From the Journals

AAP report aims to educate providers on female genital mutilation/cutting


 

FROM PEDIATRICS

Although female genital mutilation or cutting (FGM/C) is outlawed in much of the world, it still occurs for cultural reasons despite having no medical benefit, according to a clinical report from the American Academy of Pediatrics.

FGM/C is mainly performed on children and adolescents, but most of the research and teaching to date has addressed the impact of FGM/C on women of childbearing age and management during pregnancy and post partum, wrote Janine Young, MD, of the University of Colorado Denver in Aurora and colleagues. They are members of the AAP section on global health, committee on medical liability and risk management, or the committee on bioethics.

Published in Pediatrics, the report provides “the first comprehensive summary of FGM/C in children and includes education regarding a standard-of-care approach for examination of external female genitalia at all health supervision examinations, diagnosis, complications, management, treatment, culturally sensitive discussion and counseling approaches, and legal and ethical considerations,” they wrote.

The World Health Organization categorizes FGM/C into four subtypes. “Type I includes cutting of the glans or part of the body of the clitoris and/or prepuce; type II includes excision of the clitoris and labia minora, with or without excision of the labia majora; type III, infibulation, includes cutting and apposing the labia minora and/or majora over the urethral meatus and vaginal opening to significantly narrow it and may include clitoral excision; and type IV includes piercing, scraping, nicking, stretching, or otherwise injuring the external female genitalia without removing any genital tissue and includes practices that do not fall into the other three categories,” the authors wrote. Of these, type III is associated with the greatest long-term morbidity.

Data suggest that the prevalence and type of FGM/C varies by region, with the highest prevalence of type III in East Africa, where 82%-99% of girls reported FGM/C and 34%-79% of these cases involved type III, the authors reported.

Generally, pediatric health care providers in the United States have limited knowledge of FGM/C in the absence of any required courses on diagnosis or treatment for most primary care specialties. However, clinicians should be aware of possible risk factors, including a mother or sibling with a history of FGM/C, or patients with a country of origin, birth country, or travel history to a country where FGM/C is practiced, Dr. Young and associates noted.

They recommend that an assessment of FGM/C status should be part of routine pediatric care for children with possible risk factors, but acknowledged the challenges in raising the topic and addressing it in a culturally sensitive way. “Experts suggest that health care providers ask the patient or parent the term they use to name female genital cutting” and avoid the term mutilation, which may be offensive or misunderstood.

Many girls who have undergone FGM/C were too young to remember, the authors note. “Instead, it is advisable that the FGM/C clinical history taking include both the girl and parent or guardian once rapport has been established.”

Review potential medical complications if FGM/C is identified, and plans should be made for follow-up visits to monitor development of complications, the authors said. In addition, engage in a culturally sensitive discussion with teenagers, who may or may not have known about their FGM/C. In some cases, parents and caregivers may not have known about the FGM/C, which may be a community practice in some cultures with decisions made by other family members or authority figures.

“It is important for health care providers to assess each patient individually and make no assumptions about her and her parents’ beliefs regarding FGM/C,” Dr. Young and associates emphasized. “Mothers and fathers may or may not hold discordant views about FGM/C, and some clinical experts suggest that mothers who have themselves undergone FGM/C may nonetheless oppose subjecting their daughters to this practice. Instead, treating patients and caregivers with respect, sensitivity, and professionalism will encourage them to return and supports health-seeking behavior.”

The report presents 11 specific recommendations, including that health care providers should not perform any type of FGM/C and actively counsel families against such practices. In addition, children should have external genitalia checked at all health supervision examinations (with the consent of the guardian and/or child), and an assessment for FGM/C should be documented in the health records of patients with risk factors.

Notably, “[i]f genital examination findings are equivocal for the presence of FGM/C and risk factors for FGM/ C are present, a specialist trained in identification of FGM/C should be consulted,” Dr. Young and associates recommended. They also recommended defibulation for all girls and teenagers with type III FGM/C, especially for those with complications, and the procedure should be performed by an experienced pediatric gynecologist, gynecologist, urologist, or urogynecologist.

Finally, “[i]f FGM/C is suspected to have occurred in the United States, or as vacation cutting after immigration to the United States, the child should be evaluated for potential abuse. ... Expressed intention to engage in FGM/C, either in the United States or abroad, should also prompt a report to CPS [child protective services] if the child’s parent or caregiver cannot be dissuaded,” the authors wrote.

The report also includes case examples and expert analyses from legal and medical ethics experts to provide additional guidance for clinicians.

Dr. M. Susan Jay, professor of pediatrics and section chief of adolescent medicine at the Medical College of Wisconsin and program director of adolescent health and medicine at Children’s Hospital of Wisconsin, both in Milwaukee

Dr. M. Susan Jay

“This work seeks to educate pediatric health care providers on the occurrence of FGM/C, and the broader applications to the patients/population it impacts as well as the intersecting issues of diagnosis, complications, treatment, counseling needs, and the ethical and legal implications,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview.

However, challenges in implementing the recommendations “relate to the complexity of the issue and also the need for greater education of primary providers,” Dr. Jay said. “The overall message for providers, I believe, is a greater understanding of the practice [of FGM/C] as most providers have limited knowledge of this practice in the United States.”

“I believe the case-based presentations allow for a better understanding of how best to approach patients and families,” she added.

Dr. Kelly Curran, assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City

Dr. Kelly Curran

Kelly Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, said, “I think one of largest barriers to implementing the strategies [from] this report is the limited knowledge of FGM/C by most clinicians.”

“In general, many pediatricians are uncomfortable with genital examinations,” she said in an interview. “I suspect most feel uncomfortable with identifying FGM/C versus other genital pathology and may not have ready access to FGM/C experts. Additionally, having these difficult conversations with families about this sensitive topic may be challenging,” said Dr. Curran. “Fortunately, this report is incredibly comprehensive, providing extensive background into FGM/C, effectively using diagrams and pictures, and explaining the legal and ethical issues that arise in the care of these patients.”

“Ultimately, I think there will need to be more education within medical training and further research into FGM/C,” Dr. Curran added. “Clinicians should be knowledgeable about FGM/C, including prevalence, identification, health complications, and treatment, as well as legal and ethical implications.” However, “in addition to knowledge, clinicians must be able to navigate counseling patients and their families around this culturally sensitive topic.”

The report is thorough and well written, yet “there still remains significant gaps in knowledge about FGM/C in children and adolescents,” she said. “I think future research into prevalence, along with the health effects of FGM/C, including its impact on mental and sexual health, in the pediatric population will be essential.”

The study received no outside funding. Coauthor Christa Johnson-Agbakwu, MD, disclosed a grant relationship with Arizona State University from the 2018 copyright of “Female Genital Mutilation/Cutting (FGM/C): A Visual Reference and Learning Tool for Health Care Professionals.” The other researchers had no financial conflicts to disclose. Dr. Jay and Dr. Curran had no relevant financial conflicts to disclose. They are members of the Pediatric News editorial advisory board.

SOURCE: Young J et al. Pediatrics. 2020 Jul 27. doi: 10.1542/peds.2020-1012.

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