STFM May 8, 2018 FGC Community Based Research to Guide Provider training Roundtable Session 7:15am
Kristin Brownell MD, MPH, Bethlehem Degu MPH
- Introductions
- OWH DHS Grant/ DUnya Women’s Health Collaborative Project Goals
- Basic Information FGC types
- ACOG, AAP, AAFP, WHO Policies regarding FGC
- Reporting requirements
- Pitfalls and Tips about working on the Community- based FGC project thus far; How to talk about taboo/sensitive topics while being aware of our cultural biases- Harvard implicit bias test link below.
Overview:
The project seeks to:
- train medical providers on the clinical management of circumcised women and cultural competency in caring for FGC-affected women;
- conduct outreach to FGC-affected women to encourage access to high quality and culturally competent health care services; and
- provide clinical services to FGC-affected women. Implementation of the project will lead to the creation of a culturally competent FGC continuing medical education module available to providers outside our system of care, a Strategic Plan to address FGC in the community, and a lessons learned/best practices report for future directions.
The session will cover best practices for caring for FGC affected communities offering resources on how to talk about FGC and care for women affected by FGC psychosocial sexual, mental health & cultural humility. Resources on technical management on FGC will be references and training at another time.
Why Important to FM educators?
FGC causes various complications throughout a girls/women’s lifetime.
Short term complications include severe pain, excessive bleeding (hemorrhage), genital tissue swelling, Fever, infections e.g., tetanus, urinary problems, wound healing problems, injury to surrounding genital tissue, Shock, death.
Long-term complications include urinary problems, vaginal problems, menstrual problems, scar tissue and keloid, sexual problems, increased risk of childbirth complications, need for later surgeries, psychological problems.
Globally, 200 million girls and women are estimated to have undergone FGC with 3 million more are currently at-risk annually.
In the United States, 513, 000 women and girls are at risk for undergoing FGC or suffering from its adverse health outcomes. Despite the magnitude of this this issue many health providers do not receive the proper training and therefore feel unequipped to talk about, much less manage the complications of FGC.
Objective 1:
Identify 4 major types of complications of FGC and be able to describe the defibulation and the infibulation process.
Objective 2:
Learn 2 of barriers to accessing healthcare in the FGC-Affected Communities and resources to help overcome those barriers.
Objective 3:
Learn what FGC policies are by organizations: AAFP, WHO, ACOG, and AAP
Resources:
WHO 2018 FGC Clinical Guidelines over 300 pages
http://apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1
www.change-agent.eu/index.php/2-about-us/134-tools#a
CDC Refugee Health Exam FGC Guidelines
https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/female-genital-cutting.html
https://www.uscis.gov/sites/default/files/USCIS/Humanitarian/Special%20Situations/fgmutilation.pdf
https://www.acog.org/-/media/Statements-of-Policy/Public/2012GlobalWmHlthRights.pdf
http://www.who.int/reproductivehealth/topics/fgm/management-health-complications-fgm/en/
http://pediatrics.aappublications.org/content/pediatrics/early/2010/04/26/peds.2010-0187.full.pdf
https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Breast-and-Labial-Surgery-in-Adolescents
https://www.acf.hhs.gov/orr/resource/state-letter-15-08
DOJ reporting requirements
https://implicit.harvard.edu Project Implicit
OBJECTIVE 1:
CDC Refugee Health Exam FGC Guidelines
https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/female-genital-cutting.html
Female Genital Cutting
(also known as female circumcision, female genital mutilation, and female genital excision)
Female genital cutting refers to all procedures involving partial or total removal of female genitalia or other injury to female genital organs for any cultural, religious or otherwise nontherapeutic reasons.
This practice is common in many refugee populations, particularly those from East Africa (i.e. Somalia, Ethiopia, Sudan), although the practice is pervasive throughout the world. This controversial practice is considered a human rights violation by many, and it is illegal in the United States in people under 18 years of age.
