Crista Johnson-Agbakwu

Seven Things to Know about Female Genital Surgeries in Africa

HASTINGS CENTER REPORT 19 Starting in the early 1980s, media coverage of customary African genital surgeries for females has been problematic and overly reliant on sources from within a global activist and advocacy movement opposed to the practice, variously described as female genital mutilation, female genital cutting, or female circumcision. Here, we use the more neutral expression female genital surgery. In their passion to end the practice, antimutilation advocacy organizations often make claims about female genital surgeries in Africa that are inaccurate or overgeneralized or that don’t apply to most cases. The aim of this article—which we offer as a public policy advisory statement from a group of concerned research scholars, physicians, and policy experts—is not to take a collective stance on the practice of genital surgeries for either females or males. Our main aim is to express our concern about the media coverage of female genital surgeries in Africa, to call for greater accuracy in cultural representations of littleknown others, and to strive for evenhandedness and high standards of reason and evidence in any future public policy debates. In effect, the statement is an invitation to actually have that debate, with all sides of the story fairly represented. Some of the signatories of this policy statement support efforts to promote voluntary abandonment of all practices of genital surgery on children. Other signatories wish to allow parents to continue to circumcise males, but not females. Still other signatories seek to preserve the right of parents to carry forward their religious and cultural traditions and Seven Things to Know about Female Genital Surgeries in Africa

Perceptions of obstetrical interventions and female genital cutting: insights of men in a Somali refugee community.

Objectives. Somali women are at increased risk of adverse pregnancy outcomes. Anxiety and perceived stigmatization toward female genital cutting (FGC) further fuels an atmosphere of miscommunication and distrust, contributing to poorer health outcomes. While the attitudes and experiences of Somali refugee women toward healthcare are widely known, the views of Somali refugee men are largely unknown. This study examines the perspectives of Somali men toward FGC and womens childbirth experiences in one refugee community in the USA. Design. Community-based participatory research partnerships with key stakeholders within the Somali refugee community incorporated qualitative methods comprising semi-structured focus groups and individual interviews to elicit male participants’ perspectives on FGC, experiences during childbirth, and the perception of increased cesarean deliveries among Somali women. Qualitative analyses involved a framework and team-based approach using grounded theory and conventional content analysis. Results. Acculturation influenced changes in traditional gender roles fostering new dynamics in shared decision-making within the household and during childbirth. Participants were aware of FGC-related morbidity, ongoing matriarchal support for FGC, and were generally not supportive of FGC. They perceived health-care providers as being unfamiliar with caring for women with FGC fueling profound aversion to cesarean deliveries, miscommunication, and distrust of the health-care system. Conclusion. Our work yields new insights into Somali reproductive healthcare through Somali men, namely: strong matriarchal support of FGC, discomfort in mens presence during delivery, and a strong aversion to cesarean delivery. Our findings support the need for advocacy to engage Somali women, their partners/spouses, and health-care providers in facilitating greater continuity of care, building greater trust as men become engaged throughout the spectrum of care in the decision-making process while respecting traditional norms. Cultural health navigators should bridge communication and support between providers and patients. Our work provides foundational knowledge to inform culturally appropriate health interventions within a Somali refugee community.

Associations between religion-related factors and cervical cancer screening among Muslims in greater chicago.

Objective This study aimed to assess rates of Papanicolaou (Pap) testing and associations between religion-related factors and these rates among a racially and ethnically diverse sample of American Muslim women. Materials and Methods A community-based participatory research design was used in partnering with the Council of Islamic Organizations of Greater Chicago to recruit Muslim women attending mosque and community events. These participants self-administered surveys incorporating measures of fatalism, religiosity, perceived discrimination, Islamic modesty, and a marker of Pap test use. Results A total of 254 survey respondents were collected with nearly equal numbers of Arabs, South Asians, and African American respondents. Of these respondents, 84% had obtained a Pap test in their lifetime, with individuals who interpret disease as a manifestation of God’s punishment having a lower odds of having had Pap testing after controlling for sociodemographic factors (odds ratio [OR] = 0.87, 95% CI = 0.77–1.0). In multivariate models, living in the United States for more than 20 years (OR = 4.7, 95% CI = 1.4–16) and having a primary care physician (OR = 7.7, 95% CI = 2.5–23.4) were positive predictors of having had a Pap test. Ethnicity, fatalistic beliefs, perceived discrimination, and modesty levels were not significantly associated with Pap testing rates. Conclusions To our knowledge, this is the first study to assess Pap testing behaviors among a diverse sample of American Muslim women and to observe that negative religious coping (e.g., viewing health problems as a punishment from God) is associated with a lower odds of obtaining a Pap test. The relationship between religious coping and cancer screening behaviors deserves further study so that religious values can be appropriately addressed through cancer screening programs.

