Health sector involvement in the management of female genital mutilation/cutting in 30 countries

Female genital mutilation/cutting (FGM/C) is a global health issue. More than 200 million girls and women in 30 countries in Africa, Asia and the Middle East have undergone the practice [1], and more than 3.6 million girls are annually at risk [2]. The impact of FGM/C is also spreading further through migration to other parts of the world including Europe [3–6], the USA [7, 8], Australia [9] and Canada [10]. Hence policies are needed to address this issue in both countries of origin and countries of migration.

FGM/C encompasses all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons [11], and is most commonly performed on minors [12]. The World Health Organization (WHO) classifies FGM/C into four types according to the type of tissue removed: Type I partial or total removal of the clitoris (clitoridectomy) and/or the prepuce, Type II partial or total removal of the clitoris and the labia minora and/or labia majora (excision), Type III narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia majora and/or minora, with or without excision of the clitoris (infibulation). Type IV includes all other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterization.

FGM/C is associated with a greater risk for a series of health complications, dependent on the extent and type of tissue removed. Immediate health risks include pain, haemorrhage, infection, urinary retention and injury to the urethra, wound healing problems and death [13]. Long-term health complications include genitourinary (urinary tract infection, bacterial vaginosis, problems with menstruation) [14], obstetrical (caesarean section, postpartum haemorrhage, episiotomy, prolonged labour, tears or lacerations, instrumental delivery, difficult labour, external maternal hospital stay, still birth and early neonatal death, infant resuscitation at delivery) [15], sexual (dyspareunia, no sexual desire and reduced sexual satisfaction) [16], and psychological (post-traumatic stress disorder, anxiety disorder and depression) consequences [17]. FGM/C, in particular infibulation, can also interfere with other medical procedures such as gynaecological examination, cytology testing, post-abortion evacuation of the uterus and insertion of intrauterine device [18].

Considering the health impact of FGM/C, the World Health Organization (WHO) has played a key role in tackling the issue from its first international conference on FGM/C in 1979 onwards [19]. The WHO also issued the first United Nations (UN) policy statement on FGM/C in 1997 [20], reiterating it in 2008 [11]. The statement emphasized the importance of broad-based, long-term commitment as well as a multisectoral approach involving education, finance, justice, women’s affairs and health. In 2001, the WHO developed its first policy guidelines for the health sector [21], accompanied by practical and clinical guidelines [22–24] that were updated in 2016 [18]. The UN emphasize and outline the role of healthcare providers (HCP) in primary prevention and provision of care [11].

In 2008 and 2012 the World Health Assembly (WHA) and the UN General Assembly respectively agreed on resolutions against FGM/C urging all member states to develop, support and implement national policies and action plans as well as to allocate sufficient resources for its implementation [25, 26]. The resolutions also highlighted the importance of incorporating clear targets and indicators in the national plans and policies for the effective monitoring, impact assessment and coordination of programmes. The WHA also commits its member states to follow up and regularly report on a set of points targeting prevention (in particular community based interventions), legislation, guidelines and provision of care [26].

Literature on FGM/C shows that several countries have developed national policies [27–32], guidelines [33–40] and legislations [41–43], as well as making progress in the involvement of community based interventions [43–46]. Less is known however about the involvement of the health sector in national plans, nor the implementation levels, allocated resources, coordination and monitoring and evaluation of such plans in the different countries. A 2012 review of policies in 28 countries in the European Union (EU) reports insufficient and unequal distribution of support- and health services as well as inconsistent funding to ensure access to services [32]. No similar data is available from non-EU countries with high numbers of migrants from FGM/C practicing countries, nor from countries where FGM/C is traditionally practiced. Nevertheless, a 2010 progress report on the WHA resolution from African member states highlight the involvement of the health sector as an area in need for improvement [43].

In this paper, we aspire to fill this knowledge gap by presenting an overview of the current status of the involvement of the health sector in national plans on FGM/C in 30 countries, 11 of which are countries where FGM/C is a traditional practice (hereafter referred to as countries of origin), and 19 countries where FGM/C is practiced mainly by migrant populations (hereafter referred to as countries of migration). We present the data unaggregated to highlight areas for improvement for each country and to facilitate future measurement of progress.

