Training on female genital mutilation

Author: Robyn Byrne, a specialist nurse safeguarding children/MASH coordinator, Gloucestershire Health and Care NHS Foundation Trust.

Research summary

• The aim of this integrative literature review is to investigate whether training on female genital mutilation (FGM) for healthcare practitioners across countries in Europe, Africa, Oceania and the Americas has an impact on the safeguarding of women and girls from FGM.
• The study of FGM has wide-reaching implications for women’s health. Gender inequality and the representation of women within health research continue to be a cause for concern.
• Despite legal duties being in place, concerns remain that healthcare professionals’ knowledge of FGM and how to safeguard against it remains poor.
• Overall, the studies that included specific data about FGM training noted few participants having received education on FGM, either during their initial training or at a postgraduate level.
• A review of FGM training internationally may be beneficial in understanding the strengths and weaknesses of existing training programmes and guidance produced for governments and safeguarding partnerships on improving quality and compliance with FGM training.
• Community practitioners (CPs) should ensure that they are up to date with recommended FGM training, as well as have a good understanding of risk indicators, their legal responsibilities to report the risk of FGM in children/young people and the support services available.

Introduction

The practice of female genital mutilation (FGM) has been performed in many countries across Africa, Asia and the Middle East for centuries, becoming a deeply rooted cultural ritual (Kaplan et al, 2013). It is important to establish that FGM has no grounding in religion (Abolfotouh et al, 2015) and is not referenced in religious texts such as the Bible, the Quran or Hadith. FGM is defined as any procedure in which the female genitalia are ‘deliberately cut, injured or changed’ when there is no medical justification for doing so (NHS, 2019).

Despite the work of governments and other non-governmental organisations (NGOs) to eradicate FGM, it is estimated that there continue to be more than 3 million girls at risk globally (Weny et al, 2020). While much is known about prevalence in areas in which FGM continues to be a common practice, accurate data on prevalence in places such as Europe remains limited (De Schrijver et al, 2020). Many countries worldwide have implemented regulations for professionals, such as those in the public sector, mandating them to report cases of FGM and to protect girls deemed at risk of undergoing FGM (Johansen et al, 2018).

Consequently, it is essential for professionals to receive training on the identification, culturally competent management and legal implications of FGM (Holmes et al, 2017). Despite legal duties being in place, concerns remain that healthcare professionals’ knowledge of FGM and how to safeguard against it remains poor (Njue et al, 2019). While it could be considered the responsibility of the practitioner to be aware of their legal duties, Gonzalez-Timoneda et al (2018) note a greater need for healthcare organisations to communicate effectively with employees regarding their legal duties. This is supported by Choudhary et al (2019), who highlight the need for healthcare providers to provide education and information to professionals about their duties relating to FGM.

The aim of this integrative literature review is to investigate whether training on FGM for healthcare practitioners across countries in Europe, Africa, Oceania and the Americas has an impact on the safeguarding of women and girls from FGM.

Objectives were established prior to the commencement of the literature review. These were:

1. To examine health practitioner training on FGM from identification through to reporting; and
2. To analyse the implications of health practitioners’ levels of training for the safeguarding of women and girls.

Synthesis of collated data was undertaken to establish areas for practice improvements and developments, as well as consideration for future research. This paper was undertaken as part of a larger master’s dissertation. It presents one of the findings from this larger study, which identified further themes in relation to practitioner knowledge and management of FGM.

Methodology

A literature review methodology was selected for this study to enable a global perspective on healthcare professional knowledge of FGM, and to identify any good practice internationally, which could be implemented into policy in other countries to support the identification and management of FGM. Due to the aim to seek a global perspective on health practitioner knowledge of FGM, it was established that conducting primary research would be unlikely to achieve this aim within the scope of the study.

Additionally, as the Covid-19 pandemic continued, it was considered that responses from frontline healthcare professionals may be limited, which would in turn significantly impact the sample size and validity of a primary study.

The subject and study of FGM have wide-reaching implications for women’s health. Gender inequality and the representation of women within health research continue to be a cause for concern (Penny et al, 2014). Similarly, women across the world, including in developed nations, continue to receive poorer quality of healthcare than men (Heise et al, 2019), and this gender inequality in care often goes unnoticed (Travis et al, 2012).

