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Female genital mutilation/cutting: knowledge, attitude and training of health professionals in inner city London
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2, 168, pages 195 - 198
To assess the knowledge, attitude and training on female genital mutilation/cutting (FGM/C) amongst medical and midwifery professionals working in an area of high prevalence of the condition.
Prospective observational study using a questionnaire designed to assess knowledge, attitude and training received by health care professionals on the practice of FGM/C. Factors which may affect knowledge, attitude and training were compared between groups.
92.9% (n = 79) questionnaires were returned. All respondents were aware of FGM/C but only 27.8% correctly identified the grade from a simple diagram. Three quarters (72.4% and 77.2% respectively) were aware of the complications of FGM/C and of the legislation in the United Kingdom. Of the respondents, 13.9% agreed that a competent adult should be allowed to consent to FGM/C if requested but only 8.9% agreed that the procedure should be medicalised to reduce the associated morbidity. Less than 25% of respondents had received formal training in recognising or managing this condition.
Although the majority of respondents were aware of FGM/C, their ability to identify the condition and its associated morbidity remain suboptimal; more training is recommended in larger cities with a higher prevalence of this condition.
Keywords: Female genital mutilation/cutting, Opinion, Knowledge, Attitude, Training.
Female genital mutilation/cutting (FGM/C) encompasses all procedures involving partial or total removal of the external female genitals, whether for cultural, religious or other non-therapeutic reasons, with a classification system originally described by the World Health Organisation  .
Although the practice is most common in North Eastern and Western Africa, with a prevalence of more than 90% in Somalia, Sierra Leone, Mali, Egypt, Djibouti and Guinea, it is also becoming increasingly common in clusters in the Western World, due to migration from these endemic countries either for economic reasons, or when residents flee from areas of civil unrest. In 2006, the Foundation for Women's Health, Research and Development (FOWARD), in collaboration with the UK Department of Health, estimated that there are nearly 66,000 women with FGM/C living in England and Wales, nearly 16,000 girls under age 15 years at high risk of type III FGM/C and over 5000 at high risk of types I–II. The highest estimated prevalence per region is thought to be in London, with 6.3% prevalence in inner London and 4.6% prevalence in outer London  .
The United Kingdom (UK) first legislated against FGM/C with the Prohibition of Female Circumcision Act (1985) and this was subsequently updated by the Female Genital Mutilation Act in 2003  . The latter states that ‘A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris’ and also introduces the concept of extra-territoriality, making it an offence for FGM/C to be performed worldwide on UK nationals or UK permanent residents. There is evidence, however, that the procedure of FGM/C is still conducted in the UK  , although there have not yet been any arrests of medical professionals or family members for involvement in organisation of the procedure.
In 2009, the Royal College of Obstetricians and Gynaecologists (RCOG) issued their Green-top Guideline on FGM/C  , which amongst other aims stated that ‘healthcare workers should actively demonstrate knowledge and respect’ and that ‘gynaecologists and specialist nurses should be aware of the physical and psychological implications of female genital mutilation’.
There are already a few North American and Western European studies exploring knowledge and attitude of healthcare professionals towards this practice , , and  and more recently, Zaidi et al. from UK  noted significant deficiencies in theoretical knowledge and adherence to RCOG guidelines amongst 45 responders in a teaching hospital.
We sought to assess the level of knowledge, attitudes and training regarding FGM/C amongst health professionals working in boroughs in North London known to have a high prevalence of the condition, in order to examine if these factors have improved in the 4 years since the last UK study.
2. Materials and methods
An anonymous, 19-point paper questionnaire was devised by the authors based on the RCOG guideline on FGM/C  and on similar questionnaires by authors from Belgium and Egypt  and  ( Fig. 1 ). A small pilot study of five participants (two medical students, two junior doctors and a consultant in obstetrics and gynaecology) was conducted to assess the acceptability and reliability of the questionnaire.
The questionnaire assessed knowledge on classification of FGM/C (including the ability to recognise type II FGM/C in a pictorial diagram) and complications, respondents’ experience with FGM/C and UK legislation. Questions mostly invited closed answers (e.g. true, false, not sure), but free text opinions were also solicited.
Over a two-month period, the questionnaire was distributed by hand to participants of both local and regional teaching sessions, and to all staff present on labour ward (by all the authors). Of the 85 questionnaires distributed, 79 health care professionals working in North East London boroughs returned responses.
Socio-demographic data of the respondents including age, gender, country of origin, time since emigration (if appropriate), country of qualification, speciality and seniority (years trained) were collected. Data were collected onto a Microsoft Excel spreadsheet and the responses were analysed for differences between groups using the chi-squared test.
