Suffering in silence
Female genital mutilation (FGM): the United Nations considers it a violation of human rights; the Australian Government, a criminal offence. Though it has been outlawed in many countries, the 2000-year-old practice continues, with devastating outcomes for women and girls. Angela Dawson explains why FGM must end and how we can all contribute to its abolition.
Female genital mutilation (FGM) is an ancient cultural practice performed on infants and young girls. It involves the removal of the external female genitalia or other injury to the genitalia without the woman's or child's consent. Often the 'surgery' takes place in unhygienic conditions and without pain relief.
Girls who experience FGM are at risk of dying from blood loss or infection. Girls who survive can experience a lifetime of infections, chronic pain, mental health issues and, later, difficulties giving birth which can also affect the health of their baby.
We don't know how many women and girls have experienced FGM in Australia. But a UTS study with the University of Sydney and NSW Health, the first of its kind in Australia, found three per cent of women who gave birth at one metropolitan hospital in Australia between 2006 and 2012 had FGM.
These figures are set to increase, as some of the fastest growing migrant groups are from countries where there is a medium to high prevalence of FGM. In fact, the latest Australian census reveals more than 300 000 migrants were born in countries in the Middle East, and North- and Sub-Saharan Africa where FGM is identified and data is collected. However, there are approximately half a million Australians who were born in other countries like Thailand, Indonesia, Malaysia, India and Pakistan where FGM is practised, but no data exists.
UTS research has revealed many midwives lack confidence and experience caring for women with FGM. Participants in our qualitative study acknowledged a fear of caring for women because of cultural misunderstandings and language difficulties, both of which affected their ability to develop rapport with the women and their families.
That said, midwives expressed their commitment to quality care and expressed a need to improve their skills in associated clinical procedures, like episiotomies – surgical incisions which quickly enlarge the opening of the vaginal wall to allow the baby to pass through – and enhance their knowledge about FGM. Our recently published systematic reviews of midwives' and doctors' education, and FGM-related practice, paint a similar picture around the world.
Undoubtedly, there is a significant need for health professional education. UTS has been engaged in developing continuing professional e-learning modules for midwives, obstetricians and gynecologists that are soon to go live on the Royal College of Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) website.
The four modules provide an overview of FGM, the short- and long-term complications of the procedure, how to care for women with FGM during pregnancy, labour and after birth and how health professionals can become advocates for change.
We've also contributed to the development of clinical practice guidelines and job aides produced by NSW Kids and Families within the NSW Department of Health. These guidelines aim to provide NSW public health professionals with sensitive and culturally appropriate evidence-based care for women and their families affected by FGM.
Although FGM is illegal and constitutes child abuse, it is practiced on girls in Australia and has been reported in the media. Two cases involving young girls are currently before NSW courts. One involves a retired nurse, the other implicates parents who took their daughter overseas to have FGM.
When it comes to stopping this mutilation and changing social norms, research suggests legal approaches have a limited effect. Rather a comprehensive, community-level preventative approach is needed. In Australia, we need to identify these approaches in collaboration with communities, and ensure they are adequately resourced and rigorously evaluated.
Investing in prevention is not only a more cost-effective way of dealing with FGM, it also prevents psychological distress and the risk of death and disability for women, their babies and female children.
Indeed, the cost of government efforts will be offset by savings from preventing complications during birth (including obstructed labour due to a narrow vagina and perineum, which can also deprive the baby of oxygen and lead to brain damage or death), the reduced need for expensive hospital procedures (like caesarean sections, vacuum extractions and fewer babies being placed in neonatal intensive care), as well as mental health counselling. The long-term effects of prevention can also save money otherwise spent on expensive policing and the (often-times traumatic) prosecution of family members.
Changing deeply entrenched social norms around FGM won't be easy. It must come from, and be embraced by, communities, including men who can be key advocates for its abandonment and allies to women. Men-only programs involving mentors could help to improve men's understanding of not only women's and children's health but their own health too.
Health professionals, particularly community-based midwives delivering postnatal care and child and family health nurses working within home visiting programs, can also play a critical role delivering health education to women and their families to prevent FGM. Multi-professional partnerships between health professionals, teachers, social workers and other community workers can help to support families to celebrate practices that promote health and wellbeing as well as work together to change harmful practices.
We know from work in Norway, Israel and the UK that change is possible. In Australia, thanks to our work in community health education and promotion, UTS is set to be at the forefront of behavioral change.
The result, we hope, will see an end to the unnecessary suffering of women and girls and the violation of their human rights.