The World Health Organization (WHO) has condemned the practice and is making efforts to end it. The practice poses adverse medical consequences, including direct complications from the procedure (anesthesia or sedation complications, bleeding, acute infection), increased risk of death for both mother and infant in subsequent pregnancies, post-traumatic stress disorder, and urinary tract infections, among others.
In addition, there may be adverse consequences for the woman’s sexual well-being.
An external genital examination will reveal whether a girl or woman has undergone this procedure. Although this examination is required on the overseas medical evaluation, it may not have been performed, and the domestic medical screening evaluation presents an opportunity to identify women who have had the procedure. The exam may also provide opportunities to interrupt the practice in future generations.
When the practice (of FGC) is identified, the clinician should record what type of procedure was performed (Table 5). Culturally sensitive counseling and educational materials should be offered and, when necessary, referrals provided (e.g., for complications or posttraumatic stress disorder). The refugee can be informed that the procedure is illegal in the United States.
More detailed information regarding female genital cutting is available from the World Health Organization.
WHO Categorization of Female Genital Cutting:
Type1: partial or total removal of the clitoris
Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision
Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or majora (infibulation), with or without excision of the clitoris.
Type 4: All other harmful procedures to the female genitalia for nonmedical purposes e.g., piercing, incising, pricking, scraping, and cauterizating)
Page last updated: June 21, 2016
Content source: Centers for Disease Control and Prevention
OBJECTIVE 2: Learn 2 of barriers to accessing healthcare in the FGC-Affected Communities and resources to help overcome those barriers.
- BARRIERS:
- Language, cultural, transportation, concern of threat of cesarian section in Western countries
- Lack of health care providers trained on management of FGC
- Lack of trained research personnel to work with the community- need to language skills, HIPPA training, research training
- Barriers working with community of sensitive topic of FGC/M
- With Women-
- With Men – decision makers
- OPPORTUNITES to improve situation
- Offer support for in person language, educate patient empower how to use western medical system insurance and trsnportation
- Address FGC routinely in PSH GYn history during Physical well owman exam Ob initial
- Train health care professionals about FGC types and management of the condition, and how to talk to patient in confidential and culturally respectful manner
Office of Women’s Health Project Department of Health services funding project tin San Diego to offer focus groups on FGC in Somali, Arabic, Swahili, Amharic for older women 35 yrs and older. For women 30 yr sand younger we offer questionnaire of 1:1 interview in confidence. If For the men in the community, the FGC DUnya project offers questionnaires and interviews. A provider survey on FGC Knowledge , attitudes and beliefs is being administered pre and post intensive training.
Objective 3:
Learn what FGC policies are by organizations: WHO, ACOG, and AAP
- World Health Organization:
WHO recommends deinfibulation for preventing and treating obstetric complications in women living with type III FGM (1).
- ACOG: American College of Obstetrics and Gynecologist
- AAP: American Academy of Pediatrics
The traditional custom of ritual cutting and alteration of the genitalia of
female infants, children, and adolescents, referred to as female genital
mutilation or female genital cutting (FGC), persists primarily in Africa
and among certain communities in the Middle East and Asia. Immigrants
in the United States from areas in which FGC is common may
have daughters who have undergone a ritual genital procedure or may
request that such a procedure be performed by a physician. The American
Academy of Pediatrics believes that pediatricians and pediatric
surgical specialists should be aware that this practice has lifethreatening
health risks for children and women. The American Academy
of Pediatrics opposes all types of female genital cutting that pose
risks of physical or psychological harm, counsels its members not to
perform such procedures, recommends that its members actively
seek to dissuade families from carrying out harmful forms of FGC, and
urges its members to provide patients and their parents with compassionate
education about the harms of FGC while remaining sensitive to
the cultural and religious reasons that motivate parents to seek this
procedure for their daughters. Pediatrics 2010;125:1088–1093
- AAFP: American Academy of Family Physician
Female genital mutilation (FGM) (also known as female genital cutting or female circumcision) is a cultural practice affecting more than 125 million women and girls around the world, in which parts of the female genitalia (clitoris, labia minora and majora) are cut or disfigured.1
It is estimated that more than 500,000 women in the United States have undergone or are at risk for FGM.2
While most affected women arrive in the U.S. already cut, there are reports of the procedure being conducted among immigrant populations locally by traditional practitioners. There are also reports that U.S.-born and raised young girls are being sent to the parents’ home country during summer vacation for the purpose of undergoing the procedure in their country of origin.