With this understanding of gender inequalities in research and healthcare, it could be considered essential for researchers conducting studies that impact women’s health to ensure that their studies are free of gender bias and inequality. Although this study on health professionals’ levels of FGM training is a literature review and therefore not dealing directly with patients, the studies reviewed presented views from both male and female participants. Thus it remained essential throughout the review to maintain an awareness of gender inequalities and the importance of ensuring women are fairly represented without bias.

Ethical approval was not required for this literature review; however, it remained important for the review to be conducted in an ethical way. FGM is a sensitive and emotive subject, with many people across the world continuing to hold strong views in favour of the practice, as well as against it. It was essential within this study to ensure that the views represented within the literature were accurately and fairly presented, without bias, to ensure a true representation of health professional knowledge of FGM and the safeguarding of women and girls.

Data collection 

The initial search for literature reviewed all articles concerning healthcare professional knowledge of FGM undertaken globally. As this study was part of a larger dissertation, the search criteria were broader than just FGM training and included overall knowledge of FGM among healthcare practitioners. This study did not include any primary data collection from research participants. Therefore, there were no specific sampling techniques applied; however, each paper considered for the review was read in full to ensure the provision of adequate literature to review.

The initial search took place on the following databases via EBSCOhost, Academic Search Complete, MEDLINE, CINAHL, AOA Psycinfo, Child Development and Adolescent Studies, Criminal Justice Abstracts and APA PsycArticles. The databases were selected for their likelihood to contain studies relating to health professional knowledge on FGM, particularly across both physical health and mental health services to ensure the views were not focused solely on professionals from one aspect of the health economy.

The Boolean operators ‘OR’ and ‘AND’ were used in conjunction with the following key words; ‘female genital mutilation’, ‘FGM’, ‘knowledge’ and ‘experience’. This search returned 9640 results and so the additional more specific search terms ‘female genital cutting’, ‘healthcare professional’, ‘healthcare provider*’, ‘educat*’ and ‘train*’ were added, which reduced the results to 526. An additional search using the Google Scholar database was undertaken using the same search terms and Boolean operators, and this search returned 2470 results in total.

The inclusion criteria for this review were initially established as primary studies of healthcare professional knowledge of FGM published between 2016 and 2022 in English. These criteria included multiple papers from North America, Africa and the Middle East. However, to ensure representation of data from Europe and Oceania, the inclusion criteria were expanded to include studies published between 2013 and 2022, which allowed for the inclusion of studies from these areas.

FGM is prevalent in many countries across the globe and literature on FGM knowledge is likely to be published in multiple languages. The author of this review does not have a second language, therefore all papers not written in English would require translation and so were excluded from this review. Of the 22 fulfilling the inclusion criteria, two were excluded during the appraisal of the literature. This was due to incomplete information on data collection and data analysis procedures within each of the papers, leading to difficulties in establishing the quality of the papers.

Data analysis

Prior to the commencement of thematic analysis, each of the papers was critiqued to ensure its quality using a recognised assessment tool. A total of 20 papers met the inclusion criteria and were deemed to be of acceptable quality following appraisal; these were then reviewed to identify themes. These papers were a mix of quantitative, qualitative and mixed-methods research.

A methodical process was used to identify key themes within the papers, highlighting them in identified colours and transcribing these into a table of themes. Initially, six themes were identified:

• Knowledge and training
• Identification of FGM
• Understanding risk factors and complications
• Understanding of response to FGM and the law
• Attitudes of healthcare professionals
• Culturally sensitive care.

To ensure depth of analysis, these six themes were merged and condensed into three key themes:

• Knowledge, training and identification
• Understanding of response to FGM and the law
• Attitudes, opinions and culturally sensitive care.

For the purpose of this paper, only the theme of training will be further discussed, and not all 20 papers will be referenced (see Table 1).

It is important to acknowledge that bias can be introduced at any time during research and review processes (Noble and Smith, 2014). It is essential, therefore, that authors of research and reviews are open to looking at the literature constructively and consider opposing views (Kiteley and Stogdon, 2014). When undertaking the thematic analysis for this literature review, it was important to consider both positive and negative aspects of the findings, and to view all the data rather than simply considering data favourable to the author’s experiences and perspectives.

Discussion 

Engagement with ongoing education and training is an important aspect of healthcare practice to ensure compliance with changes to policy and procedure (Pool et al, 2013). In the UK, it is mandatory for healthcare staff to complete safeguarding training and for NHS trusts to ensure compliance with this training (Fleming, 2015). In many NHS trusts, this mandatory safeguarding training includes advice and guidance about FGM, while in others FGM training is obtained separately through local safeguarding partnerships. WHO has highlighted the need for improvements to FGM training for healthcare practitioners (WHO, 2001). All the studies included in this literature review were conducted after the recommendation by WHO for improvements to FGM training for healthcare professionals.

