Female genital mutilation/cutting (FGM /C ): Survey of RANZCOG F ellows, D iplomates & T rainees and FGM /C prevention and education program workers in A ustralia and N ew Z ealand

Abstract

Background

Female genital mutilation/cutting (FGM /C) is traditionally practised in parts of A frica, the M iddle E ast and S outh‐E ast A sia. Migration has brought FGM /C to the attention of health practitioners in industrialised nations. It is not known whether FGM /C procedures are being performed in A ustralia and N ew Z ealand, where legislation has been passed banning the practice.

Aims

To survey RANZCOG F ellows, T rainees and D iplomates, and FGM /C education and prevention program workers, about their experience with women and children affected by FGM /C, specifically to identify whether FGM /C is being performed in A ustralia or N ew Z ealand.

Methods

Electronic survey distributed via e‐mail to RANZCOG F ellows, T rainees and D iplomates and FGM /C program workers in A ustralia and N ew Z ealand between N ovember 2010 and F ebruary 2011.

Results

530 responses were received from RANZCOG F ellows, T rainees and D iplomates, with an overall response rate of 18.5%. Thirty‐four responses were received from FGM /C program workers. Five RANZCOG respondents and two FGM /C program workers cited anecdotal evidence that FGM /C is being performed in A ustralia and N ew Z ealand. 21.2% (82) of RANZCOG respondents had been asked to re‐suture following delivery, and 11 respondents had done so at least once. Two RANZCOG respondents had been asked to perform FGM /C on a baby, girl or young woman.

Conclusions

There is no conclusive evidence of FGM /C being performed in A ustralia and N ew Z ealand, either from direct reports or children presenting with complications, although re‐suturing post‐delivery is occurring. Anecdotal evidence suggests that it is most likely that people other than registered health practitioners are performing FGM /C .

Introduction

Female genital mutilation (FGM) is defined by the World Health Organization (2008) as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non‐medical reasons.1 Worldwide, an estimated 130–140 million women and girls have undergone such a procedure.2

The term itself has been seen by affected communities as excessively judgmental and demonstrating insensitivity towards individuals who have undergone such procedures. REACH, the UNFPA‐sponsored Reproductive, Educative, And Community Health program, coined the phrase ‘female genital cutting’, rejecting ‘female circumcision’ as a misleading euphemism.3 The expression female genital mutilation/cutting (FGM/C) will be used in this article.

Australia and New Zealand are two of 12 industrialised countries to introduce laws against FGM/C prohibiting any type of FGM or any other genital mutilation from being performed.4 In addition, since 1997, special health workers in hospitals, women's services and community agencies were funded to provide community education, strengthening knowledge about FGM/C and supporting change in attitudes in order to prevent the practice.

FGM/C‐affected women sometimes request re‐suturing following vaginal delivery. The legislation is ambiguous about whether re‐suturing following delivery is the same as re‐infibulation or whether this is suturing of a laceration.5, 6 We have no published data on how often requests for re‐suturing are made in Australia and New Zealand. The Royal Australian College of Obstetricians and Gynaecologists (RACOG) in 1994 surveyed its membership about FGM/C, with 412 responses received from doctors who saw women from areas where FGM/C was known to be performed (of a total of 650 responses). Two of these respondents estimated that 13 women had undergone a FGM/C procedure in Australia, with 10 doctors giving some form of evidence of this (mainly anecdotal, from patients). Doctors had been asked to perform a FGM/C procedure, with some reporting that they had been asked to re‐suture labia post‐delivery.7

There is mounting evidence that in the countries of concern, the rate and severity of procedures being carried out is reducing, following concerted efforts to introduce policies and programs addressing the complex social dynamics behind FGM/C and involving the community in changing traditional practices.8-10

In Australia and New Zealand, there is a lack of information about whether such procedures are taking place. We sought to survey medical practitioners through RANZCOG (Fellows, Diplomates and Trainees) to ascertain current practice and draw comparisons with the 1994 ACOG survey. A modified survey was sent to FGM/C education and prevention program workers (FGM/C workers) in both countries, as it was felt that they would have wider experience and possibly evidence of FGM/C occurring here that had not come to the attention of medical practitioners.