To identify elements central to the health sector involvement in national policies on FGM/C, we first conducted a desktop review of the WHO policies and declarations [11, 26, 47, 48], national and clinical guidelines [18, 21, 27–31, 33–37, 49] and other relevant literature [8, 35, 38, 39, 41, 50]. The key elements identified were: Training of HCP, involving HCP in the preventive work, legal regulations on HCP duties to avert and report as well as to perform FGM/C, and finally the availability of healthcare services (deinfibulation, clitoral reconstruction, sexual and psychological counselling). These elements were then grouped in three categories: 1) training and duties of HCP, 2) performing FGM/C by HCP, and 3) availability of health services. A fourth category ‘the availability and systematic use of medical codes’ was then added since medical records are important not only for proper medical care, but also to inform health policies. REBJ and MMZ used these categories, together with questions on the existence and the level of implementation of national policies on FGM/C, allocation of funds, coordination, and monitoring and evaluation systems to develop a questionnaire with closed- and open-ended questions. EL and BSD commented and revised the questionnaire. The questionnaire was then pilot-tested in three countries resulting in minor revisions. The final version (Additional file 1) was then distributed through e-mails in the period April–June 2016 to 61 countries, of which 33 were countries of origin and 29 countries of migration.¹ For data collection in the 33 countries of origin, assistance was first asked from the WHO headquarter and the UNFPA-UNICEF Joint Programme on Female Genital Mutilation, but they were unable to help at the time. Therefore, we have instead contacted the WHO country offices, NGOs and researchers known to work on FGM/C in these countries inviting them to participate in the study or to put us in contact with the relevant persons/authorities. Up to three reminder e-mails were sent to non-respondents. Eleven respondents representing 11 countries of origin returned filled questionnaires. These respondents filled the questionnaires in their capacity as: the WHO country office (Ghana), researchers (Burkina Faso, the Gambia, Iran, Kenya, Mali, Sierra Leone and Sudan) and NGO’s (Egypt, Ethiopia and Somaliland). Supportive documents were provided for only two countries (Iran and the Gambia).

Invitations to participate were also e-mailed to government representatives, researchers and NGOs known to work on FGM/C in 29 countries of migration. Up to three reminder e-mails were sent to non-respondents. Twenty-one respondents representing 19 countries of migration returned filled questionnaires. Fifteen of the respondents were researchers representing 14 countries (Australia, Austria, Belgium, Finland, Ireland, Italy, the Netherlands, Norway, Portugal, Saudi-Arabia, Spain, Sweden, UK and the USA), as UK had two responding researchers. Three of the respondents were government representatives for three countries (Greece, Slovakia and Sweden). In one country (Switzerland) the questionnaire was filled by a researcher/WHO. Finally, two NGO’s representatives filled the questionnaire for two countries (France and Germany). Supportive documents/sources were also provided for ten countries (Australia, Belgium, Greece, Ireland, the Netherlands, Norway, Portugal, Slovakia, Spain and Sweden). Since both the UK and Sweden had more than one respondent each with conflicting response, we decided after cross-checking with provided/available sources which response to use.

The data was entered into SPSS 22 and analysed. We then cross-checked the results from each country with provided or available sources and documents. Inconsistencies in certain data (duty to avert and duty to report, availability of sexual and psychological counselling services, availability and systematic use of medical codes and legal regulations for HCP concerning performing FGM/C on adults) were discovered. Therefore we contacted all respondents in 2017 and through face-to-face and/or phone interviews and e-mail cross-checked, clarified potential misunderstandings and largely corroborated all information with a special focus on areas of discrepancy. The corroborated quantitative data was then reanalysed and presented in tables, while clarifying and additional provided data were used to elucidate the different contexts and practices in different countries.

A limitation of the study is that the focus on national policies obscured in-country variation. Another methodological limitation is the low response rate, particularly in countries of origin. Thus, the findings may not be representative, but rather biased towards countries that have FGM/C high on their political agenda. Furthermore, the low level of responses from responsible government departments can be a weakness, as some of the respondents might have lacked a full knowledge of government policy. Still, having most questionnaires filled by non-governmental representatives could also give more realistic and unbiased information.

National policies on FGM/C can signify governmental commitment to the prevention and provision of care for those at risk of FGM/C and those who have been subjected to FGM/C, and might be triggered by the ratification of certain legally binding policy documents, such as the Maputo Protocol or the Istanbul Convention. National action plans, in particular, provide a platform and structure for long-term and systematic work on FGM/C whereby different sectors can collaborate effectively. To enable monitoring and evaluation, and accountability, distribution of responsibilities, targets and outcome indicators should be clearly stated. Hence, significant efforts have been made in securing that both countries of origin and countries of migration have such policies in place [32, 60]. Twenty-four of the participating countries in this study reported to have a national policy on FGM/C, of which 19 countries had clear distribution of responsibilities (Table 1). Nevertheless, 13 countries did not allocate funding for their plans and only few established systems for monitoring and evaluation. Moreover, the extent of involvement of the health sector in these plans varied considerably across the participating countries.

