September 2014

FEMALE GENITAL MUTILATION THEN AND NOW

OUTLINE

Background Research project Clinical implications Cosmetic vulval surgery: some questions

TERMINOLOGY Female genital mutilation (FGM):

•  Inter-African Committee on Traditional Practices Affecting the Health of Women and Children 1990, WHO 1991

•  Emphasises harm caused and violation of human rights Female genital cutting (FGC):

•  More respectful when working with women and practising communities

•  “Something bad has happened to me: don’t hurt me more with your language.”

FGM/C: •  Hybrid term currently used by UNICEF •  Attempt to bring policy and community approaches together

FGM/C IN EARLY 1990s

• Anecdotal experience

• Seeking information to guide practice

• Information booklet for RANZCOG

• Passage of legislation in Victoria 1997 • Establishment of FARREP program

BACKGROUND: ABOUT FGM/C Range of practices involving removal of part or all of clitoris, labia minora and/or majora, with or without narrowing the vaginal opening by stitching (“infibulation”), also nicking or cutting (WHO types I-IV) Variable age infancy to adolescence Nature of procedures vary within and between countries Prevalences vary from a few % to 90%+ 29 countries Africa and Middle East plus others

CONSEQUENCES OF FGM/C No health benefits

Short term: •  Pain, distress, bleeding, infection, death

Long term: •  Scarring, abscesses •  Urinary infections •  Sexual problems •  Childbirth complications (Caesarean section, tears) •  Psychological problems

SEXUAL FUNCTION

UK: Sexual quality of life scores: significant differences between women with Type 3 or unspecified FGM and controls. Andersson et al 2012. BJOG: 119; p1606-11

Saudi Arabia: No differences in desire, but significant differences in arousal, lubrication, orgasm and satisfaction scores, eg 3.7±1.2 vs 4.2±1.4 in 5 point scale. Alsibiani S and Abdulrahim AR 2010. Fertil Steri:l 93: p722-4

CAESAREAN SECTION RATES

Epidemiological studies show consistently higher caesarean section rates for sub-Saharan African and Somali women, with limited evidence to explain the differences. Merry et al: International migration and caesarean birth: a systematic review and meta-analysis. 2013 BMC Pregnancy and

Childbirth: 13; p1-23

Small et al: Somali women and their pregnancy outcomes postmigration: data from six receiving countries. 2008 BJOG: 115;

p1630-40

REASONS FOR FGM/C Social norm:

• Perceived social obligation

• Important others do it

• It’s believed to be expected by others

• Part of belonging: fear of censure/sanctions

Requires collective action and leadership to change

INTERNATIONAL

Twenty-four of the 29 countries where FGM/C is concentrated have enacted decrees or legislation related to FGM/C (2 in 1960s, 8 in late 90s, 14 plus amendments since 2000. Growing recognition that legislation must support social change. Doctor charged in UK 2014.

Research lead: Cathy Vaughan (MSPGH) Louise Keogh (MSPGH) Narelle White (MSPGH) John Tobin (MLS) Chris Bayly (the Women’s) Bich Ha (NYCH) Maria Ibrahim (NYCH)

COMMUNITY CONSULTATION PHASE 7 focus groups with 91 participants

Established community interest in research

Confirmed project should proceed

Provided input into objectives and methods

Findings included:

•  Some questioned the need for research: “why are we still discussing this? Nobody does it any more”

•  Some interest in differences in attitudes within and between groups

•  All groups thought health service experiences important to examine

AIMS AND METHODS Engage with women and communities to explore:

•  Knowledge of FGC and legal status; •  Views on the role and meaning of FGC; •  Health-service and health promotion experiences; •  Suggestions for health services in relation to FGC.

12 groups for 102 community members Interviews for 11 community members and 11 health professionals 8 groups and 21 interviews recorded and transcribed Thematic analysis

ROLE AND MEANING OF FGC Declining importance Change led by community Cultural tradition, social norm, community membership Some mixed feelings about abandonment Generational change

ROLE AND MEANING OF FGC “It’s culture and it’s embedded psychologically. It’s the norm. It’s not that man force it or the woman force it. It’s normal, it’s the system. Like having lunch. You don’t ask whether there’s lunch or not, you get hungry, it’s midday, you go for lunch… We never thought of it other way.”

“You can’t blame your mum, you know, because this is like a culture. People you know, they do it you know, [so] you have to do it. Even maybe if you don’t do it you feel you are, uh, different from other people you know when you grow up.”

“You have to cut. It is culture.”

“It’s a form of growing up, it’s like getting your period, this is another thing. You have to do this or you don’t become a big girl kind of thing.”

“When I went back my grandma was like ‘oh you can’t tell people that you weren’t circumcised, it’s embarrassing.’”

KNOWLEDGE AND IMPACTS Generally aware of illegality Knowledge of health effects supports change Young women learning they are different: •  shame and stigma •  what will it mean to them?