Seventy-nine healthcare professionals (78.5% female; 20.3% male) returned completed questionnaires (92.9% response). Age distribution was as follows: 24.1% (n = 19) aged 20–25 y, 40.5% (n = 32) aged 26–35 y, 12.7% (n = 10) aged 36–45 y, 10.1% (n = 8) aged over 45 y and 12.7% (n = 10) did not declare their age. The study was able to encompass various disciplines (obstetricians, paediatricians, midwives, student midwives, foundation year trainees and medical students), and the speciality and country of origin of the respondents are depicted as Fig 2 and Fig 3.
All 100% of respondents were aware of the practice of FGM/C, but just over half (58.2%) appreciated that there are four grades. Only 40.5% felt confident in diagnosing FGM/C and only 27.8% (n = 22) were able to correctly identify grade II FGM/C from the graphic representation in the questionnaire. The majority (75.9%, n = 60) correctly identified that FGM/C was most commonly thought to be performed for cultural reasons, although 16.5% (n = 13) thought that it was carried out for both cultural and religious reasons. The majority were aware of complications of FGM/C (67.3%) and were abreast with UK legislation (71.8%) (depicted in Table 1 and Table 2). Only 31.6% (n = 25) correctly thought that the best time to perform de-infibulation was before pregnancy, 11.4% thought it correct to perform it in the second trimester of pregnancy (only correct if not performed prior to conception) but 17.7% (n = 14) thought that the ideal time was in labour ( Table 3 ).
|Associated complication?||Correct (%)||Incorrect (%)||Don’t know (%)|
|Perineal/genital tears in labour||96.2||0.0||5.1|
|Practice association with FGM/C||Legal (%)||Illegal (%)||No policy (%)||Don’t know (%)|
|Family/religious figure performing FGM/C in UK||3.8||88.6||2.5||5.1|
|UK doctor performing FGM/C||11.4||77.2||6.3||5.1|
|Re-infibulation after delivery||16.5||67.1||13.9||2.5|
|Sending child abroad for FGM/C to be performed||1.3||78.5||16.5||3.8|
|Perceived time to practice deinfibulation||%|
Results were also analysed for differences between country of origin of respondents, junior (foundation trainees, senior house officers) vs. senior (registrars and consultant) doctors, and medical vs. nursing/midwifery staff (including students training in these professions). Senior doctors were much more likely than juniors to be aware of the four grades of FGM/C (92.9% vs. 50%; p < 0.05) and this reflected the fact that 50% of senior doctors had had formal training in FGM/C compared to only 7.1% of juniors. Doctors who received their primary training in the African subcontinent compared to elsewhere (74% vs. 30.6%), senior vs. junior doctors (78.5% vs. 17.8%) and midwifery staff vs. medical staff (60.8% vs. 32.7%) were more confident in their ability to diagnose the condition (all p < 0.05).
A total of 40.5% (n = 32) of respondents had never been involved with the care of FGM/C patients but 20.3% (n = 16) had seen more than ten cases. Reassuringly, only three respondents (all midwives) had been asked by a family member to perform FGM/C or re-infibulation after delivery.
Eleven respondents (13.9%) thought that a competent adult should be allowed to consent to FGM/C and interestingly, 8.9% (n = 7) thought that FGM/C should be medicalised and thus legalised, in order to reduce immediate and long term complication rates: 17.7% of respondents said that they would support a woman's request for re-infibulation after childbirth if it were legal. One respondent commented that although she would not accept re-infibulation in the UK, she would reluctantly support it if she worked in Somalia as the woman and her children would likely be ostracised as a consequence of refusal.
Subgroup analysis of data from medical students revealed that 37.5% were aware of the grading system, 75% knew that FGM/C was most common in Africa and 100% knew that it was carried out for cultural reasons. Seventy-five per cent of medical students were aware of the complications associated with FGM/C but only 60% were familiar with the UK law. Only one student had been involved in the care of a woman with FGM/C and none of the students had received any formal training in FGM/C, despite them all believing they required more: 25% were not sure about whether they should refer a child in danger of FGM/C to social services.
Overall, only 87.3% (rather than the expected 100%) of respondents would warn social services of a child in danger of FGM/C, with doctors being more likely than nursing or midwifery staff to report their suspicion (90.9% vs. 78.2%; p < 0.05). Interestingly, a third of respondents (n = 28) agreed that cosmetic labiaplasty or labial piercings were a form of FGM/C, and pointed out that these procedures are included in the WHO classification as grade IV FGM/C (i.e. all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping and cauterising). Country of origin of respondent did not appear to statistically influence these attitudes on practice of FGM/C.
The highest prevalence of FGM/C in the UK occurs in London (6.3%) and we felt that contemporary data on knowledge, attitude and training across a broad spectrum of health professionals working here would allow us to assess if these factors have improved in the 4 years since the study by Zaidi et al.  .
General awareness of FGM/C amongst medical professionals is universal amongst our study respondents and there is an overall improvement in knowledge compared to the previous UK study (e.g. a sevenfold increase in the ability to classify types of FGM/C). In our study, three quarters of a broad spectrum of health care professionals were conversant with the Female Genital Mutilation Act of 2003 whereas only 40% of UK responders were in 2007. We feel, however, that respondents still have an insufficient knowledge base about the diagnosis and classification of FGM/C.