Materials and Methods

Ethics approval was gained from The Royal Children's Hospital Melbourne Human Research and Ethics Committee (HREC Ref: 30144 A). RANZCOG's Continuing Professional Development Committee approved the survey for distribution. In November 2010, a secure link to an electronic survey (SurveyMonkey ^®, Palo Alto, CA, USA) was sent via e‐mail to addresses of Fellows, Diplomates and Trainees provided by RANZCOG. A modified version of the survey was also e‐mailed to FGM/C workers in each state and territory of Australia and New Zealand, via a nationwide contact list of FGM/C education programmes. These recipients were asked to forward the e‐mail to relevant workers in their area. A further reminder was sent two months later, and the survey was closed after a total of 12 weeks.

Results

The survey link was sent to 3090 e‐mail addresses supplied by RANZCOG, of which 222 were undeliverable. The overall response rate was 18.5% (530 responses), comprising a 22.4% rate from Fellows (307 responses), 9% from Diplomates (113 responses) and 23.9% from Trainees and Members (109 responses).

The survey link was sent to 37 FGM/C program contacts in Australia and New Zealand. Thirty‐four responses were received. A response rate could not be calculated as the initial recipients were asked to forward the link to relevant colleagues, and therefore, the total number of recipients of the link is unknown.

Three hundred and ninety six respondents of 524 who answered (75.6%) see women and children from some African countries, the Middle East and areas of South‐East Asia, where FGM/C is known to be performed. Of these, 98 (24.7%) had not seen any women or children having had an FGM/C procedure in the past five years (Table 1).

Table 1. How many women have you seen over the past 5 years who have had a FGM /C procedure?

	0	1–5	6–10	11–20	21–30	31–40	41–50	>50
RANCZOG (n  = 396)	24.7% (98)	40.4% (160)	14.6% (58)	10.6% (42)	3.3% (13)	1.0% (4)	0.8% (3)	4.5% (18)
FGM/C Workers (n  = 19)	10.5% (2)	36.8% (7)	5.3% (1)	5.3% (1)	5.3% (1)	5.3% (1)	0% (0)	31.6% (6)

• Data shown as % (n ).

Those who chose the option to state the number they estimated had the procedure in Australia or New Zealand did not give an actual figure, and their responses were therefore added to the ‘None’ category if the free‐text response was ‘0’, or the ‘Don't Know’ category if the response was something other than a numerical value (Table 2).

Table 2. In how many of these women or children would you estimate that the procedure was performed in A ustralia or N ew Z ealand?

	None	Don't know
RANZCOG (n  = 298)	77.9% (232)	22.1% (66)
FGM/C Workers (n  = 19)	57.9% (11)	42.1% (8)

• Data shown as% (n ).

Respondents who answered ‘Yes’ to the question “Are you aware of any other convincing evidence of such procedures being performed in Australia or New Zealand?” quoted anecdotal evidence that these procedures were being performed in Australia or New Zealand (Table 3).

Table 3. Are you aware of any other convincing evidence of such procedures being performed in A ustralia or N ew Z ealand?

	No	Yes
RANZCOG (n  = 385)	98.7% (380)	1.3% (5)
FGM/C Workers (n  = 19)	89.5% (17)	10.5% (2)

• Data shown as% (n ).

FGM/C workers were asked whether they were aware of women or children travelling overseas for the purpose of FGM/C procedures. Five of the 19 respondents answered ‘Yes’. They cited anecdotal evidence of mothers taking Australian‐born children home for family celebrations and having FGM/C performed at the time.

Most commonly seen complications were urinary problems (incontinence, voiding difficulties, recurrent infections), labour problems (dystocia, need for de‐infibulation, perineal tears, haemorrhage) and dyspareunia, with a few respondents also reporting psychosexual complications (Table 4).

Table 4. How many women or children have you seen with medical problems related to these procedures?