Overall, the studies that included specific data about FGM training noted few participants having received education on FGM, either during their initial training or at a postgraduate level. The lowest level of training was observed by Relph et al (2013), where no participating medical students had received training on FGM; the paper does not detail levels of training received by other professional groups surveyed.

Similarly, a further six studies also specifically noted poor levels of training received by healthcare practitioners: between 5% and 29% of participants reported that they had received training (Molina-Gallego et al, 2021; Young et al, 2020; Calvert et al, 2020; Castle et al, 2018; Gonzalez-Timoneda et al, 2018; Jackson, 2017; Sureshkumar et al, 2016).

Two further studies noted that most of their participants had not received formal training in FGM: 68.8% in the study undertaken by Cappon et al (2015) and 66% in the study by Akinsulure-Smith et al (2021). Similar results were noted by Deane et al (2022), who found that 90% of respondents felt more training was required to support them in the delivery of care to women and girls with FGM.

Donnenwirth et al (2021) surveyed whether schools of nursing in the US included FGM as part of their curriculum; only 37% of the responding schools of nursing did. It is important to note that none of the studies included in this review found a majority of participants stating that they had received training on FGM.

These studies provided a perspective of practitioners across the health economy, including doctors, nurses, midwives and mental health practitioners from the Americas, Europe, Africa and Australia. It could therefore be interpreted that the findings provide a global picture of limited or poor-quality FGM training delivered to healthcare practitioners. Similar data was noted in an earlier literature review by Zurynski et al (2015), which found low levels of training across participants in the studies reviewed. As it pertains to safeguarding, limited training received by healthcare practitioners is likely to impact the practitioner’s ability to recognise FGM and those at risk of undergoing FGM, and to respond effectively when safeguarding protocols need to be initiated. This is supported by Simpson et al (2012) and Rose (2019), who highlight the importance of training for healthcare practitioners to ensure that women and girls are safeguarded from FGM. It could be concluded from the data presented within the included studies that a review of FGM training internationally may be beneficial in understanding the strengths and weaknesses of existing training programmes and guidance produced for governments and safeguarding partnerships on improving quality and compliance with FGM training.

Conclusion 

This review aimed to establish whether levels of FGM training are impacting the safeguarding of women and girls from FGM across the whole spectrum of risk, from identification before it occurs to response when it has already occurred. The studies included identified that the overall level of training was poor across all geographical regions and healthcare professions included in this study. This review suggests that there may be a systemically low level of training on FGM internationally, which could be impacting practitioners’ ability to safeguard effectively.

Recommendations for future research 

This review has identified areas in which future research may be beneficial in supporting better overall knowledge of FGM, as well as clinical practice. Further research to understand the types and quality of FGM training provided across the globe may be beneficial in identifying good practice, as well as identifying gaps in training that need improvement. This may also support the development of training programmes to enable better healthcare practitioner knowledge of FGM.

Recommendations for future practice 

Globally, there appear to be low levels of training on FGM received by healthcare practitioners. The overall recommendation for practice following this review would be for considering the development and implementation of comprehensive and robust training packages for staff. These packages should include the following: detailed information on the identification of FGM, including classification and possible variations; risk indicators for practitioners to identify those at risk of FGM; and detailed descriptions of local FGM laws and the expected responses from practitioners where FGM risk is identified.

In the UK, this training should be delivered to all healthcare practitioners who work clinically with patients, such as specialist community public health nurses, GPs, midwives and those who may encounter at-risk women and girls in non-clinical roles such as specialist safeguarding teams. It could be considered that enhancing the quality and quantity of FGM training delivery may be the most effective way to enhance practitioner knowledge and make the safeguarding of women and girls at risk of FGM more effective.

Implications for community practitioners

CPs such as community nurses and specialist community public health nurses may be well placed to identify risk factors for those at risk of FGM or who may have undergone FGM previously. These CPs may often be the first health practitioner someone encounters when they have a health issue or concern, and as such may be the first practitioner to identify these concerns. It could therefore be considered pertinent that CPs ensure that they are up to date with recommended FGM training, as well as have a good understanding of risk indicators, their legal responsibilities to report the risk of FGM in children/young people and the support services available.