Female genital mutilation: the role of health professionals in prevention, assessment, and management

Dear Editor,
We read the thorough Clinical Review by Simpson and colleagues [1] with great interest and are pleased that this important subject is covered in the British Medical Journal as Female Genital Mutilation (FGm) is common in clusters in the Western World, due to migration from endemic countries. As discussed in the review, the Foundation for Women’s Health, Research and Development (FORWARD), in collaboration with the United Kingdom Department of Health, estimated that there are nearly 66,000 women with FGM living in England and Wales, with the highest estimated prevalence being in Inner London [2] (6.3% prevalence compared to 1.48% nationally).

So far, there has only been one UK study exploring knowledge and attitude of healthcare professionals towards this practice: Zaidi et al [3] noted significant deficiencies in theoretical knowledge and adherence to Royal College of Obstetricians and Gynaecologists’ (RCOG) guidelines amongst 45 responders in a teaching hospital. We would like to share the results of a study we conducted to assess the level of knowledge, attitudes and training regarding FGM, amongst health professionals working in North London boroughs known to have a high prevalence of the condition in order to examine if these factors have improved in the four years since Zaidi’s study in 2007.

Seventy-nine healthcare professionals from various disciplines (obstetricians, paediatricians, midwives, student midwives, foundation year trainees and medical students; 78.5% female, 20.3% male) completed anonymous, 19 point paper questionnaire based on the most recent RCOG guidelines on FGM.

Our study indicates an overall improvement in knowledge compared to the previous UK study [3] (e.g. 7 fold increase in the ability to classify types of FGM): this is a tribute to RCOG and Royal College of Midwifery (RCM) training curricula and also to passionate advocates against the practice such as Dr Comfort Momoh [4]. Three quarters of this broad spectrum of health care professionals sampled were conversant with the Female Genital Mutilation Act of 2003 whereas only 40% of UK responders did so in 20073. However, we feel that respondents still have insufficient knowledge base about the diagnosis and classification of FGM, about some of the complications and about organising appropriately timed defibulation to allow safe child birth (68.4% did not know when best to perform defibulation). We also point out that even in high prevalence areas, less than 21% of healthcare professionals have seen more than 10 cases and less than 25% of respondents had received formal training in recognising or managing this condition.

Attitudes of the respondents were interesting: nearly 10% thought that medicalising and therefore making FGM legal (or at least when performed by a medically trained person) would make the practice more open and safe, and thus possibly reduce complications. Recent controversy was raised by attempts from the American Association of Paediatricians to medicalise the condition by suggesting that a symbolic “nick” could be acceptable culturally as an alternative to FGM, thus reducing the risk of formal circumcision [5]. Similar to findings from a Flemish study [6], some of our responders also thought that genital piercing and cosmetic genital surgery are a form of FGM, mirroring the issue raised in the recent commentary in the British Journal of Obstetrics and Gynaecology [7].

Health care professionals are also required to identify children at risk of FGM, of which there are an estimated 20,000 in the United Kingdom [2], and report these children via child protection protocols. It is of concern to us that only 87.3% of respondents, working in London boroughs where child protection is highly topical, would act upon this requirement.

The future of the medical profession lies in the hands of our undergraduate colleagues. Of the eight medical students on their gynaecology placement who participated in our study, only 37.5% were aware of the classifications system for FGM, and only 60% were aware of UK law. FGM is also becoming more visible on the undergraduate curriculum with educational modules [8] being available in mainline journals such as Student BMJ.

We stress that current knowledge demonstrate the amount of work which still needs to be done, in training health professionals about this ongoing breach of human rights, with the resultant goal of eradicating the practice.

Correspondence email: wai.yoong@nmh.nhs.uk

References:

[1] Simpson J, Robinson K, Creighton S and Hodes D. Female Genital Mutilation: The role of health professionals in prevention, assessment and management. BMJ 2012; 344:e542

[2] Dorkenoo E, Morison L, Macfarlane A. A Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales: Summary Report. Foundation for Women’s Health, Research and Development (FORWARD). 2001.

[3] Zaidi N, Khalil A, Roberts C, Browne M. Knowledge of female genital mutilation among healthcare professionals. J Obstet Gynaecol. 2007; 27(2): 161-4.

[4] Momoh C; Female Genital Mutilation. Radcliffe Publishing Ltd (2005). ISBN: 1 85775 693 2.

[5] MacReady N. AAP retracts statement on controversial procedure; The Lancet (2010); 375 (9734): 15

[6] Leye E, Ysebaert I, Deblonde J, Claeys P, Vermeulen G, Jacquemyn Y, Temmerman M.
Female genital mutilation: knowledge, attitudes and practices of Flemish gynaecologists. Eur
J Contracept Reprod Health Care 2008; 13(2): 182-90.flemisg

[7] Kelly B, Foster C. Should female genital cosmetic surgery and genital piercing be
regarded ethically and legally as female genital mutilation? BJOG 2012; 119: 389-92

[8] Ironside J, Raman L, Relph S, Ray A, Yoong W. A Pregnant Woman With A Problem;
Student British Medical Journal 2010; 18: c2208.