Female Genital Mutilation - Experience of The Royal Women s Hospital, Melbourne

50 AUST AND NZ JOURNAL OF OESTETRICS AND GYNAECOLOCY Coital frequency was decreased in association with dyspareunia and decreased orgasmic quality in the third trimester and these results were similar to other studies. Pregnancy, which is obviously a time of physiological change in the female, is also a time of psychological adjustment for both parents. Coital frequency and orgasmic response were affected during pregnancy. The concerns of women and their partners about their sexual relationships during pregnancy should receive more clinician consideration by caregivers. References 1. Bogren LY. Changes in sexuality in women and men during pregnancy. Archives of Sexual Behaviour 1991; 20: 35-45. 2. Perkins RP. Sexuality in pregnancy: What determines Behaviour? Obstet Gynaecol 1982; 59: 189-198. 3. Cohn SD. Sexuality in pregnancy. A review of the literature. Nursi Clin North Amer 1982; 17: 91-98. 4. Masters WH, Johnson VE. Human Sexual response. Boston: Little, Brown and Co. 1966; 141-168. 5. Solberg D, Butler J, Wagner N. Sexual behaviour in pregnancy. N Engl J Med 1973; 288: 1098-1103. 6. Ryding EL. Sexuality during and after pregnancy. Acta Obstet Gynecol Scand 1984; 63: 679-682. 7. Reamy KJ, White SE. Sexuality in the puerperium: A review. Archives of Sexual Behaviour 1987; 16: 165-187. 8. Robson KM, Brant HA, Kumar R. Maternal sexuality during first pregnancy and after childbirth. Br J Obstet Gynecol 1981; 88: 882-889. 9. Elliott SA, Watson JP. Sex during pregnancy and the first postnatal year. Psychosomatic Research 1985; 29: 541-548. 10. Barclay LM, McDonald P, O Loughlin JA. Sexuality and pregnancy: an interview study. Aust NZ J Obstet Gynaecol 1994; 34: 1-7. 11. Steege JF, Jelove\sek FR. Sexual behaviour during pregnancy. Obstet Gynecol 1982; 60: 163-168. Aust NZ J Obstet Gynaecol 1999; 39: 1: 50 Female Genital Mutilation - Experience of The Royal Women s Hospital, Melbourne Rachael Knight B Med Sci, MBBS, Ann Hotchin MRACOG, Chris Bayly2 MD, FRACOG and Sonia Grover) MD, FRACOG Royal Women s Hospital, Melbourne, Victoria EDITORIAL COMMENT The prevention of female genital mutilation in all its forms deserves the support of Australian health professionals. This survey identijied 61 women with a previous history of female genital mutilation in a 14-month period in one large hospital, although the study design did not allow for prevalence estimation. It confirms that Australian doctors are seeing affected women with complications of the procedures and readers will agree that all medical practitioners should be aware of the problems, anatomical and psychological, that these women may experience. If we also recognize and understand some of the cultural complexities around the issue, we will be better able to provide appropriate responsive health care. This will support prevention by building trust in our services and in the health messages we provide about harmful effects of the practices. It will also assist community development and education, which includes efforts to find ways to retain the ceremonies and rituals associated with the maturing of girls while eradicating the harmful practices which have traditionally accompanied them. Readers seeking further information about the practices and health care needs are referred to Female genital mutilation: information for Australian health 1. Registrar in Obstetrics and Gynaecology. 2. Director, Division of Community Health Services, 3. Senior Consultant Obstetrician. Address for correspondence: Dr Rachael Knight, 132 Grattan Street, Carlton, Victoria, 3053.