HCP can play a key role in the prevention of FGM/C by providing health education to patients and/or parents during consultations, as their educational background and social status give extra credit to their messages [11, 37, 44]. Also, the regular interactions with families provide them with unique opportunities to share such information. Our findings show that providing health education on FGM/C to patients and/or parents during consultations is part of HCP duties in only eight countries, all of which are countries of migration (Table 2). It is striking to see that the preventive role of HCP is highly underused in countries of origin. Several studies have identified numerous challenges to the involvement of HCP, particularly in countries of origin. Some HCP support FGM/C or consider it as a sensitive issue and consequently resist working against the practice [44, 61–64]. This resistance is further aggravated by a high workload [44] and the lack of skills to adequately address FGM/C [65].

On the other hand, as shown in Table 2 many countries oblige HCP to avert (three countries of origin and 16 countries of migration) and/or report FGM/C (two countries of origin and 14 countries of migration), duties that unlike provision of health education may present ethical challenges for HCP [66]. One particular challenge is the problem of dual loyalty where HCP have the simultaneous obligation to a patient and to a third party, often the state [67]. Medical ethics have long recognized the paramount importance of loyalty to patients in the form of confidentiality and the patient’s best interest. Increasingly, health professionals are asked to weigh this loyalty against objectives of governments or other third parties. Dual loyalty poses a particular challenge when patient’s confidentiality poses a risk of a human rights violation, such as in the case of FGM/C. Where state regulations codify “duty to avert FGM/C” or “duty to report FGM/C”, the problem of dual loyalty of health care providers must be addressed. Numerous countries exempt HCP from medical confidentialities in cases of violence against children. In such cases, either the risk and/or the occurrence of FGM/C are defined as a serious abuse, thus the child-protection laws allow or compel HCP to break medical confidentiality in the best interest of the child [32]. There is however disagreement as to whether reporting is in the best interest of the child given that FGM/C is not the same as repetitive, recurrent child abuse [32]. If reporting leads to a care order for the girl in question or imprisonment of her parents, some see this as compromising the child’s best interest, as she loses the care of her parents in addition to being subjected to FGM/C [68–70]. On the other hand, the reporting of parents might protect other female siblings from being subjected to FGM/C. Another concern is a fear that mandatory reporting can deter parents from seeking necessary healthcare for their children for fear of legal repercussions [71].

Another ethical dilemma for HCP is requests to perform FGM/C. In some countries HCP are replacing traditional circumcisers in performing FGM/C as a way of harm reduction [51, 72]. In Sudan, midwifes were trained to perform FGM/C [73] and in Egypt FGM/C was allowed only in State hospitals “by trained physicians under hygienic conditions” [62]. A recent study found that 26% of women age 15 to 49 with FGM/C had been cut by a HCP, with the highest rates in Sudan (67%), Egypt (38%), Guinea (15%), Kenya (15%) and Nigeria (13%) [51].

The WHO, however, condemns the medicalization as it is considered a perpetuation and legitimization of a harmful practice that counteracts efforts towards its abandonment [18, 47, 51, 54, 59, 72, 74]. Moreover, HCP also perform FGM/C for reasons other than harm reduction, such as financial gain, support for the practice and pressure from the communities [75]. As shown in Table 3, HCP are prohibited from performing FGM/C on minors in 24 countries (six countries of origin and 18 countries of migration) and on adults in 22 countries (six countries of origin and 16 countries of migration), including two countries (Egypt and Kenya) with high FGM/C medicalization rates. Sudan, on the other hand, has yet to regulate the problem of medicalization in the country. Furthermore, eight of the countries that prohibit HCP from performing FGM/C do not specifically stipulate reinfibulation as illegal in their laws (Table 3). This could be problematic since reinfibulation is not clearly stated in any of the four types of FGM/C in the WHO classification, and prohibiting FGM/C per se, might not always be interpreted to include reinfibulation [76]. Another problematic area is cosmetic surgeries of female genitalia such as labia reduction, clitoral lift and vaginal tightening, all of which are very similar to the different types of FGM/C. Legal regulations concerning female genital cosmetic surgery were beyond the scope of this study. It is important though for future studies to explore the possible impact of not prohibiting female genital cosmetic surgeries on FGM/C.

