Female Genital Mutilation – Beyond Cultural Judgements

How to guide doctors to identify the physical and psychological needs of women who have suffered female genital mutilation?

Female genital mutilation, also known as female genital cutting or female circumcision, is a harmful practice that involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons. It's recognized internationally as a human rights violation. The practice is related to cultural traditions in various ethnic groups in the world. In every society where it occurs, female genital mutilation is an expression of deeply rooted gender inequality.

The most recently published study in Spain indicates that there are 18,836 girls (0–14 years old) and 80,279 women who come from a country where female genital mutilation is performed (mainly Senegal, Nigeria, Ghana and Mali)

According to UNICEF at least 200 million girls and women alive today living in 31 countries have undergone female genital mutilation. The most recently published study in Spain indicates that there are 18,836 girls (0–14 years old) and 80,279 women who come from a country where female genital mutilation is performed (mainly Senegal, Nigeria, Ghana and Mali). Catalonia, Andalusia, Aragon and Madrid are the Autonomous Communities of Spain where women coming from countries where female genital mutilation is performed are mostly concentrated.

A forgotten practice

Since 2003, Spain has a specific criminal law provision on female genital mutilation. The legal protection of minors regulates the obligation of state public agencies to intervene if there is risk of a minor being subjected to female genital mutilation or when it has been performed. Primary health care settings are actively involved in these prevention acts of the practice among young girls coming from family backgrounds originated from countries/ethnical backgrounds where the practice is prevalent. A Spanish study reported a profound lack of knowledge of health professionals around the concept, typology, and countries where female genital mutilation is practiced, which precludes them to detect risk factors and identify women at risk.

A Spanish study reported a profound lack of knowledge of health professionals around the concept, typology, and countries where female genital mutilation is practiced, which precludes them to detect risk factors and identify women at risk

In addition to the coordinated activities between the police, primary care, and school settings to prevent the female genital mutilation practice, there is an unaddressed need to systematically detect the practice among women who may suffer physical and psychological consequences. Female genital mutilation can include immediate complications, such as severe pain, hemorrhage, infections, urinary problems, wound healing problems, or even death. At long-term, female genital mutilation can cause urinary tract infections, vaginal problems, menstrual problems, sexual problems, deinfibulation, increased risk of childbirth complication and newborn deaths as well as psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem etc.). These complications are attended at primary healtchare level but in most cases there is no causal relation made with the female genital mutilation practice.

There is an unaddressed need to systematically detect the practice among women who may suffer physical and psychological consequences

Orienting health staff

ISMiHealth tool is an innovative clinical decision-support system for migrants that guides general practitioners through computer prompts about screening recommendations for infectious diseases and female genital mutilation. During its pilot phase, led by ISGlobal Migrant Health Research Group, Fundació Clínic, Catalan Institute of Health (ICS for its Catalan acronym) and the University Research Institute at Primary Care-Jordi Gol (IDIAPJGol), the tool was integrated within the primary care electronic patient record in Catalonia and displayed prompts about screening recommendations based on an individualized approach that uses three variables: sex, age and country of origin.

The immediate and long-term female genital mutilation complications are neglected health conditions that do not get screened and treated at primary healthcare

The screening of female genital mutilation is conducted through a short ad hoc questionnaire to be linked to the electronic patient record that will help the health professionals to assess whether this practice is common in their ethnicity/region/family, if the patient has suffered it and if so, whether she has young daughters. This process could result in the identification of female genital mutilation where the health professionals should examine possible health consequences among women and if necessary their referral to another specialist.

Barriers to address female genital mutilation

Parallel to the ongoing ISMiHealth clustered randomized control trial (PI: Ana Requena-Méndez, Head of Migrant Health Research Group), we are conducting a mixed-methods research study (PI: Stella Evangelidou, senior research fellow in global mental health and gender-based violence at ISGlobal Migrant Health Research Group) to explore what are the barriers of addressing female genital mutilation at primary healthcare settings in Catalonia together with ICS, IDIAPGol, medical experts in violence against women and female genital mutilation, as well as migrant women community leaders, who come from countries where female genital mutilation is prevalent. Towards this objective we are launching a survey for primary health professionals, in-depth interviews with adult migrant women who have suffered the practice and focus group discussions with women who come from countries/ethnicities where female genital mutilation is prevalent. The study locations are Olot, Lleida and Mollet del Vallès. The ongoing qualitative research study is conducted by white European researchers with a topic guide that had been reviewed by migrant women community leaders.

Preliminary findings show that migrant women do not always feel comfortable to address the issue with health professionals at primary care, since they “prefer silence over judgements against their culture”. Some feel “guilt”, “shame” and “anger”, whereas others “pride” for having undergone the practice. As part of joint efforts to eliminate this harmful tradition, we need to acknowledge women’s perspectives, working together with them, not against their beliefs, avoiding any judgmental attitudes. Towards this direction, culturally sensitive initiatives focus on the sensibilization and health education of women who have suffered the practice. On the other side, personal taboos or lack of training on the thematic may lead primary health professionals to oversee the negative consequences female genital mutilation can have on women’s health. Female genital mutilation is a symptom, rather than a cause of women’s health and social problems. Structural analytical frameworks call for treating female genital mutilation not as an isolated health phenomenon, rather located in the context of migrant women’s welfare needs.

As part of joint efforts to eliminate this harmful tradition, we need to acknowledge women’s perspectives, working together with them, not against their beliefs, avoiding any judgmental attitudes

While female genital mutilation is a cultural practice, our understanding should not be limited to cultural terms. According to women’s own female genital mutilation experiences, the established imagery of female genital mutilation as a cultural issue has posed barriers in migrant women’s access to healthcare, since their experiences of gender-based violence are intertwined with structural violence they face on the account of their gender, class and country or origin in the host country.

Personal taboos or lack of training on the thematic may lead primary health professionals to oversee the negative consequences female genital mutilation can have on women’s health

Although there are established legal measures to prevent and end culturally normative forms of violence against women, such as female genital mutilation, in Catalonia, such actions should not bypass affected migrant women’s needs to make sense of their female genital mutilation own experiences in safe and dialogic environments at primary care and community settings.