Range of health problems •  none •  consummation problems and other sexual difficulties •  pap tests and examinations difficult and painful •  vaginal tearing and caesarean births

HEALTH SERVICES Care has improved over 20 years Experiences inconsistent: not all health professionals informed Problems with care attributed to lack of knowledge by providers Problems:

•  not feeling listened to •  prejudice, racism: feeling other, different, shocking •  cross-cultural communication and expectations •  complications eg tears attributed to lack of knowledge by

health professionals about FGC

TRAINING Know when to consider FGC and what issues might be Communication: how to talk about FGC Deinfibulation:

•  When to do it: o  Prior to first sex o  Second trimester o  At time of birth

•  How to do it: o  Usually simple procedure o  Often can be done under local

CLINICAL PRACTICE Ask about/discuss FGC Offer deinfibulation if appropriate Discuss antenatally any request for postpartum reinfibulation Identify/refer with other clinical problems Explain reasons for CS, tearing etc Routinely have postnatal discussion re daughters Work with interpreters, FARREP, colleagues Place of reconstructive surgery?

YOUNG WOMEN FGC in countries of origin.

In adolescence come to realise they are different.

“If you come back from Africa you, you can say it with pride, you know ‘hey I’m like this’ you know, but when you come here…if you say it, it’s a shame”.

Wonder what has been done and how it will affect their sexual relationships and childbearing.

Psychological issues may emerge.

How can we help?

School programs?

Clinician awareness important.

OTHER IMPLICATIONS Work with communities: •  recognise and build on community-led change •  involve men and community leaders •  reach newer and less obvious communities •  acknowledge differing priorities and other settlement concerns With community assistance/involvement: •  ensure public discussion informed and reflects complexities •  improve communication between women and HPs •  increase awareness of services •  address specific needs of young women

IS FGM/C RELEVANT TO COSMETIC SURGERY? What study participants said:

“It was also a beauty not to see all those hanging pieces, [and] it increases male sexual pleasure.”

“But it happens as well in free countries. There’s the plastic surgeon who is doing that.”

“If an 18 or 19 year old woman wants to do it, why the law will stop her and not stop the other women?. This is a racial issue.”

“There is this huge stigma that you know that uh, circumcised women want their thingy narrower, tighter, you know?” contrasting the lack of apparent stigma around labiaplasty.

WHAT THE LAW SAYS Crimes Act 1958 – Sect 32 (1997)

A person must not perform female genital mutilation:

• Infibulation

• Excision or mutilation of whole of a part of the clitoris, the labia minora or labia majora

• Any procedure to narrow or close the vaginal opening

• The sealing together of the labia minora or labia majora

• The removal of the clitoral hood.

Consent is not a defence.

Exceptions:

Removal of the clitoral hood at age ≥18

EXCEPTIONS TO SECTION 32 (34A) (1)  It is not an offence against section 32 if the performance of the female genital

mutilation is by a surgical operation which is -

(a) necessary for the health of the person on whom it is performed and which is performed by a medical practitioner; or

(b) is performed on a person in labour or who has just given birth, and for medical purposes or the relief of physical symptoms connected with that labour or birth, and which is performed by a medical practitioner or a midwife; or

(c) is a sexual reassignment procedure which is performed by a medical practitioner.

(2) For the purposes of subsection (1)(a), in determining whether an operation is necessary for the health of a person, the only matters to be taken into account are those relevant to the medical welfare or the relief of physical symptoms of the person.

LABIAPLASTY Australian medical websites show before and after

photographs and describe procedures to reshape and

beautify the labia or to help women feel more confident

about the way they look, the implication being that normal

female genitalia can be improved.

Are there parallels with FGM/C?

Are we constructing a new social norm?

GUIDANCE: RCOG

RCOG “Hymenoplasty and labial surgery” 2009, extract: RCOG “is concerned that requests for both labioplasty and hymenal reconstruction surgery may be made by women who do not realise that the appearance of the external genitalia varies from one woman to another. Furthermore, there is the potential for a woman to be harmed by these procedures, with very little scientific evidence regarding their benefits.”

GUIDANCE: RANZCOG

RANZCOG “Vaginal ‘Rejuvenation’ and Cosmetic Vaginal Procedures” 2008, under review: The College strongly discourages the performance of any surgical procedure that lacks current peer reviewed scientific evidence other than in the context of an appropriately constructed clinical trial. The real risks of potential complications such as scarring, permanent disfigurement, infection, dyspareunia and altered sexual sensations should be discussed in detail with women seeking such treatments.

CONCLUSIONS

Cosmetic surgery has some parallels with FGM/C.

Role of clinicians to focus on health needs of those affected by FGM/C.

Main work is asking and listening, working with interpreters and cultural support as needed.

Ensure doctors and midwives are trained in this area.

Responsive health care and accurate information can be expected to build trust and support efforts to eliminate FGM/C.

Support communities to work for change.