Mental Health Screening Among Newly-Arrived Refugees Seeking Routine Obstetric and Gynecologic Care

Posttraumatic stress disorder (PTSD), anxiety, and depression are common mental health disorders in the refugee population. High rates of violence, trauma, and PTSD among refugee women remain unaddressed. The process of implementing a mental health screening tool among multiethnic, newly arrived refugee women receiving routine obstetric and gynecologic care in a dedicated refugee womens health clinic is described. The Refugee Health Screener-15 (RHS-15) is a culturally responsive, efficient, validated screening instrument that detects symptoms of emotional distress across diverse refugee populations and languages. An interdisciplinary community partnership was established with a local behavioral health services agency to facilitate the referral of women scoring positive on the RHS-15. Staff and provider training sessions, as well as the incorporation of bicultural, multilingual cultural health navigators, greatly facilitated linguistically appropriate care coordination for refugee women in a culturally sensitive manner. Twenty-six (23.2%) of the 112 women who completed the RHS-15 scored positive, of which 14 (53.8%) were Iraqi, 1 (3.8%) was Burmese, and 3 (11.5%) were Somali. Among these 26 women, 8 (30.8%) are actively receiving mental health services and 5 (19.2%) have appointments scheduled. However, 13 (50%) are not enrolled in mental health care because of either declining services (46.2%) or a lack of insurance (53.8%). Screening for mental disorders among refugee women will promote greater awareness and identify those individuals who would benefit from further mental health evaluation and treatment. Sustainable interdisciplinary models of care are necessary to promote health education, dispel myths, and reduce the stigma of mental health.

Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes

AIMS This study aimed to highlight the salient sociocultural factors contributing to sexual health and dysfunction and to offer recommendations for culturally sensitive clinical management and research as well for an ethically sound sexual health care, counseling and medical decision-making. BACKGROUND There are limited data on the impact of sociocultural factors on male and female sexual function as well as on ethical principles to follow when clinical care falls outside of traditional realms of medically indicated interventions. METHODS This study reviewed the current literature on sociocultural and ethical considerations with regard to male and female sexual dysfunction as well as cultural and cosmetic female and male genital modification procedures. RESULTS It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. Both clinicians and researchers should develop culturally sensitive assessment skills and instruments. There are a number of practices with complex ethical issues (eg, female genital cutting, female and male cosmetic genital surgery). Future International Committee of Sexual Medicine meetings should seek to develop guidelines and associated recommendations for a separate, broader chapter on ethics.

Adaptation of an Acculturation Scale for African Refugee Women

Newly-arrived African refugees are a vulnerable group of immigrants for whom no validated acculturation measures exist. A valid measurement tool is essential to understand how acculturative processes impact health and health disparities. We adapted the Bicultural Involvement Questionnaire (BIQ) to characterize its reliability among ethnic Somali women residing in Minnesota, and Somali, Somali Bantu, and Burundian women in Arizona. Surveys were administered to 164 adult women. Analyses were conducted along socio-demographic variables of ethnicity, geographic residence, age, and length of time in the United States through t tests and one-way analysis of variance. Exploratory factor analysis was conducted on the modified BIQ. Exploratory factor analyses yielded five subscales: “Speak Native Language”, “Speak English Language”, “Enjoy Native Activities”, “Enjoy American Activities”, and “Desired Ideal Culture”. The subscales of the modified BIQ possessed Cronbach’s α ranging from 0.68 to 0.92, suggestive that all subscales had acceptable to excellent internal consistency. The modified BIQ maintained its psychometric properties across geographic regions of resettled Central and East African refugees.