RACHAEL KNIGHT ET AI. 51 professionals, available free of charge on written application to FGM booklet request, RACOG, 254-260 Albert Street, East Melbourne, 3002. More personal accounts are included in the biography of Aman(A) and in Alice Walker s novel(b). (A)Aman. The story of a Somali Girl by Aman as told to Virginia Lee Barnes and Janice Boddy. Bloomsbury Publishing Plc London; 1995. (B) Walker A. Possessing the Secret of Joy. Harcourt Brace Jovanovich, New York; 1992. Summary: This study was performed to improve our knowledge and understanding of the needs of women affected by female genital mutilation. We looked at the types of complications of these practices which present to a large metropolitan women s hospital in order to determine how we can appropriately treat and support affected women. This was an observational study of women from countries with a high prevalence of female genital mutilation who presented to the Royal Women s Hospital between October, 1995 and January, 1997. Fifty one patients with a past history of female genital mutilation who were attending the hospital for antenatal or gynaecological care consented to participate in the study. We found that 77.6% of women identified as having had female genital mutilation had undergone infibulation. More than 85% of the women in our study reported a complication of the procedure. The major complications were dyspareunia, apareunia and urinary tract infections; 29.4% of these women required surgery to facilitate intercourse. In our study group there was no difference in Caesarean section rates between the women who had previously delivered in Australia compared with those who had delivered in Africa. Women who have had a female genital mutilation procedure have specific needs for their care which present challenges to both their general practitioners and obstetriciadgynaecologists. These women have significant complications related to their procedure including social and psychosexual problems which require sympathetic management. This study arose in the context of changing immigration patterns leading to an increase in the number of women from Africa attending the Royal Women s Hospital, many of whom had a history of female genital mutilation. The World Health Organization s terminology female genital mutilation (table 1) is preferred to the almost always anatomically incorrect female circumcision, while recognizing that suitable terms which avoid offence should be used in consultation (1). This term refers to procedures which range from incision of the clitoral foreskin to excision of the clitoris, labia minora, parts of the labia majora, and infibulation which refers to suturing or otherwise securing the vulva in the midline. Another reason for the study was the increasing number of women presenting to the hospital with complications of female genital mutilation including sexual dysfunction and problems during labour and delivery. Recent publicity in both the popular and scientific press has resulted in increased awareness of potential problems associated with genital mutilation but has also concentrated on the rarer and more severe complications. Female genital mutilation is an old tradition dated as early as 2400 BC and practised most commonly in parts of Africa, but also in a variety of Middle Eastern, Asian and South American countries. It is estimated that 130 million women worldwide have had a genital mutilation procedure (2). The justifications given for female genital mutilation are supported by a variety of rationales including tradition, personal hygiene, protection of a woman s and thus her family s honour, preservation of virginity and religion. Although practised commonly in some Muslim countries, female genital mutilation has also been practised by Christians and Jews (3). Many Muslim countries do not practise female genital mutilation at all. It has also been used as medical treatment for nymphomania and compulsive masturbation (3). Information from the Department of Immigration regarding patterns of immigration from countries with a high prevalence of female genital mutilation indicate that the number of people from these countries in Australia has increased in all States over the past 10 years (4). Thus the number of women with complications related to female genital mutilation presenting in general and obstetric practice can be expected to increase. METHODS Women from countries with a high prevalence of female genital mutilation were identified when attending antenatal outpatient clinics at the Royal

~~ ~~~~~~~~~~~ 52 ALJST AND NZ JOURKAL OF OBSTETRICS AND GYNAECOLOGY Women s Hospital between October, 1995 and January, 1997. Women attending the gynaecology clinics for problems directly related to female genital mutilation were not included. Women were informed of the study and consent was obtained. Patients were asked a set of standard questions about the procedure they had undergone, complications relating to the procedure and details of past obstetric history. All complications were self-reported; there was no microbiological confirmation of vaginal or urinary tract infections. Each patient also had a gynaecological examination which included assessment of introital size, and speculum and vaginal examination were performed where possible and appropriate. The total number of patients identified was 62; 11 patients refused to participate, the reason given in 10 being that they did not wish to discuss such a sensitive topic, while the other woman did not want to have an examination. This left a total of 51 patients with completed questionnaires and examination findings. RESULTS The average age of these women at presentation to the Royal Women s Hospital was 25.3 years. The average age of genital mutilation was 6 years, with a range of 1-14 years, and the average age when childbearing commenced was 21.6 years. Of these women 37 (72.6%) were from Somalia, 9 (17.6%) from Ethiopia, 4 (7.8%) from Eritrea and 1 (2%) was from Djibouti. The procedure had been