	0	1–10	11–20	21–30	31–40	41–50	>50
RANZCOG (n  = 385)	53.0% (204)	42.6% (164)	2.3% (9)	1% (4)	0.5% (2)	0% (0)	0.5% (2)
FGM/C Workers (n  = 19)	42.1% (8)	26.3% (5)	5.3% (1)	5.3% (1)	0% (0)	0% (0)	21.1% (4)

• Data shown as% (n ).

RANZCOG respondents were asked, “Have you been asked to re‐suture after childbirth?” Of the 387 responses to this question, 21.2% (82) answered ‘Yes’ and 78.8% (305) answered ‘No’. Of those who answered ‘Yes’, 95.1% (78) replied that they had been asked to do so on five or fewer occasions, one respondent replied on ‘21–30’ occasions and one respondent replied on ‘more than 50 occasions’. Those people were then asked, “On how many occasions have you performed re‐suturing or re‐infibulation?” and 86.6% (71 replies) stated that they had never done so, while 12.2% (10) had done so on 1–5 occasions, and 1.2% (1 respondent) had done so on more than 50 occasions.

The question for FGM/C workers was phrased differently, to acknowledge that these health workers are often involved in education programs rather than labour care. When asked “Have FGM/C‐affected women enquired about re‐suturing (re‐infibulation) post‐childbirth?” 66.7% (12) answered ‘Yes’ and 33.3% (6) answered ‘No’.

FGM/C workers were asked to state how many times they had heard of re‐suturing taking place post‐delivery. 46.2% (6) had never heard of it occurring, while 38.5% (5) had on 1–5 occasions, a further 7.7% (1 respondent) was aware of re‐suturing occurring on 6–10 occasions, and 7.7% (1 respondent) replied with ‘more than 50’ occasions.

When asked if in the past five years they have been asked to perform a FGM/C procedure on a baby, child or young girl, 99.5% (384) of RANZCOG respondents replied ‘No’, while 0.5% (2 respondents) replied ‘Yes’. Of the two people who replied ‘Yes’, one had been asked on five or fewer occasions, while the other had been asked 6–10 times.

At the conclusion of the survey, respondents were given the opportunity to add comments. Ten of the 34 FGM/C workers surveyed added a comment, while 63 of 530 RANZCOG respondents did so. These comments illustrated varied views amongst the respondents, including anecdotal evidence that re‐suturing takes place post‐delivery, the belief that some re‐suturing is needed for patient comfort, strong views for and against the use of terminology such as ‘cutting’ instead of ‘mutilation’, and comparisons between the acceptability or otherwise of FGM/C and requests for cosmetic labioplasty or ‘vaginal tightening’ procedures.

Discussion

FGM/C has traditionally been practised in communities in Africa, the Middle East and parts of South‐East Asia, where it continues today, despite the strenuous efforts of organisations such as the World Health Organization. With migration of affected women to industrialised nations, there has been increasing awareness of these procedures worldwide, and measures to legislate against the practice have been introduced.

This survey of obstetricians and gynaecologists and trainees, Diplomates of RANZCOG, and workers in the field of prevention and education of FGM/C represents current experience in Australia and New Zealand, with more than one in five RANZCOG Fellows and Trainees and nearly one in 10 Diplomates submitting responses. The overall response rate (18.5%) is low and an obvious weakness of our study. It is significantly affected by the 9% response rate from Diplomates. The authors received some replies from Diplomates who did not complete the survey, but indicated that they did not do so because their practice did not involve FGM/C‐affected women. Another consideration is that migrants from countries where FGM/C is practised are often resettled in rural Australian communities, while 76.6% of RANZCOG respondents were in metropolitan or urban areas. Many of these rural settings may not have an access to RANZCOG Fellows or Diplomates. It is also possible that the timing of the survey (November 2010–February 2011) reduced the overall response rate as it coincided with the holiday season. It is unlikely that a second reminder to complete the survey would have significantly improved the response rate. We were not able to calculate a response rate for the FGM/C workers, as the survey link was distributed to FGM/C education and prevention program contacts in each state and territory of Australia, and in New Zealand, who were then asked to distribute the survey to their workers.

