Nesrin Varol

A systematic review of doctors’ experiences and needs to support the care of women with female genital mutilation

Female genital mutilation (FGM) involves partial or complete removal of the external female genitalia or other injury for non‐therapeutic reasons. Little is known about the knowledge and skills of doctors who care for affected women and their practice in relation to FGM.

The role of men in abandonment of female genital mutilation: a systematic review

BackgroundMen in their roles as fathers, husbands, community and religious leaders may play a pivotal part in the continuation of female genital mutilation (FGM). However, the research on their views of FGM and their potential role in its abandonment are not well described.MethodsWe undertook a systematic review of all publications between 2004 and 2014 that explored men’s attitudes, beliefs, and behaviours in regards to FGM, as well as their ideas about FGM prevention and abandonment.ResultsWe included twenty peer-reviewed articles from 15 countries in the analysis. Analysis revealed ambiguity of men’s wishes in regards to the continuation of FGM. Many men wished to abandon this practice because of the physical and psychosexual complications to both women and men. Social obligation and the silent culture between the sexes were posited as major obstacles for change. Support for abandonment was influenced by notions of social obligation, religion, education, ethnicity, urban living, migration, and understanding of the negative sequelae of FGM. The strongest influence was education.ConclusionThe level of education of men was one of the most important indicators for men’s support for abandonment of FGM. Social obligation and the lack of dialogue between men and women were two key issues that men acknowledged as barriers to abandonment. Advocacy by men and collaboration between men and women’s health and community programs may be important steps forward in the abandonment process.

Female genital mutilation/cutting – towards abandonment of a harmful cultural practice

Globally, the prevalence of, and support for, female genital mutilation/cutting (FGM/C) is declining. However, the entrenched sense of social obligation that propagates the continuation of this practice and the lack of open communication between men and women on this sensitive issue are two important barriers to abandonment. There is limited evidence on the role of men and their experiences in FGM/C. Marriageability of girls is considered to be one of the main driving forces for the continuation of this practice. In some countries, more men than women are advocating to end FGM/C. Moreover, men, as partners to women with FGM/C, also report physical and psychosexual problems. The abandonment process involves expanding a range of successful programs, addressing the human rights priorities of communities and providing power over their own development processes. Anecdotal evidence exists that FGM/C is practised amongst African migrant populations in Australia. The Australian Government supports a taskforce to improve community awareness and education, workforce training and evidence building. Internationally, an African Coordinating Centre for abandonment of FGM/C has been established in Kenya with a major global support group to share research, promote solidarity, advocacy and implement a coordinated and integrated response to abandon FGM/C.

Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation: A review of global experience

OBJECTIVE to identify how midwives in low and middle income countries (LMIC) and high income countries (HIC) care for women with female genital mutilation (FGM), their perceived challenges and what professional development and workplace strategies might better support midwives to provide appropriate quality care. DESIGN an integrative review involving a narrative synthesis of the literature was undertaken to include peer reviewed research literature published between 2004 and 2014. FINDINGS 10 papers were included in the review, two from LMIC and eight from HIC. A lack of technical knowledge and limited cultural competency was identified, as well as socio-cultural challenges in the abandonment process of the practice, particularly in LMIC settings. Training in the area of FGM was limited. One study reported the outcomes of an education initiative that was found to be beneficial. KEY CONCLUSIONS professional education and training, a working environment supported by guidelines and responsive policy and community education, are necessary to enable midwives to improve the care of women with FGM and advocate against the practice. IMPLICATIONS FOR PRACTICE improved opportunities for midwives to learn about FGM and receive advice and support, alongside opportunities for collaborative practice in contexts that enable the effective reporting of FGM to authorities, may be beneficial and require further investigation.

Smooth muscle in the female pelvic peritoneum: a clinicopathological analysis of 31 women

Aim: To study the presence and morphological features of smooth muscle in the subcoelomic mesenchyme with the aim of establishing both a normal range for the female pelvis, and its possible relationship to endometriosis, diffuse peritoneal leiomyomatosis (LPD) and other forms of ‘müllerianosis’. Methods: Seventy laparoscopically obtained pelvic peritoneal biopsies accessioned over a 16‐month period were examined from 31 women clinically suspected of endometriosis. These biopsies were selected for the presence of assessable, appropriately oriented peritoneum, sufficiently distant from focal endometriosis to allow a presumption of ‘normality’. The histological features and morphometric measurements of smooth muscle in these biopsies were documented. Pathological changes, where present, were recorded. Results: Focal endometriosis was identified in 28 (40%) of the biopsies, nine (12.9%) displayed other manifestations of ‘müllerianosis’, 11 (15.7%) showed focal chronic inflammation or fibrosis only, and 22 (31.4%) displayed no specific pathological changes. Of 70 biopsies, 52 contained smooth muscle within the subcoelomic mesenchyme, directly below the peritoneal mesothelium. Biopsies in which smooth muscle was identified were predominantly from the region of the uterosacral ligaments (16/18) and pelvic side wall (22/25). The biopsies without a smooth muscle layer were predominantly from the pararectal area (7/8) or the rectal serosa (2/4). Where present, smooth muscle varied in prominence, depth, thickness of the layer and organisation of muscle bundles. Patterns ranged from thin, widely spaced and wispy fibres to a more or less continuous band of either horizontally and/or vertically organised fibres. Both focal and diffuse arrangements were evident. ‘Neovascularisation’ was observed laparoscopically in some areas that corresponded with prominent smooth muscle development. Conclusions: Smooth muscle occurs sufficiently frequently immediately beneath the peritoneum of the female pelvis, and with a sufficiently predictable anatomical distribution, to be regarded as a normal component of the microanatomy of this tissue in the patients studied.

Evidence-based policy responses to strengthen health, community and legislative systems that care for women in Australia with female genital mutilation / cutting

BackgroundThe physical and psychological impact of female genital mutilation / cutting (FGM/C) can be substantial, long term, and irreversible. Parts of the health sector in Australia have developed guidelines in the management of FGM/C, but large gaps exist in community and professional knowledge of the consequences and treatment of FGM/C. The prevalence of FGM/C amongst Australian women is unknown. Our article reviews the literature on research on FGM/C in Australia, which focuses on health system response to women and girls with FGM/C. Recommendations are made for policy reform in health, legislation, and community programs to provide the best healthcare, protect children, and help communities abandon this harmful practice.Main bodyMidwives and doctors in Australia acknowledged a lack of knowledge on FGM/C, clinical guidelines and consequences for maternity care. In a metropolitan Australian hospital with specialised FGM/C care, women with FGM/C had similar obstetric outcomes as women without FGM/C, underlining the importance of holistic FGM/C clinics.Greater focus on integration of refugee and migrant populations into their new cultures may be an important way of facilitating the abandonment of this practice, as is education of communities that practise FGM/C, and experts involved in the care and protection of children. Men could be important advocates for protecting women and girls from violence and FGM/C through a man-to-man strategy with programs focussing on men’s health and other personal issues, education, and communication.The Australian Government has identified gender-based violence as an area of priority and has been implementing a National plan to reduce violence against women and their children 2010–2022. A multidisciplinary network of experts on FGM/C could be established within this taskforce to develop well-defined and rapid referral pathways to care for and protect these children, as well as coordinate education and prevention programs to help communities abandon this harmful practice.ConclusionCountries of migration can be part of the solution for abandonment of FGM/C through community interventions and implementation of national and coordinated training in FGM/C of experts involved in the care and protection of children and women. The global focus on collaboration on research, training and prevention programs should be fostered between countries of FGM/C prevalence and migration.