The role of the health sector in contributing to the abandonment of female genital mutilation

Female genital mutilation (FGM) is a harmful practice associated with a range of health complications. Achieving abandonment of FGM is an international priority, which requires multi-sectoral actions, including engagement of the health sector to provide high quality care to women and girls affected by FGM while also taking actions to promote prevention. Female genital mutilation (FGM) is a harmful practice associated with a range of health complications. Achieving abandonment of FGM is an international priority, which requires multi-sectoral actions, including engagement of the health sector to provide high quality care to women and girls affected by FGM while also taking actions to promote prevention. Female genital mutilation (FGM) is a traditional harmful practice that involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons. The practice has been classified into four types with Type I consisting of partial or total removal of the clitoral glans and/or the prepuce/clitoral hood. Type II is the partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia majora. Type III, also known as infibulation, 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 clitoral glans and prepuce. Type IV includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing the genital area. There are no health benefits to FGM, but rather it increases risk of health problems affecting women’s physical, psychological, and sexual health both immediately following the practice and over the life course. Immediate complications include hemorrhage, pain, shock, genital swelling, infection, problems with urination and wound healing, and in some cases, death.1Berg R.C. Underland V. Odgaard-Jensen J. Fretheim A. Vist G.E. Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis.BMJ Open. 2014; 4: e006316https://doi.org/10.1136/bmjopen-2014-006316Crossref PubMed Scopus (132) Google Scholar Women who have undergone FGM have greater risk of obstetric and neonatal complications, such as cesarean section, postpartum hemorrhage, episiotomy, prolonged or difficult labor, extended hospitalizations, still birth, and early neonatal death, as compared with women without FGM.2Berg R.C. Underland V. The obstetric consequences of female genital mutilation/cutting: a systematic review and meta-analysis.Obstet. Gynecol. Int. 2013; 2013: 496564https://doi.org/10.1155/2013/496564Crossref PubMed Google Scholar Sexual problems associated with FGM include dyspareunia, and other forms of sexual dysfunction while psychological risks include post-traumatic stress disorder, anxiety disorder, and depression.3Berg R.C. Denison E. Fretheim A. Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/C): a systematic review of quantitative studies. Norwegian Knowledge Centre for the Health Services, 2010Google Scholar Gynecological and urinary complications, including urinary tract infections and menstrual problems, have also been associated with FGM.4De Silva S. Obstetric sequelae of female circumcision.Eur. J. Obstet. Gynecol. Reprod. Biol. 1989; 32: 233-240https://doi.org/10.1016/0028-2243(89)90041-5Abstract Full Text PDF PubMed Scopus (93) Google Scholar,5Ali H.A.A.E.W. Arafa A.E. El Fattah Abd Allah Shehata N.A. Fahim A.S. Prevalence of Female Circumcision among Young Women in Beni-Suef, Egypt: A Cross-Sectional Study.J Pediatr Adolesc Gynecol. 2018; 31: 571e574https://doi.org/10.1016/j.jpag.2018.07.010Abstract Full Text Full Text PDF Scopus (4) Google Scholar Data from population-based surveys in 31 countries in Africa, Asia, and the Middle East show that there are an estimated 200 million women and girls alive today who have undergone the practice (data from UNICEF). The absolute number of women and girls affected is expected to increase as large cohorts of young girls in countries with a high prevalence of FGM reach the age at which the practice occurs (https://www.unfpa.org/resources/bending-curve-fgm-trends-we-aim-change). Some evidence suggests that FGM prevalence is likely to increase in the context of the COVID-19 pandemic because girls may not have access to the protective services, prevention messages, and care networks that usually offer a degree of protection from the practice, which is illegal in most settings (https://www.unfpa.org/news/millions-more-cases-violence-child-marriage-female-genital-mutilation-unintended-pregnancies). In addition, families may be under more intense pressure from traditional practitioners and extended family members to have their daughters undergo FGM. The practice is widely believed to have originated during Pharaonic times and has been perpetuated and justified for a range of reasons, including to ensure virginity, to limit promiscuity, to promote fidelity, to ensure marriageability, to serve as a rite of passage into womanhood, for aesthetic reasons, to ensure family honor, and to conform to ideals of womanhood. Once the practice has become deeply entrenched as a social norm within communities (https://www.unicef-irc.org/publications/pdf/iwp_2009_06.pdf),6Mackie G. LeJeune J. Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory.in: Special Series on Social Norms and Harmful Practices. Innocenti Working Paper No. 2009-06. UNICEF Innocenti Research Centre, Florence2009https://www.unicef-irc.org/publications/pdf/iwp_2009_06.pdfGoogle Scholar non-conformity may bring negative consequences to girls and their families. This can serve as a strong incentive for families to continue the practice.7Edberg M. Krieger L. Recontextualizing the social norms construct as applied to health promotion.SSM Popul. Health. 