Guidelines Updated on Care for Women With Genital Mutilation

Becky McCall

July 14, 2015

Physicians should clearly understand the complete range of health issues, both physical and psychological, associated with female genital mutilation (FGM), particularly in pregnancy, according to a new guideline on FGM from the United Kingdom's Royal College of Obstetricians and Gynaecology (RCOG). UK clinicians should also be familiar with the legal and regulatory framework surrounding this issue, the group emphasizes.

The guideline, "Female Genital Mutilation and Its Management," published online July 10, provides evidence-based advice on the clinical care of women with FGM, with particular reference to before, during, and after pregnancy, which presents a key opportunity to identify vulnerable women. This is an updated version of the 2009 guideline with a similar title.

At a press briefing to launch the new guideline, Sarah Creighton, MD, from the University College London Hospitals National Health Service Trust, United Kingdom, coauthor of the guideline, said, "This is a new review of the latest information available, and we hope that obstetricians and gynecologists at every level will find this helps to deliver better care for women, but also protect girls at risk of FGM."

FGM applies to all procedures involving partial or total removal of the external female genitalia or other injury to female genital organs for nonmedical reasons.

Manish Gupta, MBChB, from Whipps Cross University Hospital, London, United Kingdom, is cochair of the RCOG Guidelines Committee. He explained the reasons for the new guideline, pointing out that since the 2009 edition, there had been significant changes both in understanding how best to deliver care to women who have had FGM and in the legal and regulatory frameworks that must be applied.

"FGM is a human rights violation and a form of child abuse," he added emphatically. "We at the RCOG declare the practice as abhorrent, and we are committed to range key strategies nationally and internationally to tackle FGM."

Physical and Psychological Care Needed

Also discussing the new guideline, coauthor Naomi Low-Beer, MD, from Chelsea and Westminster Hospital, London, United Kingdom, and Lee Kong Chian School of Medicine, Singapore, highlighted the importance of delivering high-quality care, both physical and psychological. "Healthcare professionals need to understand the range of health problems that women with FGM experience, both short and long term," she said. "[W]e work with very vulnerable young women who find it difficult to talk about their problems, and many suffer severe psychological consequences as a result of their FGM, so it is vital that they have access to psychological support and assessment."

Referring to the physical effects of FGM, she said: "It can vary from scarring, menstrual difficulties, painful sexual intercourse, obstetric complications as well as chronic pain, recurrent urinary symptoms, and sexual difficulties among other problems."

The World Health Organization classifies FGM as types 1 to 4. The guideline emphasizes risks associated with types 2 and 3 during pregnancy. FGM type 2 involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision); FGM type 3 involves narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia (infibulation).

Specific training is required for managing these patients, stressed Dr Low-Beer, highlighting a key point in the guideline. "During pregnancy, particularly in women with FGM type 2 or 3, there is an increased risk of childbirth complications, and we need to ensure care is provided by an obstetrician and there is a designated FGM consultant and midwife lead in hospitals."

The guideline also addresses de-infibulation and clitoral reconstruction. It recommends that women who are likely to benefit from de-infibulation be counseled and offered the procedure before pregnancy, and ideally before first sexual intercourse. In addition, it says clitoral reconstruction should not be performed because current evidence suggests there are associated complication rates without conclusive evidence of benefit.

Re-infibulation is illegal, there is no clinical justification for the procedure, and it should not be undertaken under any circumstances, according to the guideline.

The Law Relating to FGM and Child Protection

Focusing on UK law regarding FGM in the child protection setting, Dr Low-Beer highlighted that within the guidelines, they had made it very clear "that it is absolutely critical that doctors clearly understand the law on FGM and be able to communicate that to patients. It is also important that they themselves are working within the law."

In short, the Female Genital Mutilation Act 2003 in England, Wales, and Northern Ireland states that FGM is illegal unless it is a surgical operation for medical reasons; it is also illegal to assist in sending a UK national or resident overseas for FGM. Also, if FGM is confirmed in a girl younger than 18 years, reporting it to the police is mandatory.

"It is absolutely key that doctors are open to identifying children who are at risk and understand the processes to take to ensure that children are protected," Dr Low-Beer stressed.

Because pregnancy is a time when delivery of high-quality care and child protection converge, Dr Low-Beer said all pregnant women must have a risk assessment by an obstetrician to assess the risk to their existing children and their unborn child, echoing the 2015 Department of Health recommendations.

She added that risk assessment needs to be conducted in a sensitive way and on a case-by-case basis. "It should not be assumed that just because a pregnant woman had FGM as a child that she intends to inflict FGM on her own daughters. In fact, the reverse is often true."

Recording and Reporting FGM Findings

The guideline states that the health professional must understand the difference between recording and reporting, as well as their respective responsibilities. Dr Creighton clarified the difference between recording and reporting FGM: "Recording is collecting information on the numbers of women who have had FGM and the type of FGM." She added that, "the aim is to understand the numbers of women affected by FGM and the types of care and planning services needed. It also aims to estimate the numbers of girls at risk in order to help safeguard them."

Data recorded are submitted to the Health and Social Care Information Centre FGM Enhanced Dataset.

"Reporting is when FGM is reported to the police and/or the social services when a child is at risk of [or has had] FGM," highlighted Dr Creighton. 'We have provided guidance in the document, and this is new for this version of the guideline."

She added that it was not mandatory to report every woman with FGM to the police and social services, but it was important that every individual have an assessment carried out as described in the guideline.

Dr Creighton also noted that that once the United Kingdom's 2015 Serious Crime Act is passed, some of the recommendations might change.

Although the guidelines are aimed at obstetricians and gynecologists, Dr Gupta pointed out that it is also relevant to other healthcare professionals including general practitioners, midwives, and nurses. He also recommended that healthcare professionals refer to Health Education England's FGM e-learning program.

The new guideline is the second edition of the RCOG guideline on FGM, after an earlier version was published in 2009. Before this, an RCOG statement with the same title was published in 2003.

More detailed information on all aspects of the guideline is available on the RCOG website.

Dr Low-Beer, Dr Creighton, and Dr Gupta have disclosed no relevant financial relationships.

"Female Genital Mutilation and Its Management." RCOG. Published online July 10, 2015. Full text


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