The practice is internationally recognized as a human rights violation, torture and a form of violence and discrimination against women and girls.1
United States federal law (18 U.S. Code § 116 Female Genital Mutilation) makes it illegal to perform FGM in the U.S. or to knowingly transport a girl out of the U.S. for the purpose of performing FGM.3
The AAFP supports all measures to eliminate the practice of female genital mutilation in the United States. The AAFP also supports all other international efforts to eliminate the practice of female genital mutilation and to protect young girls and women at risk of undergoing the procedure.
The AAFP encourages family physicians to educate themselves about the practice, the health consequences of FGM and how to manage them in clinical practice, particularly during pregnancy and childbirth. Family physicians are encouraged to provide culturally sensitive counseling and education to the patient and her family members about the negative physical and emotional consequences of the procedure and discourage them from having the procedure performed.
The AAFP advises its members that the practice of reinfibulation (reapproximating the edges of the labia majora back together, usually following childbirth) is sometimes requested by women to restore a sense of normalcy and genital self-image. While allowed by federal law, reinfibulation is ethically complex and should merit careful thought and discussions with the patient and her family in the antepartum period.
Reinfibulation itself is not considered FGM, but if performed by a physician, it may appear to condone the practice. Therefore, the AAFP strongly cautions its members against performing reinfibulation.
Where possible, physicians should refer the patient to social support groups that can help them cope with changing societal mores.4 (1998) (2015 COD)
References:
Reporting Requirements:
Is FGM/C Legal in the United States?
Federal law prohibits anyone in the United States knowingly circumcising, excising or infibulating the genitals of any child under 18 years of age. In addition, 23 States have laws prohibiting FGM/C.
U.S. law does not prohibit a woman or girl whose genitals have been cut from entering the country.
Is it Legal to Send a Child Abroad to Have FGM/C Performed?
Federal law makes it a crime to send, or attempt to send, a girl under 18 from the United States to have FGM/C performed in another country.
How Can I Report a Suspected Crime of FGM/C?
If you have information about someone who is performing FGM/C in the U.S., or if someone you know may be at risk of having the procedure done here or at risk of being taken abroad to have FGM/C performed, please contact the U.S. Department of Justice at 1-800-813-5863; HRSPTIPS@usdoj.gov
How Can the Practice of FGM/C be addressed within Refugee and Immigrant Populations?
Refugees and immigrants should be informed of the adverse health consequences of FGM/C, in addition to the legal consequences. The following are some suggested mechanisms of disseminating this information to refugee and immigrant communities:
- Establish community-led campaigns to inform refugees of the adverse consequences of FGM/C, and
- Establish educational campaigns to inform refugee service providers and mainstream providers of the potential health problems that may emerge as a result of FGM/C, in particular pertaining to reproductive health.
How can I get additional information about FGM/C?
If you believe you are at risk of FGM/C or have undergone FGM/C, have questions about FGM/C, have information about someone who is performing FGM/C in the United States, or know of someone who may be at risk of having the procedure done here or outside the United States, please contact this number for additional information about available resources: 1-800-994-9662.
Additionally, the following resources are available:
U.S. Citizenship and Immigration Services fact sheet, available at: www.justice.gov/sites/default/files/criminal-hrsp/legacy/2015/02/05/0...Visit disclaimer page
.
U.S. Department of Justice brochure, available at: www.justice.gov/criminal/hrsp/additional-resources/2015/hrsp-brochure...Visit disclaimer page
.
Ethnic community-based organizations have also developed resources that address FGM/C in culturally appropriate ways.
-Women Watch Afrika: http://womenwatchafrika.org/Visit disclaimer page
-African Family Health Organization: www.afaho.net/Visit disclaimer page
Last Reviewed: January 2, 2018
See file of handouts given today