The majority of respondents (75.3% of RANZCOG, 89.5% of FGM/C workers) have seen at least one woman in the past five years who has had an FGM/C procedure, reflecting that FGM/C is still being practised in many societies. However, this may be exaggerated by non‐response bias.

Most RANZCOG respondents (77.9%) and FGM/C workers (57.9%) estimated that none of the FGM/C‐affected women they had seen had undergone the procedure in Australia or New Zealand. In total, seven respondents reported evidence of FGM/C taking place in Australia or New Zealand, citing anecdotal evidence.

In the comments submitted by respondents, mention was made of young women being taken overseas by their families to have FGM/C procedures performed, with five of 19 FGM/C workers stating that they had evidence that this had taken place. Again, there is no substantive evidence, nor any reports of young women with potential complications from such procedures presenting to hospitals in Australia.

Respondents had a good understanding of the range of obstetric and gynaecological complications that can be seen in women who have undergone an FGM/C procedure. Requests for re‐suturing post‐delivery were not common, with only 21.2% having been asked to do so, the vast majority (95.1%) on five or fewer occasions. Re‐suturing is an area of some legal ambiguity, with most practitioners believing that it is acceptable to oversew labia majora tissue to reduce the risk of infection and fusion, without performing a complete re‐infibulation, which is known to be illegal in Australia and New Zealand.

Only two respondents have been asked to perform an FGM/C procedure on a baby, girl or young women, one on five or fewer occasions, and one on 6–10 occasions.

In 10 years' experience at The Royal Children's Hospital (RCH) Melbourne, neither the gynaecology service nor the Victorian Forensic Paediatric Medical Service has seen any girl or young woman with acute complications related to a recent FGM/C procedure. Given that RCH is the state paediatric referral centre, it seems reasonable to infer that very few, if any, FGM/C procedures are being performed here.

FGM/C is a topic that generates considerable debate. The terminology in itself also causes controversy, with some advocating the use of the term ‘circumcision’ to avoid offending affected women by use of the word ‘mutilation’ for a procedure which these women often consider culturally appropriate, while others feel that doing so condones the practice and should be avoided in all circumstances.

The results of this survey help us to understand the current attitudes and practice of health professionals in Australia and New Zealand in relation to FGM/C. Organisations such as the WHO and RANZCOG have done much to educate health professionals about FGM/C,11 and this knowledge and sensitivity is reflected in the responses to the survey. This is important as the results indicate that many RANZCOG Fellows, Diplomates and Trainees have seen FGM/C‐affected woman in the past five years.

Recommendations for Practitioners

1. It is essential that discussion with FGM/C‐affected women is respectful of their cultural beliefs, acknowledging that in spite of the views of health practitioners, for a woman with FGM/C, the practice may not be relevant to her current health problem, or even perceived by her as a traumatic life event.
2. Where available, health practitioners should involve local FGM/C prevention and education program workers in consultations with affected women.
3. Discussion regarding intrapartum care of FGM/C‐affected women must occur antenatally where possible, ensuring confidentiality and avoiding discussion in front of family or community members.
4. It is essential that discussion, and if needed, negotiation, regarding de‐infibulation, the extent of this, and the issue of re‐suturing takes place antenatally. Use of a mirror and/or diagrams may aid this discussion.
5. Practitioners should be aware that medicolegal opinion regarding intrapartum care of FGM/C‐affected women states that re‐suturing a laceration does not constitute re‐infibulation (the latter being illegal in Australia and New Zealand).

Conclusion

There is no conclusive evidence of FGM/C being performed in Australia and New Zealand, either from direct reports or children presenting with complications. Re‐suturing post‐delivery is being requested and performed by practitioners in Australia and New Zealand, although it is not clear that this involves re‐infibulation. Anecdotal evidence suggests that FGM/C may be occurring, most likely by people other than registered health practitioners.

Acknowledgements

The authors wish to thank all those who took time to respond to the survey, particularly those who provided comments. Dr. Paddy Moore provided helpful comments on the original research proposal.