Taking a look at female genital mutilation: risk assessment and safeguarding

Female genital mutilation of any type is recognized as a harmful practice with damaging effects on health and well-being. It affects women of all ages, from all socio-professional backgrounds. This harmful practice originates from ancestral traditions, none of which correspond to the precepts of any religion. Worldwide, 200 million women and girls have fallen victim to this practice, with 125,000 mutilated adult women believed to reside in France according to a 2010 estimate. The mutilations are various in type and frequently include alteration of the sexual organs, partial or total removal of the clitoris (clitoridectomy) or labia majora (excision) or narrowing of the vaginal orifice through labia suturing (infibulation).

It is critical that health professionals be familiar with these harmful practices in order to participate in identification and risk prevention, but also to know how best to react should they discover genital mutilation in one of their patients, whether she is a minor or an adult. To meet these challenges, the HAS published a recommendation on the prevention and management of female genital mutilation.

Understanding prevalence, harm and gravity of female genital mutilation

The daughters of women having undergone genital mutilation are at increased risk that they too will fall victim to this harmful practice, as parental beliefs and family pressure from those living in the country of origin act as strong risk factors. Indeed 11% of all daughters of victims of female genital mutilation will be forced to undergo this practice. Between 12 and 20% of the total population of girls aged up to 18 years old–residing in France and originating from a country where female genital mutilation is commonly practiced–are believed to be at risk.

As it interferes with healthy genital tissue in the absence of medical necessity, genital mutilation may lead to severe and immediate complications including death from hemorrhage, septicemia, severe pain, infection and compression fracture. Medium to long-term health complications may include chronic vulvar and pelvic pain, poor healing, sterility, dysmenorrhea, sexual disorders (decreased desire and pleasure, vaginismus) and increased obstetric risks of pregnancy, especially during childbirth. Female genital mutilation is also associated with mental health problems such as post-traumatic stress syndrome, depression, and behavioral disorder.

Identifying at-risk patients

Health care professionals should be alerted to the risk of occurrence of female genital mutilation. Parents’ geographic origin is a primary factor to be taken into consideration. Indeed, the proportion of women having undergone genital mutilation is higher in African countries. Other regions of the world are also affected, the Near and Middle East and Asia¹, but to a lesser degree. Unicef ​​provides a map of the countries where different types of female genital mutilation are commonly practiced.

It is essential to know whether a patient has undergone female genital mutilation, as it may be the case with her family members or close circle. Being able to assess the importance family assigns to these practices, as well as the overall intention to respect this harmful tradition, is absolutely decisive.
Concerning minors, it is thus necessary to be particularly attentive to travel plans or vacationing in the country of origin, upcoming celebrations and rituals, and any concern directly expressed by the underage patient or loved one.

Starting the conversation is extremely delicate, thus the professional must make every attempt to free the patient of any guilt by being tactful in their choice of words, using suitable and accessible vocabulary. In its recommendation, the HAS suggests different approaches to confidently start the conversation during a medical visit.

Safeguarding minors and adults

When faced with an imminent risk of female genital mutilation concerning a minor, health professionals are required to submit an urgent referral. The Public Prosecutor must be informed by telephone, fax or by email with receipt of acknowledgement. A written copy of the referral must then be communicated to the departmental unit in charge of collecting alarming information for child protection or the corresponding departmental council. If faced with a non-imminent risk, health professionals are encouraged to submit alarming information to the same unit.

In the case of adult patients at imminent risk, healthcare professionals are to recommend that their patients reach out to one or more of these dedicated sources of assistance: 3919 (the national and toll-free number for Violence Against Women), a specialized association (including the network France Victim), a center for Women's and Family Rights Information (CIDFF) or an emergency shelter via the toll-free number 115.

Offering care on multiple levels when confronted with a victim

External signs suggestive of a patient having undergone female genital mutilation are various in nature: behavioral change, running away, menstrual pain, medical examination refusal, etc. If, during a medical examination, a health professional identifies female genital mutilation in a minor, he is required to submit an urgent referral to the Public Prosecutor. If the victim is an adult, the health professional would require patient consent to make such a referral. Beyond this legal obligation, victims must be referred to a pediatric surgical service (minors) or a multidisciplinary team experienced in the treatment of female genital mutilation.

In all cases, management goes beyond the surgical dimension and must include psychological support to manage disorders such as anxiety, depression and post-traumatic stress syndrome. Specific approaches concerning pregnant women and sexual disorders are to be taken into account.

¹ Egypt (87%), Sudan (87%), Sierra Leone (86%), Eritrea (83%), Mali (83%), Burkina Faso (76%), Gambia (75%), Mauritania (67%), Ethiopia (65%), Indonesia (49%), Guinea-Bissau (45%), Liberia (44%), Chad (38%), Côte d'Ivoire (37%), Central African Republic (24%), Senegal (23%), Kenya (21%), Yemen (19%), Nigeria (18%), Tanzania (10%), Benin (9%), Iraq (8%), Togo (5%), Ghana (4 %), Niger (2%), Cameroon (1%).