Considering the magnitude and complexity of HCP duties in the prevention of FGM/C that comes in addition to their caregiving duties, comprehensive training of HCP is of utmost importance. Training is also expected to decrease medicalization [48]. Our study findings (Table 2) show that 24 countries (10 countries of origin and 14 countries of migration) conduct training for HCP. However, many studies have revealed a lack of knowledge among HCP on many aspects concerning FGM/C such as prevalence, identification of types, diagnosis and clinical management, as well as their professional roles and responsibilities, cultural competence, referral systems and legal issues [65, 77–81]. This could indicate that the reported training is inadequate in most of the above mentioned 24 countries. A possible explanation is that in as many as nine countries, of which seven are countries of migration; training is provided only on an ad-hoc basis.

Besides the competence of HCP, the availability of the necessary services is an important aspect of healthcare provision for those subjected to FGM/C. Infibulated girls and women can benefit from deinfibulation to improve health problems associated with infibulation and to allow sexual intercourse and childbirth [14, 18, 82–84]. Our findings (Table 4) show that deinfibulation is available in almost all responding countries. FGM/C is also associated with an increased risk of various psychological disorders in both children and adults [17, 85–87], challenges that seem to intensify in countries of migration [85, 88]. Cognitive behavioural therapy is the recommended management in such cases [18]. FGM/C is also associated with higher rates of sexual problems [16]. In countries of migration, experiences of stigma and/or being different can increase women’s concerns over their own sexuality [89–91]. The WHO recommends sexual counselling for preventing or treating female sexual dysfunction among women living with FGM/C, but not clitoral reconstruction [18]. Clitoral reconstruction was reported to be available in 13 countries (three countries of origin and 10 countries of migration) (Table 4). Many countries providing these services, however, combine surgical consultation with a multidisciplinary care model, including preoperative psycho-sexual counselling [92, 93]. Still, it is a cause of major concern that 17 countries, of which as many as nine countries are countries of origin, have reported a lack of psychological and sexual counselling services with a special competency on FGM/C (Table 4).

Another area for improvement is the systematic use of FGM/C codes in medical records. Records serve many central purposes such as providing an overview of the management of a particular disease, monitoring and improving quality of care, and providing robust databases for research [94]. Data on FGM/C in most medical records has so far been negligible for several reasons including lack of codes on FGM/C in some countries and inconsistencies in its use in others [32]. This is consistent with our findings (Table 5). Less than half of the participating countries reported to have designated medical codes on FGM/C, none of which are countries of origin. Only two countries (the Netherlands and UK) reported to use these codes systematically. Nevertheless, six of the countries that reported to have no designated medical code for FGM/C (Austria, Burkina Faso, Ghana, Kenya, Slovakia and Switzerland) reported during cross-checking to use ICD-10. Considering that in 2016 a new code on personal history of FGM/C (code Z91.7) was added to ICD-10 [59], all of these six countries could arguably be said to have available medical codes on FGM/C. These findings suggest that there is a great potential for strengthening healthcare provision and acquiring quality data on FGM/C prevalence and health complications, if countries were to adopt and systematically use ICD codes or harmonized national codes on FGM/C. Nonetheless, the mere introduction of ICD codes for FGM/C is not sufficient on its own, but has to be combined with comprehensive training on FGM/C. Existing research suggests that inconsistencies in the use of FGM/C codes are often attributed to a lack of knowledge, fear of causing stigmatization and concern over medical confidentiality [81, 95], and that coding improves considerably after training [95].

For the last decades the international community has emphasised the importance of a multisectoral approach to tackle FGM/C and the crucial role of HCPs in this approach. Our study findings indicate that substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. There is nevertheless a need for countries of origin and countries of migration to incorporate systems for monitoring and evaluation into their plans of action. We have also identified five areas for improvement in the involvement of the health sector in the management of FGM/C: First there is a need to strengthen systematic training of HCP, particularly in countries of migration. Secondly, the role of HCP in averting and reporting FGM/C is unclear and inconsistent. There is therefore a need for studies that can evaluate and compare the different practices in different countries. It is also an ethical dilemma that HCP have a duty to avert and report in 19 and 16 countries respectively, but have a duty to provide relevant health education in only eight of these countries of which none are countries of origin. Thirdly, a stronger emphasis on the role of HCP in the provision of health education is needed everywhere but mainly in countries of origin. Further, provision of psychological and sexual counselling services with competency on FGM/C is lacking in 82% of the countries of origin and 42% of the countries of migration, and should be prioritized. Finally, routines and guidelines should be put in place to ensure the availability of FGM/C codes, particularly in countries of origin, and their systematic use in medical records in all countries.