done by a traditional midwife who was an older and respected female from the village in 60.8% of cases and a doctor in 39.2%. No anaesthetic was used in 51%, local analgesia only in 33.3% and general anaesthesia in 7.8%; 7.8% of the women could not remember any details of the procedure and the type of anaesthetic was unknown. Table 1 summarizes the World Health Organization classification of female genital mutilation which we used in our study. Table 1. World Health Organization Classification of Female Genital Mutilation Type 1. Excision of the prepuce +/- excision of the clitoris Type 2. Excision of the clitoris and partial or total excision of the labia minora Type 3. Excision of part or all of the external genitalia and infibulation Type 4. Unclassified (This includes: pricking, piercing, incision, stretching and the introduction of corrosive substances into the vagina) Table 2 outlines the distribution of the types of female genital mutilation in our series and illustrates that types of female genital mutilation differed according to the country of origin. Procedures such as clitoridectomy and excision of the labia minora were more common in the women from Ethiopia and infibulation was more common in those from Somalia. Table 2. Distribution of Types of Female Genital Mutilation in Our Study Sample Total Somalia EthiopiaEritrea Djibouti (n = 51) (n = 37) (n = 13) (n = 1) No visible procedure 2% 2.7% 0 0 Type 1 6% 0 23.0% 0 5Pe 2 14.3% 8.1% 38.5% 0 Type 3 11.6% 89.2% 38.5% 100% Type 4 0 0 0 0 The estimation of introital size in mulliparas was made by the practitioner performing the examination and the results are shown in table 3. The frequencies of complications reported are shown in table 4. The obstetric outcomes of the 27 multigravidas were analysed retrospectively for those who had previously delivered in Africa and Australia. The number having normal deliveries was greater in Africa, (12 of 14, 85.7%), compared with those who had delivered in Australia (7 of 13, 53.8%) although a further 4 (30.8%) had been delivered vaginally with forceps. The number of Caesarean sections was the same in the 2 groups with 2 Caesarean sections having been performed in each. Table 3. Distribution of Size of Introitus in Nulliparas Size of Introitus Number % 10 mm or less 11-19 mm 20 mm or more Table 4. Complications of Female Genital Mutilation Number % Dyspareunia 39 16.5 Apareunia 8 11.7 Surgery required before intercourse 15 29.4 Dysmenorrhoea 8 15.1 Urinary tract infection 14 27.5 Recurrent urinary tract infections 1 1.9 Vaginal infection 4 7.8 DISCUSSION Female genital mutilation procedures are commonly performed in as many as 28 African countries, parts of the Middle East, Asia, India and many other places worldwide. Our study identified

~ ~~~ RACHAEL KNIGHT ET AL 53 cases of genital mutilation only in women whose country of origin was Somalia, Ethiopia, Entrea or Djibouti where the prevalence of female genital mutilation is estimated at greater than 80%. The type of female genital mutilation varied with country of origin. Case reports and studies based on women presenting with complications of female genital mutilation will give a biased impression of the impact this practice has on women s health, sexuality and reproductive function. We attempted to avoid this bias by interviewing women who had immigrated from relevant countries when they attended our general antenatal clinics. Over the period from 1985-1996 a total of 7,584 migrants from African countries known to practise female genital mutilation entered Australia. The annual numbers increased 10-fold between 1985 and 1996. The proportion of immigrants per State are shown in table 5; larger numbers entered Victoria, New South Wales and Western Australia, however all States have a significant number of women from these areas and the size of these communities can be expected to increase (4). Accordingly any medical practitioner in Australia may see a patient who has undergone a genital mutilation procedure. We found a high rate of infibulation among the women identified in our study. Previous reports of obstetric complications in women with female genital mutilation have been associated with a narrow scarred introitus (3,5). Reported complications include vaginal and perineal tears, vesicovaginal fistula formation, prolonged labour and increased rates of delivery by forceps and Caesarean section. Table 5. Immigrants to Australia from Countries with a High Prevalence of Female Genital Mutilation (1985-1996) Intended State of residence Total number of immigrants New South Wales 1,888 Victoria 3,598 Western Australia 1,219 Queensland South Australia Tasmania Northern Temtory Australian Caoital Territorv 145 241 87 135 355 More than half of the women in our study who had not had children had an introitus measuring less than 10 mm. As the skin margins following infibulation are usually smooth, as distinct to the irregular but distensible hymen, measurement of diameter is likely to give an indication of coital function. A size of less than 20 mm usually correlates with difficulty in undertaking a vaginal examination. The high rates of dyspareunia and apareunia in this study are consistent with previous reports (6). Surgery was required for normal sexual function in a large proportion of the women in our study. The rate of dyspareunia reported in the general population is 10% compared with 76% in our study group (7). The rates of vaginal infection and dysmenorrhoea are not significantly greater than in previously published studies where the incidence of infective vaginitis has been reported to be between 10 and 25% (8) and the incidence of dysmenorrhoea as high as 40% (9). The rate of urinary tract infections in our study (27.5%) is higher than previously reported incidences of 2-10% (lo), but may reflect prevalence, self-reporting and nonconfirmed urinary symptoms. Our recommendations are that women with a genital mutilation or related procedure should be assessed thoroughly at first presentation