Interventions to Address Sexual Function in Women Affected by Female Genital Cutting: a Scoping Review

Purpose of ReviewGlobal migration trends necessitate that health care providers, regardless of location, address sequelae from female genital cutting (FGC). Surgical interventions to treat sexual dysfunction in this population are proliferating despite limited evidence of their impact. We conducted a scoping review to describe interventions to address sexual dysfunction in FGC-affected women.Recent FindingsThirty-four citations in four categories of peer-reviewed literature emerged: surgical technique descriptions, case reports, literature reviews, and original research including qualitative analyses, anatomically focused studies and surgical interventions.SummarySurgical strategies to address sexual function in FGC-affected women, although promising, are limited by low-quality evidence. FGC-affected women require, but are rarely receiving, multidisciplinary care to address myriad influences on sexual function. Research is needed to clarify the impact of surgical interventions and promising non-surgical strategies including education and counseling.

Commentary on the Supplement American Journal of Obstetrics and Gynecology: A Hormonal Contraceptive Update: A Decade of Innovation and Transformation.

In the October 2011 issue of the American Journal of Obstetrics and Gynecology, there was an excellent review of hormonal contraceptives. The monograph entitled “A Hormonal Contraceptive Update: A Decade of Innovation and Transformation” was both informative and insightful as it outlined the benefits and risks of combined hormonal contraception. The monograph reviewed the positive aspects to a woman’s overall general health including cancer prevention (ovarian, endometrial, and colorectal), decreased rates of unintended pregnancy, acne, dysmenorrhea, and premenstrual dysphoric disorder. Some of the adverse effects were mentioned, albeit not all. We found that the monograph neglected to discuss the ongoing controversy concerning the use of combined oral contraceptives (COCs) and their potential negative impact on women’s sexual health. Although the debate is ongoing and data are continuously forthcoming, we believe that a thorough discussion of COCs must include the negative effects that COCs may have on women’s sexuality. The sexual medicine community must join in this educational process and help disseminate the emerging sexual research concerning COC and sexual dysfunction. Globally, over 150 million women are using hormonal contraception and recent data in the field of sexual medicine indicate that COC may have substantial negative sexual side effects including decreased libido and dyspareunia. All COCs decrease circulating free testosterone by increasing sex hormone binding globulin (SHBG). Furthermore, new data also indicate that in some women, even after they have discontinued COCs, their SHBG levels may not return to normal, precontraceptive values and, therefore, their free testosterone levels may remain suppressed [1]. It is hypothesized that COCs may in fact alter genetic expression in the mitochondria permanently. Many women with decreased sexual interest and desire have low free testosterone levels and note that the changes in their sexual energy were coincident with the initiation or shortly after the initiation of low dose COC, particularly those with 20 mcg of estradiol or less. There are women who are hormonally sensitive to fluctuations and the decline in free testosterone levels, and will present with lowered sexual interest, poor sexual arousal, and decreased sexual satisfaction. The data on testosterone linking it with improved desire are solid and both the American Congress of Obstetricians and Gynecologists as well as the North American Menopause Society have issued practical guidelines for off label testosterone therapy in women [2,3]. In addition to sexual desire and hormonal concerns, there is a preponderance of emerging sexual medicine literature which supports a causal relationship between sexual pain syndromes including vestibulodynia (vulvar vestibulitis syndrome) and COCs [4–6]. Many women will experience positive effects on their sexuality from COC (the teen with lowered sexual self-schema due to acne, the overwhelmed mother of young children who desperately desires birth spacing, or the woman with severe and debilitating dysmenorrhea are a few examples). When counseling a patient on COCs, it is necessary to provide a balanced picture of benefits and risks, allowing her to exercise her autonomy when it pertains to contraceptive choices. The age of individualized medicine is upon us where risks and benefits must be discussed and documented with our patients who are partnering with us, as healthcare professionals, to educate them. Withholding information will only denigrate the therapeutic alliance we so desperately want to develop with our patients. It is inappropriate to omit the potential sexual ramifications of COCs in our discussions with patients. Informed consent concerning the potential pros and cons of COCs remains paramount. Furthermore, we believe in bringing awareness to female sexual equality and wellness even when societal constraints seem determined to squelch mainstream female sexuality and expression. Clearly more data and well-designed trials are needed to further elucidate the effects of COCs on female sexuality. Unfortunately, there is a paucity of funding and support for such studies. Nevertheless, there are already enough data indicating that for some women, there are substantial negative 1

