455-8.

Factors Associated with Health Care Provider Attitudes, and Confidence for the Care of Women and Girls Affected by Female Genital Mutilation/Cutting

Background: Female genital mutilation/cutting (FGM/C) is a cultural practice that includes procedures that intentionally alter or cause harm to female genital organs for nonmedical reasons, affecting ∼200 million women and girls globally. Health care providers in the United States often lack confidence to provide appropriate FGM/C-related care, and experience attitudes that may negatively impact quality of care for FGM/C. Methods: We conducted a cross-sectional survey of health care providers to explore the associations between health care provider characteristics, awareness of health complications of FGM/C, attitudes, and confidence for FGM/C care. Results: Factors associated with more Confidence for Clinical FGM/C Care include awareness of health complications, ever cared for a woman with FGM/C, being a woman or person of color, and more than 5 years of clinical practice. Increased Confidence in Communication Skills for FGM/C Care was associated with awareness of more health complications for FGM/C. Women endorsed significantly less Negative Attitudes toward FGM/C compared with men; no other factors were associated with health care provider attitudes. Conclusion: Future research should further investigate factors associated with health care provider attitudes toward FGM/C and those affected by the practice to promote quality care. Health providers require adequate training for clinical FGM/C care and in the communication skills that promote patient/provider communication cross-culturally. Trial Registration: Clinical Trials.Gov ID no. NCT03249649, Study ID no. 5252. Public website: https://clinicaltrials.gov/ct2/show/NCT03249649.

United States' Obstetrician/Gynecologists' Readiness to Care for Women Affected by Female Genital Cutting

Background: Female genital cutting (FGC) is a form of gender-based violence with obstetrical and gynecological complications that require recognition and care. Data suggest that United States' physicians are not prepared to care for those who have been affected by this practice. This study evaluated the knowledge and practices of United States' obstetricians and gynecologists to care for patients who have undergone FGC. Materials and Methods: This was a cross-sectional confidential survey distributed electronically to a sample of clinically active members of the American College of Obstetricians and Gynecologists. The survey consisted of questions characterizing care of patients who had undergone FGC and barriers to optimal support. Results: Five hundred forty-eight participants representing a wide range of years in practice, geographical locations, subspecializations, and patient demographics participated. Sixty-six percent of participants had cared for patients who had undergone FGC. Participants' description of their patient population racial/ethnic composition did not correlate with likelihood of treating this patient population. Forty percent of participants reported some form of education about FGC, more often among women, younger physicians, and those in practice for fewer years. Thirty-one percent of participants were comfortable counseling about and 20% were comfortable performing deinfibulation; these percentages were higher among those who had received education or had recently cared for an affected patient. Participants reported insufficient training as the largest barrier to providing care to women. Conclusions: While most physicians in this national cohort had cared for women who had undergone cutting, a minority had any form of education. However, prior education correlated with indicators of improved care. Physicians require additional guidance in treating this important and growing patient population.

Searching for content on female genital cutting/mutilation in curriculums of U.S. Nursing Schools

BACKGROUND

Over 500,000 women and girls in the U.S. are at risk for female genital cutting/mutilation, (FGC/M) because their cultural heritage is from countries where FGC/M is prevalent. Nurses lack knowledge about FGC/M, making them less likely to provide culturally congruent care. Little is known about FGC/M-related information in nursing school curriculums.

METHODS

A total of 403 schools of nursing (SONs) responded to an anonymous online survey to identify the extent, placement, and educational approaches regarding FGC/M found in curricular content in nursing schools in the U.S.

RESULTS

Fifty-seven percent of respondents did not know if nurses cared for FGC/M-affected women in the region where their nursing school was located. Only 27% of responding schools indicated FGC/M was taught in their curriculums, mostly in undergraduate programs, and primarily during classroom lectures, and rarely by simulation. SONs that were aware that nurses in their region provided care to women and girls at risk for FGC/M were more likely to have content on FGC/M in their curriculums.

CONCLUSION

Though respondents indicated that this topic is important to global nursing education, it appears that few U.S. nursing students are learning to provide culturally congruent care to women and girls at risk for FGC/M. It is vital that nurse educators include this topic in appropriate places in the curriculum, so that students learn the unique healthcare needs of this population.

National Survey of US Plastic Surgeon Experience with Female Genital Mutilation

Female genital mutilation (FGM) is a growing problem in the United States, with the past few decades showing a dramatic increase in prevalence. This study aims to understand the plastic surgeon experience with FGM and inform preparedness for this rising problem.