or when rapport is established to assess any complications both past and present and to determine and document the extent of the past surgery. Counselling and further management can then be arranged if necessary. Further management may consist of a reversal of infibulation procedure which can be done simply as a day case under general anaesthesia as a treatment for dyspareunia or apareunia or as preparation for childbirth (1,6). There are particular antenatal management considerations. As previous studies have reported obstetric complications such as obstructed labour, fetal distress, perineal, vaginal, rectal and urethral injuries, haemorrhage, infection, fistula and incontinence of faeces and urine it is recommended that a thorough assessment of vaginal and vulva1 scarring should be made. Women who have had infibulation should be considered for release of the fused labia electively. Knowledge of the procedure can lead to antenatal discussions regarding the timing of the division. This can be done in the second or third trimesters or when the patient presents in early labour. Among the multigravidas in our study there was no difference in past obstetric outcomes according to place of delivery. Once the female genital mutilation procedure has been managed appropriately these women probably have no difference in outcome obstetrically to the general population. Further data are required to confirm this statement. The findings from this study are that women with a history of female genital mutilation may have specific medical needs and the majority in the population studied suffered complications. It is important that female genital mutilation-related problems be considered in the broader perspective of the other psychosocial issues that confront new immigrants particularly from a country with overwhelming social disruption. While this study did not specifically address these issues, the fact that 16% of women

54 AUST AND NZ JOURNAL OF OBSTETRICS AND GYNAECOLOGY approached were not prepared to participate highlights the sensitive and complex nature of female genital mutilation. We recommend that all practitioners be aware of and sensitive to the cultural and social background of these patients in addition to the potential complications of the procedure which they may have experienced. 4. Department of Immigration and Multicultural Affairs, Settler Arrival 1995-1996. Statistical report no. 22. Canberra, 1997. 5. Shandall AA. Circumcision and infibulation of females. Sudan Med J 1967; 5: 178. Summarized and Discussed in Obstet Gynecol Sum 1968; 23: 1084-1087. 6. Erian MMS, Goh JTW. Female circumcision. Aust NZ J Obstet Gynaecol 1995; 35: 83-85. 7. Pauly IB, Goldstein SG. The prevalence of significant sexual problems in medical practice. Medical Aspects of Human Sexuality, 1970; 4: 48-63. References 8. Thomason JL. Gelbart SM, Scaglione NJ. Bacterial vaginosis: 1. Gilbert E, ed. Female genital mutilation: information for Current review with indications for asymptomatic therapy. Australian health professionals. Melbourne: The Royal Australian College of Obstetricians and Gynaecologists, 1997. Am J Obstet Gynecol 1991; 165: 1210-1217. 2. World Health Organization. Female genital mutilation: a joint 9. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, WHO/UNICEF/UNFPA statement. Geneva: World Health dyspareunia, pelvic pain, and irritable bowel syndrome in Organization, 1997. primary care practices. Obstet Gynecol 1996; 87: 55-58. 3. Cutner LP. Female genital mutilation. Obstet Gvnecol Sum 10. Cunningham FG, Urinary tract infections complicating 1985; 40: 437-443. - pregnancy. Bailliere s Clin Obstet Gynaecol 1987; 1: 891-908. Aust NZ J Obstet Gynaecol 1999; 39: I: 54 The Introduction of a Woman-Held Record into a Hospital Antenatal Clinic: The Bring Your Own Records Study Caroline S.E. CM MN, Gregory K. Davi~~,~ MD FRACOG and Louise S. Everitt3. CM Grad Dip Com Hlth Midwifery Practice and Research Centre, Family Health Research Unit4 and Department of Obstetrics and Gynaecolog$, St George Hospital, New South Wales Summary: We report the introduction of a woman-held record into an antenatal clinic in a NSW teaching hospital using a randomized controlled trial. In 1997, 150 women were randomized to either retaining their entire antenatal record through pregnancy (women-held group) or to holding a small, abbreviated card, as was standard practice (control group). A questionnaire was distributed to women to measure send of control, involvement in care and levels of communication. Availability of records at antenatal visits was also measured. Women in both groups were satisfied with their allocated method of record keeping, however, those in the women-held group were significantly more likely to report feeling in control during pregnancy. Women in the control group were more likely to feel anxious and helpless and less likely to have information on their records explained to them by their caregiver. The number of records available at each clinic was similar in both groups. Successive reports on maternity services in the United Kingdom and Australia (1-3) have concluded that pregnant women want more choice and control over their care during pregnancy and labour. A 1. Research Midwife. 2. Staff Specialist. 3. Clinical Midwifery Consultant. Address for correspondence: Caroline Homer, Family Health Research Unit, St George Hospital, Gray Street, Kogarah, New South Wales 2217. woman-held antenatal record is one method proposed to help meet these needs. By carrying their own records, women are able to absorb information at their leisure, the results of investigations are readily available and these can be shared with partners, who may not be able to attend antenatal visits. A number of studies have provided support for the introduction of a system where the woman holds the only record generated (4-7). In conventional antenatal clinics, clerical staff retrieve the antenatal records at each hospital visit. The woman keeps a small card, a cooperation card,