2020; 10: 100560https://doi.org/10.1016/j.ssmph.2020.100560Crossref PubMed Scopus (5) Google Scholar There is also a concerning trend of health workers performing FGM in some settings, which is known as “FGM medicalization" and includes acts of FGM by a health worker, either within a health care setting or in a private setting. Existing evidence from 17 countries with repeat surveys suggests an increasing trend in medicalization of FGM in Egypt, Guinea, Mauritania, Nigeria, Sierra Leone, Sudan, Chad, and Yemen (https://www.unfpa.org/resources/brief-medicalization-female-genital-mutilation). This trend is alarming because it goes against the “do no harm” medical ethics principle by which health care workers abide, and it counters FGM abandonment efforts by further endorsing this harmful practice and also creating a false sense of safety from its health complications. A review of the literature showed that there are four main reasons why health care providers perform FGM—they are members of practicing communities and subject to the same social norms and may therefore be supportive of the practice; they are satisfying a demand, which may seem inevitable, and they see themselves as supplying a service to families; many claim that they are reducing harm by performing FGM because they can do it in a safer way; and many report carrying out the practice for financial reasons to supplement income or to receive in kind payments from community members.8Doucet M.H. Pallitto C. Groleau D. Understanding the motivations of health-care providers in performing female genital mutilation: an integrative review of the literature.Reprod. Health. 2017; 14: 46https://doi.org/10.1186/s12978-017-0306-5Crossref PubMed Scopus (21) Google Scholar Regardless of the justifications mentioned by the health care providers, by performing FGM, they are further perpetuating a harmful practice and violating the rights of girls. FGM violates a number of human rights principles, including the rights of the child, the right to be free from cruel or inhumane treatment, the right to bodily integrity, the right to be free from discrimination, and the right to health due to the well-documented risk of health consequences associated with the practice. These health complications also have cost implications. A recent health economic analysis showed that treatment of the health complications of FGM costs health systems 1.4 billion USD per year (www.srhr.org/fgmcost) a number that is expected to increase unless urgent action is taken. In addition to these quantifiable costs, there are likewise less quantifiable costs to the psycho-social well-being of women and girls (S. O’Neill and C.C.P., unpublished data). A recent review of qualitative literature demonstrated that FGM status can affect the ways that women interact with family, community members, and society more generally, both within high prevalence and diaspora communities. When a woman’s FGM status deviates from the social norms in which she lives, she is more likely to experience stigma, social isolation, and psychologically abusive behaviors, which can adversely affect health and health seeking behavior as well as lead to relationship difficulties. Despite these financial and psychosocial costs and the health risks suffered, the health sector has not played an active role in preventing FGM or ensuring quality care to manage its health complications, even in settings where the majority of women and girls undergo this practice. There are a number of reasons for the limited attention of the health sector in addressing FGM. The competing priorities and limited human and financial resources in many countries mean that public health systems prioritize the most urgent, visible, and high burden health problems, such as pandemics and other health emergencies, which require timely and integrated responses. In addition, the health sector is often not considered an active player in achieving the Sustainable Development Goals related to harmful practices such as FGM (SDG 5.3), and investment from governments and the international community has traditionally targeted other sectors. It is well recognized that multi-sectoral efforts are needed to bring an end to this harmful practice, although there is insufficient evidence on what interventions or combination of interventions will drive the lasting change needed to achieve abandonment. Enacting laws and creating enabling environments (https://www.unfpa.org/sites/default/files/pub-pdf/Policy_Brief-_Enabling_Environments_for_Eliminating_Female_Genital_Mutilation.pdf) for their implementation are critical but insufficient steps. Laws without community acceptance may inadvertently drive the practice underground, discourage disclosure, and prevent women and girls from seeking necessary health services for fear of being reported.9Muthumbi J. Svanemyr J. Scolaro E. Temmerman M. Say L. Female Genital Mutilation: A Literature Review of the Current Status of Legislation and Policies in 27 African Countries and Yemen.Afr J Reprod Health. 2015; 19: 32-40PubMed Google Scholar Some promising evidence of community-based abandonment efforts in high-risk communities has shown that community engagement, such as awareness raising activities, empowering opinion leaders, community dialogs,10Evans W.D. Donahue C. Snider J. Bedri N. Elhussein T.A. Elamin S.A. The Saleema initiative in Sudan to abandon female genital mutilation: Outcomes and dose response effects.PLoS ONE. 2019; 14: e0213380https://doi.org/10.1371/journal.pone.0213380Crossref PubMed Scopus (7) Google Scholar and alternative rites of passage,11Osur J. Alternative rite of passage: A new way to end FGM.Journal of Obstetrics and Gynaecology Canada. 2020; 42: e18-e19https://doi.org/10.1016/j.jogc.2019.11.029Abstract Full Text PDF PubMed Scopus (0) Google Scholar can change attitudes and shift social norms. Likewise, working through the education sector to provide information and to inform girls of their rights,12Abathun A.D. Sundby J. Gele A.A. Pupil’s perspectives on female genital cutting abandonment in Harari and Somali regions of Ethiopia.BMC Womens Health. 