Effects of Flibanserin on the Pharmacokinetics of a Combined Ethinylestradiol/Levonorgestrel Oral Contraceptive in Healthy Premenopausal Women: A Randomized Crossover Study

PURPOSE This study aimed to investigate the effect of steady-state exposure to flibanserin, a 5-HT1A agonist/5-HT2A antagonist approved for the treatment of hypoactive sexual desire disorder in premenopausal women, on the single-dose pharmacokinetics of the contraceptive steroids ethinylestradiol and levonorgestrel in healthy premenopausal women. METHODS Healthy female volunteers (N = 24) received 2 single doses of a combined oral contraceptive containing ethinylestradiol 30 μg and levonorgestrel 150 μg, either alone (reference) or preceded by treatment with flibanserin 100 mg once daily for 14 days (test). The 2 treatments were given in randomized order, with a 4-week washout period following the last administration of the first treatment. Plasma concentrations of ethinylestradiol and levonorgestrel were measured over 48 hours after dosing for the determination of pharmacokinetic parameters; the primary end points were Cmax and AUC0-∞ of ethinylestradiol and levonorgestrel. FINDINGS Of the 24 women enrolled (mean age, 38.0 years), 23 completed the study. Mean (SD) Cmax and AUC0-∞ values of ethinylestradiol were 66.7 (16.3) pg/mL and 693 (268) pg · h/mL, respectively, following the oral contraceptive alone, and 72.7 (25.5) pg/mL and 740 (235) pg · h/mL, respectively, when the oral contraceptive was preceded by flibanserin. In both cases, the 90% CIs of the reference/test ratios of Cmax and AUC0-∞ were within the range of 80% to 125%, indicating that flibanserin had no significant effect on the pharmacokinetic properties of ethinylestradiol. Similarly, the mean (SD) Cmax and AUC0-∞ values of levonorgestrel were 5.0 (1.6) ng/mL and 52.2 (18.7) ng · h/mL, respectively, with the oral contraceptive alone, and 5.0 (1.6) ng/mL and 53.3 (20.4) ng · h/mL, respectively, following flibanserin; again, in both cases, the 90% CIs of the reference/test ratios were within the range of 80% to 125%, indicating that flibanserin had no significant effect on the pharmacokinetic properties of levonorgestrel. All adverse events were mild to moderate in intensity (incidence: 12.5% and 70.8% with ethinylestradiol/levonorgestrel treatment alone and following administration of flibanserin, respectively). IMPLICATIONS Pretreatment with flibanserin 100 mg once daily for 2 weeks did not produce a clinically relevant change in oral contraceptive drug exposure following single-dose administration of ethinylestradiol/levonorgestrel. This finding is relevant to women with hypoactive sexual desire disorder who might prefer oral contraceptives to other forms of birth control. EudraCT No: 2006-006960-46.

“Before the war we had it all”: Family planning among couples in a post-conflict setting

ABSTRACT There is little evidence about family planning knowledge, attitudes, and use among couples in post-conflict Democratic Republic of the Congo. We used qualitative descriptions to analyze data from 75 participants. Intimate partner violence (IPV) was common among participants. They were aware of family planning methods; however, IPV and fears of side effects were barriers to use. Although participants were concerned about the cost of large families, had positive attitudes toward family planning, and intended to use it, actual use was uncommon. The need for family planning was acute because of war-related poverty. Couples negotiated, but men had strong influence over family planning decisions. Couples saw health workers as a valuable resource. Interventions in this setting should include a couple-based approach that addresses IPV as well as family planning content.