Female genital mutilation/cutting in Regional Victoria:

Transcription

1 Female genital mutilation/cutting in Regional Victoria: Research to practice Cathy Vaughan, Narelle White, Louise Keogh (MSPGH) John Tobin (MLS) Adele Murdolo, Regina Quiazon (MCWH) Chris Bayly (the Women s)

2 Background to the project University was approached by North Yarra Community Health (now cohealth) and jointly developed a community-based research project in inner Melbourne Extensive community consultations informed the Listening to North Yarra communities project Through this work we were invited to the National Summit on FGM.

3 DOHA targeted grant round Grant awarded to fund research in regional Victoria, with a view to informing policy and practice (clinical, health promotion, health education, and support services) Budget limitations meant focus was Victoria, and in the four locations with largest populations from potentially relevant countries (Ballarat, Geelong, Latrobe Valley and Shepparton)

4 A global issue Estimated that 125 million girls and women have undergone female genital mutilation/cutting (FGM/C, or female circumcision) worldwide Illegal in Australia, considerable investment in prevention However thousands of women and girls now living in Australia had experienced circumcision prior to their arrival including women now living in regional centres

5 Terminology Female genital mutilation (FGM): Inter-African Committee on Traditional Practices Affecting the Health of Women and Children 1990, WHO 1991 Emphasises harm caused and violation of human rights Female genital cutting (FGC): More respectful when working with women and practising communities Something bad has happened to me: don t hurt me more with your language. FGM/C: Hybrid term currently used by UNICEF and UNFPA Attempt to bring policy and community approaches together

6 About FGM/C Range of practices involving removal of part or all of clitoris, labia minora and/or majora, with or without narrowing the vaginal opening by stitching ( infibulation ), also nicking or cutting (WHO types I-IV) Variable age, infancy to adolescence Nature of procedures vary within and between countries Prevalences vary from a few % to 90%+ 29 countries Africa and Middle East plus others

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9 Consequences of FGM/C No health benefits Short term: Pain, distress, bleeding, infection, death Long term: Scarring, abscesses Urinary infections Sexual problems Childbirth complications (Caesarean section, tears) Psychological problems

10 Sexual function UK: Sexual quality of life scores: significant differences between women with Type 3 or unspecified FGM and controls. Andersson et al BJOG: 119; p Saudi Arabia: No differences in desire, but significant differences in arousal, lubrication, orgasm and satisfaction scores, eg 3.7±1.2 vs 4.2±1.4 in 5 point scale. Alsibiani S and Abdulrahim AR Fertil Steri:l 93: p722-4

11 Caesarean Section rates Epidemiological studies show consistently higher caesarean section rates for sub-saharan African and Somali women, with limited evidence to explain the differences. Merry et al: International migration and caesarean birth: a systematic review and meta-analysis BMC Pregnancy and Childbirth: 13; p1-23 Small et al: Somali women and their pregnancy outcomes postmigration: data from six receiving countries BJOG: 115; p

12 Reasons for FGM/C Social norm: Perceived social obligation Important others do it It s believed to be expected by others Part of belonging: fear of censure/sanctions Many and varied explanatory reasons understood and given. Controlled by women, attitudes of men vary. Requires collective action and leadership to change.

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14 International response Twenty-four of the 29 countries where FGM/C is concentrated have enacted decrees or legislation related to FGM/C (2 in 1960s, 8 in late 90s, 14 plus amendments since 2000). Growing recognition that legislation must support social change. Doctors charged in UK, Egypt 2014.

15 What the law says HERE Crimes Act 1958 Sect 32 (1997) A person must not perform female genital mutilation: Infibulation Excision or mutilation of whole of a part of the clitoris, the labia minora or labia majora Any procedure to narrow or close the vaginal opening The sealing together of the labia minora or labia majora The removal of the clitoral hood. Consent is not a defence. A person must not take or arrange for another person to be taken from the State with the intention of having prohibited FGM performed on that person

16 Exceptions to section 32 (34A) Removal of the clitoral hood at age 18 A surgical operation which is - necessary for health and performed by a medical practitioner done in labour or just after birth, for medical purposes performed by a medical practitioner or a midwife a sexual reassignment procedure performed by a medical practitioner In determining whether an operation is necessary for health, the only matters to be taken into account are those relevant to the medical welfare or the relief of physical symptoms.

17 Affected communities in Victoria Australia (21.5M): 109,000 Victoria (5.3M): 35,000 (Egypt, Sudan, Ethiopia, Somalia, Kenya, Eritrea) Benalla (13K): 81 (2/3 Indian) Greater Shepparton (62K): 1576 (India, Iraq, Sudan, Malaysia, Nigeria, Egypt, Kenya) From ABS statistics

18 Objectives of the research The project engaged with community members and service providers in Ballarat, Geelong, Latrobe Valley and Shepparton to explore: community and service provider knowledge; community and service provider attitudes in relation to FGM/C; women s health service needs and experiences of health services, in relation to FGM/C; capacity of service providers to meet community needs in relation to FGM/C; and the most appropriate strategies for building regional service provider capacity to provide FGC-related care to women from affected communities in regional Australia.