2018; 18: 167https://doi.org/10.1186/s12905-018-0653-6Crossref PubMed Scopus (3) Google Scholar as well as keeping them in schools and ensuring linkages with child protection services, are important steps (https://www.unicef.org/media/88751/file/FGM-Factsheet-2020.pdf). The health sector has been less present in abandonment efforts to date despite the fact that most women come through the health system on numerous occasions, particularly during reproductive years, and health care providers tend to be trusted and well-respected members of the community who have the potential to influence behaviors in positive ways. The health sector is increasingly serving a health promotion and prevention role in addition to a curative role. Emphasis on quality of care through person-centered service delivery and application of rights-based approaches has shown that health workers can promote health not just to ensure the absence of disease but also to achieve “a state of complete physical, mental and social well-being” as articulated in the World Health Organization (WHO)’s constitution. Promoting well-being includes preventing harmful practices that violate human rights and cause ill health. Indeed, the health sector in low- and middle-income countries has a history of community outreach and a large network of service outlets and providers of different cadres serving communities. This includes involving community members or leaders in community health committees to promote behavior change in a wide range of health topics, including violence prevention, immunization, breastfeeding, and HIV prevention. As respected members of their communities who are also familiar with and subject to the same social norms, pressures, and beliefs, they are well placed to engage with their patients and clients in preventing FGM through one-on-one counseling during clinical visits or home visits or in groups during health education sessions and community health outreach activities. It is important to frame conceptually where the health system sits within the larger social system and its interaction with the community and other sectors. Macro-level factors such as socio-economic, political, legal, and developmental factors (i.e., literacy and secondary education levels of women, total fertility rates, GDP and percentage of GDP spent on health, maternal mortality rates, gender equality, and other health-related indicators) can directly or indirectly affect the continuation or abandonment of FGM as a community norm. Further, the political stance and commitment of government officials or other influential actors to end this practice as well as the presence of criminalizing laws and availability of financial or human resources will affect the scale and effectiveness of interventions to end this practice. These macro-level factors affect all sectors including the health sector and specifically the health system building blocks (https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf), which include the health work force, service delivery, health information systems, access to essential medicines, financing, leadership, and governance. These factors determine the quality and coverage of health sector interventions on FGM prevention and care that directly impact the health service user at facility or community level. It is also critical that the health sector addresses FGM through a public-health approach grounded in gender equality and human rights with the aim of offering the highest quality of prevention and care services possible for women and girls at risk as well as those who have undergone FGM. One important aspect of this is the need for the health sector to play a more active and direct role in ending FGM medicalization by working closely with its workforce and indirectly through reducing the demand from health service users. In 2010, WHO and partners released the Global Strategy to Stop Health Care Providers from Performing FGM (https://www.who.int/reproductivehealth/publications/fgm/rhr_10_9/en/), which is a four-prong strategy that provides countries with a framework to structure health sector plans to address FGM, including through strengthening governance and political will, improving training of health care providers to provide prevention and care services, enacting regulatory and accountability mechanisms for professional codes of conduct, and monitoring and evaluating programs and actions to document impact within the health sector. Responses need to be implemented in a sustained and systematic manner using evidence-based interventions and programmatic data to contribute meaningfully to increasing the quality of life for FGM survivors as well as reducing FGM incidence. Ministries of health and related stakeholders need to engage actively to develop strategic health sector plans that address FGM. These plans need to be informed by contextual factors specific to each setting, including the epidemiology of the practice, the specific drivers as well as the health system profile and readiness to address it. These plans include activities ranging from integration of FGM into pre-service and in-service training of health care providers to improving management of complications and communicating for FGM prevention; establishing accountability measures for providers who carry out FGM, such as loss of licenses or fines; developing health policies against FGM practice; generating data through health information systems; ensuring that all providers have a sufficient level of awareness and training to be able to communicate effectively about FGM prevention and to manage complications; and ensuring that FGM is included in essential service packages for sexual, reproductive, maternal, neonatal, child, and adolescent health (SRMNCAH) strategies, plans, and service packages. FGM should also be integrated within health emergency-response packages. Emergencies often lead to or aggravate gender inequality and can put women and girls at higher risk of FGM. Women and girls may be viewed as a “burden” with no ability to provide income for their families. Protecting virginity becomes closely linked with values like family honor and marriageability and fidelity. Insecure times can result in breakdown in social systems that cause families to assert traditions and can roll back advances in gender equality. These realities should be recognized and addressed from the outset of emergencies to prevent further health risk to women and girls. Priority seed funding should be invested into activities to catalyze the roll out in implementation. countries specifically Guinea, Sudan, and to date have health sector plans with the of WHO and are in different implementation in out activities. and implementation will inform scale for other countries to actively engage the health sector to address FGM. It is also important that health sector of the many evidence-based and resources that can be to a range of including and to health care providers to be able to address FGM. an international a WHO to bring resources on FGM for countries to to their context on and in each setting. 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