What GPs need to know about tackling female genital mutilation

Neelima Choahan

23/07/2018 2:24:43 PM

Australian GPs are exposed to female genital mutilation but they just don’t know it, according to survivor Khadija Gbla. Here is how GPs can help fight this practice.

Knives used for FGM. Photo: Wikimedia Commons
Knives used for FGM. Photo: Wikimedia Commons

Khadija Gbla was 13 when her periods started. It brought with it a pain so severe she needed to be hospitalised.
No one in Australia realised her symptoms were a consequence of female genital mutilation.
Least of all the doctors.
‘I was misdiagnosed with endometriosis, I had a laparoscopy done,’ Ms Gbla said.
‘I spent almost six years in Australia being told to go do an x-ray, all sorts of scans were done looking for things internally that could not be found because my doctor didn’t ask a simple question.
‘If he had asked “did you have any cutting done?” … then we would have been able to quite quickly piece together that my heavy, painful period, the constant urinary tract infection were a result of the FGM [female genital mutilation] and they would have had a proper plan.’

Khadija-Hero.jpgFGM survivor Khadija Gbla says GPs should ask patients if they have had the ‘cut’ during the initial check-up.

Ms Gbla, who is the executive director of No FGM Australia, said an increasingly multicultural population means that more health practitioners have patients with FGM.
‘Lots of doctors in Australia are exposed to female genital mutilation, but the issue is they won’t even know it, because they don’t even know what constitutes it,' Ms Gbla said.
The World Health Organization has classified female mutilation into four types:

  • Clitoridectomy: the partial or total removal of the clitoris, and in very rare cases, only the prepuce, the fold of skin surrounding the clitoris.
  • Excision: the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.
  • Infibulation: this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris.
  • The fourth types includes all other harmful procedures to the female genitalia for non-medical purposes, including pricking, piercing, incising, scraping and cauterizing the genital area.
According to new research released by No FGM Australia, more than 200,000 Australian women and girls have, or are at risk of, FGM, and 11 girls a day are born to this group of survivors.
The numbers, based on global prevalence figures and data from the Australian Bureau of Statistics, show that the figures of survivors and those at risk have more than doubled from 83,000 to 209,099 since 2014.
Ms Gbla said No FGM Australia expected the number of Australian women and girls affected would rise, but even they are stunned at these figures.
‘This should be a massive call to action for our politicians to get behind funding programs to support survivors and protect these girls,’ she said.
Ms Gbla said GPs are very well placed to tackle FGM and should take a basic step of asking women about the procedure during the initial check-up.
But, she said, they should ask that question of all women, irrespective of their race.
‘We are calling doctors to action,’ she said. 
‘They are in such a good position, an empowered position to truly make a difference to women who have been affected by FGM, to give them proper, appropriate care. A care that will go on to help them have a better quality of life and allow them to have a semblance of dignity and respect given back to them after what they have gone through.’
Dr Magdalena Simonis, author of the RACGP’s guidelines on female genital cosmetic surgery, told newsGP she first encountered FGM when she was just starting her career and training as a GP obstetrician in the late 80s and early 90s.
‘I’d had no training whatsoever, but I knew FGM existed,’ Dr Simonis said.
‘I was really upset for the woman, but I was very controlled.
‘I think I just adopted the stance of “focus on the patient, not my own feelings and reactions”.’

Dr_Magdalena_Simonis-hero.jpgGP Dr Magdalena Simonis says FGM can be confronting, but GPs should focus on the patient not their own feelings.

Dr Simonis said it is important for doctors to be careful with the language they use, especially when presented with a physical abnormality for the first time.
‘When you do actually see a woman who has had FGM, it can be very confronting and upsetting to the doctor, but it is important to take stock and remember the person is very vulnerable,’ she said.
‘They are at their most vulnerable in sharing that part of their body with you, and you really need to be very professional with the language and expressions you choose.’
Dr Simonis said the key is to make the consultation patient-centred rather than focusing on their own feelings
‘When you make it patient-centred you are asking “Okay, how do you feel about this? What symptoms are you experiencing? How does this affect you? How do you want me to help you?”’
Dr Simonis said GPs need to take FGM into account if a woman is from a cultural background where the practice is prevalent. According to the World Health Organization, the custom is most common in the western, eastern, and north-eastern regions of Africa and some parts of Middle East and Asia.
‘GPs need to ask specifically about it, [but] the important thing is to actually ask the question in a non-judgemental manner,’ she said.
‘It is very important that we address the physical complaints and the physical issues that the woman might present with.’
Longer term effects of FGM include:
  • Chronic pain
  • Chronic pelvic infections
  • Development of cysts,
  • Abscesses and genital ulcers
  • Excessive scar tissue formation
  • Infection of the reproductive system
  • Decreased sexual enjoyment
  • Psychological consequences, such as post-traumatic stress disorder.
Dr Simonis said that if it is revealed upon questioning that the patient is an FGM survivor, then GPs should investigate how FGM impacts the patient’s life and if they have any concerns including about their sexual life, gynaecological wellbeing, and any symptoms from it.
‘I will ask what’s their pregnancy planning, if they have consummated their marriage, and if it is comfortable or uncomfortable,’ she said.
‘If they have daughters, I will ask them specifically about their attitudes towards FGM for their children, and I will warn them that it is illegal in this country.’
Dr Simonis said living in Australia didn’t necessarily protect the children from having the procedure.
‘I think what is important here is that we don’t alienate the woman, that we actually get into a partnership in terms of helping them with whatever they need to happen to have a more comfortable sexual life, gynaecological health and education around the illegality and the inappropriateness of [the procedure],’ she said
‘Unless they understand it is not required of them in order to be culturally and socially accepted, this habit is not going to break.’
Ms Gbla said doctors should use words such as ‘female cutting’ or ‘female circumcision’ to describe FGM as their patients would be more familiar with those terms.  
‘So ask, “Where you come from do they cut girls? In your family do they do cutting and have you been cut?”’
She said if doctors aren’t familiar with the different types of FGM, then they can write down what they can or can’t see.
‘The types are a guide,’ she said.
‘Write what you can’t see. Say, “After doing the examination of the patient I can’t see a clitoris, I can’t see a labia minora, there is a presence of a scar which I am concerned is FGM”.’
Ms Gbla said if a GP thinks a child is at risk of getting FGM then it is their responsibility to alert the authorities. However, she said they have to be careful they are not making any assumptions.
‘Women who have had FGM, their daughters are at high risk of having FGM, that’s a reality,’ she said.
‘But one cannot call child protection services unless you have information or in good faith believe the child is at risk.
‘That can only be ascertained through questioning the mother,does she believe in FGM? Does she want to have FGM done to her daughter?’
Ms Gbla said she is not asking GPs to push or trigger people, but to give information about FGM in a very professional manner as they would on any other topic.
‘It’s the manner in which you tackle it,’ she said.
‘You do it gently, professionally, and you do it with respect and dignity.
‘I am not asking any health professional to be a crusader … just keep in mind to do no harm, and do no harm also applies in the way you question somebody, in the way you have conversation with them, in the way you gather the intel that you need to provide them care but also safeguard other people who may potentially at risk.’

“Female “Reproductive “Women’s and genital health” mutilation” sexual

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