19 Methods Community members recruited through service providers; health service providers recruited through organisational networks Nine FGDs with community members (51 participants in total) Fourteen interviews with service providers (GPs, consultants, midwives, community health workers) Thematic analysis of qualitative data Ethics

20 Knowledge in relation to FGM/C Most community members demonstrated both awareness and acceptance of Australian law Small number of participants unaware that taking children abroad for circumcision illegal Women usually aware of health consequences, particularly those women affected by the practice However need to avoid WHO language : If you ask [affected women] how was it done? they can tell you, but not what type of circumcision They can explain what skin is removed If you ask how was it performed? they will tell you (Community member, Shepparton)

21 Role of FGM/C Rationale for FGC was most often described as curtailing female sexual desire and sexual activity General consensus that the practice is in decline However, abandonment remains a contested issue for some families People back home they will still call us and say no you have to bring the kids back and do this and this and I said to her, to them, 'no this is not the time I can do these things to my kids because I don't think it's right' (Community member, Shepparton) Some misunderstanding around religious obligations, particularly from non-practicing cultural groups

22 Impacts on women s lives Discrepancies between some service providers impression of the impact of FGC and community members experiences [FGC] Services are relevant. They need to be there (Community member, Shepparton) Some women experienced no health problems; others discussed impact on childbirth, examinations, and sexual lives and relationships It's very hard to have babies. And you don't have any feeling, you don't have, you don't enjoy anything, very hard (Interpreter for community member, Latrobe)

23 Access to FGC-related care All regional service providers reported very few presentations Screening practices inconsistent across the state (not all practitioners asked about FGC during refugee health screening note need to explain why the question asked as well) Service providers often unsure how to broach the subject and feeling uncomfortable to ask Most people find it very confronting and an easier choice just to leave it be and see whether you can discover it on examination (doctor, Shepparton)

24 Access to FGC-related care con. Major challenges regarding availability and use of interpreters Continuity important for establishing trust If someone's seeing someone different all the time there's no way, um, people are gonna provide information to someone randomly without building up that rapport and trust. There s, there's just no way in the world that anyone's gonna open up about anything (Midwife, Latrobe) However, most often, participants satisfied with care, but felt service providers unaware of the impact of their (negative) attitudes towards FGC

25 Women s expressed needs Information, discussion and support around sexual relationships and sexual pleasure; women s health information more broadly (note that for some women, contraception may be a more sensitive issue than FGC) Like information, yeah [in a] group, and we need to know more of the, about the women's health, yeah. Even how you connect with your girls at home you know about, about period, if it's coming, after how long will be terrible, something like this will be good (Community member, Shepparton) In every FGD, women expressed the need for more information on pap smears Improved communication

26 A word on young women Young women were not the explicit focus of this study and few of the participants were young. However, in North Yarra: Yeah, it s a shame, it s just a disgrace, you feel, you feel less, you feel little yeah? And then you can t really speak up. Back home if you said it, well hey man like nobody can say anything against it, but here you feel you re not like everybody else When I went back my grandma was like oh you can t tell people that you weren t circumcised, it s embarrassing to be that one that broke the cycle. And to be the family that broke it, then it s like the whole family yeah, that s looked upon You re thinking, no I m sure it s not something bad if my parents, my parents would know best, you know? Sometimes we don t want to remember things

27 Service provider experiences and perceptions Almost half of the service providers had previously undertaken PD in relation to FGC Most, but not all, felt that refresher training from time to time important and noted turn over of staff Service providers felt FGC-related information could be presented in the context of raising cultural awareness, how to raise sensitive issues, crosscultural SRH work Service providers wanted links to resources they could use and clinical providers they could seek advice from

28 There's some very, ah, defensive behaviours or with women with pap smears. So that's why I'm wondering about how I can, what I could say, for instance how I could change the way that I approach or talk to people when I do pap smears. It might be an occasion when I can screen for that [FGC] and domestic violence The issue for me is how to deal sensitively in history taking and examination for people who may have been traumatised in the past in one way or another including genital mutilation (GP, Geelong)

29 Implications Health service providers need to know when to consider FGC, what the issues might be, and how to talk about FGC. Clinical service providers need to know about deinfibulation (which not all women who have experienced FGC will need): When to do it: o Prior to first sex o Second trimester o At time of birth How to do it: o Usually simple procedure o Often can be done under local

30 Thinking about FGC in your practice Ask about/discuss FGC Offer deinfibulation if appropriate Discuss antenatally any request for postpartum reinfibulation Identify/refer with other clinical problems Explain reasons for CS, tearing etc Routinely have postnatal discussion re daughters Work with interpreters, FARREP, colleagues Place of reconstructive surgery? Consider psychological issues that may emerge for young women (wondering what has been done and how this may affect relationships, childbearing) Role of school nurses Not ignoring sexual relationships and sexual pleasure

31 Other implications Work with communities: recognise and build on community-led change involve men and community leaders reach newer and less obvious communities acknowledge differing priorities and other settlement concerns With community assistance/involvement: ensure public discussion informed and reflects complexities improve communication between women and HPs increase awareness of services address specific needs of young women

32 Clinical resources Royal Women s Hospital Deinfibulation Clinic Nurse-led clinic, women s health nurses Support and education Deinfibulation in the clinic when wanted and appropriate Pregnant and non-pregnant women Any FGM/C issues Health professionals call Marie Jones (coordinator) on with any queries

33 Other resources FARREP workers, who can be found through the NEFTA website: Family Planning Victoria Family Planning New South Wales Colleges of Nursing and Midwives Multicultural Centre for Women s Health

34 Thank you to Regional health and resettlement service providers, and members of the Kenyan, South Sudanese, Sudanese and Togolese communities living in Ballarat, Geelong, Latrobe (including Moe, Morwell and Traralgon) and Shepparton All the individual participants, and the many health services, community groups and associations that made this possible. Special thanks to the staff of the Ethnic Council of Shepparton and District, and Thon Thon in particular, for their strong role in facilitating community engagement and participation.