It is also understandable that country of origin and seniority of the respondents had an influence on knowledge: doctors whose primary medical degrees were from the African subcontinent were at least twice as confident about their diagnosis of FGM/C compared to UK qualified doctors.
While we recognise that medical opinion regarding the association of FGM/C with obstetric fistulae and HIV is subject to much debate, and that the association of certain complications to the type of FGM/C which a woman has undergone is suspect, we have marked the responses to questions about associated complications according to WHO opinion documents as we felt that this would be the most widely accepted theory. As such, we have demonstrated that study participant's knowledge about the complications associated with FGM/C is suboptimal.
Furthermore, when asked about organising appropriately timed deinfibulation to allow safe childbirth, only 31.6% of participants were aware that the ideal time to reverse FGM/C was prior to childbirth. We acknowledge that in reality the majority of women do not present to a gynaecologist or midwife until they are already pregnant, when the most appropriately timed deinfibulation is during the second trimester. Nine respondents (11.4%) chose this option. This is despite the common practice of deinfibulation immediately after marriage, in many African countries where FGM/C is commonplace.
We also point out that even in high prevalence areas, less than 21% of healthcare professionals have seen more than 10 cases, although that being said, the eight UK medical students questioned appear to be better informed than a similar cohort in Egypt  .
Attitudes of the respondents were interesting: nearly 10% thought that medicalising and therefore making FGM/C legal (or at least when performed by a medically trained person) would make the practice more open and safe, and thus possibly reduce complications. Recent controversy was raised by attempts from the American Association of Paediatricians to medicalize the condition by suggesting that a symbolic “nick” could be acceptable culturally as an alternative to FGM/C in cases where the family would otherwise take the girl abroad for FGM/C in the native country  , thus reducing the risk of formal circumcision. This statement was later retracted
In our study 13.9% of respondents were of the opinion that a competent adult had the right to ask for FGM/C, and only 87.3% will warn social services of suspected FGM/C in children. Similar to findings from a Flemish study  , some of our responders also thought that genital piercing and cosmetic genital surgery are a form of FGM/C, the main difference between the two being that the former are performed on an adult woman with the legal competence to make the decision.
As discussed at the RCOG and Royal College of Midwives (RCM) Joint Meeting on the 2012 International Day of Zero Tolerance to Female Genital Mutilation in London, health professionals actively working towards abolition of FGM/C on a worldwide scale are aware that education is key. The present paper, however, is the first formal documentation of levels of knowledge and understanding regarding female genital mutilation/cutting within a high prevalence UK region for nearly 5 years.
We acknowledge that the study is relatively small (n = 79) and as it only represents north London boroughs, cannot be extrapolated to the UK as a whole. The documentation of current knowledge does, however, demonstrate the amount of work which needs to be done in training health professionals about this ongoing breach of human rights, with the resultant goal of eradicating the practice.
We have no funding organisations to acknowledge.
-  OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO. Eliminating female genital mutilation: an interagency statement; 2008. ISBN 978-92-4-159644-2.
-  E. Dorkenoo, L. Morison, A. Macfarlane. A statistical study to estimate the prevalence of female genital mutilation in England and Wales: summary report. (Foundation for Women's Health, Research and Development (FORWARD), 2001)
-  United Kingdom Female Genital Mutilation Act 2003. Chapter 31. www.legislation.gov.uk/ukpga/2003/31 .
-  Mahmood M, Mills E. Britain's 100,000 mutilated women. Sunday Times 2012, April; no. 9789.
-  Royal College of Obstetricians and Gynaecologists (May 2009): Female Genital Mutilation Management (Green-top 53).
-  B. Chalmers, O. Hashi. 432 Somali women's birth experience in Canada after early female genital mutilation. Birth. 2000;27:227-234 Crossref.
-  F. Jager, S. Schulze, P. Hohifeld. Female genital mutilation: a survey among gynaecologists. Swiss Medical Weekly. 2002;132:259-264
-  E. Leye, I. Ysebaert, J. Deblonde, et al. Female genital mutilation: knowledge, attitudes and practices of Flemish gynaecologists. European Journal of Contraception and Reproductive Health Care. 2008;13:182-190 Crossref.
-  N. Zaidi, A. Khalil, C. Roberts, M. Browne. Knowledge of female genital mutilation among healthcare professionals. Journal of Obstetrics and Gynaecology. 2007;27:161-164 Crossref.
-  S.R. Mostafa, N.A. El Zeiny, S.E. Tayel, E.I. Moubarak. What do medical students in Alexandria know about female genital mutilation?. Eastern Mediterranean Health Journal. 2006;12 Suppl. 2:S78-S92
-  N. MacReady. AAP retracts statement on controversial procedure. Lancet. 2010;375:15 Crossref.
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