Female genital cutting (FGC) & cervical : A guide for practitioners

WHAT IS FEMALE PERCENTAGE OF GIRLS AND WOMEN AGED 15 TO 49 YEARS WHO HAVE UNDERGONE FGM/C GENITAL CUTTING? 90-100% SOMALIA, GUINEA, 60-70% MAURITANIA 20-30% NIGERIA, SENEGAL, CENTRAL The World Health Organization DJIBOUTI, SIERRA LEONE AFRICAN REPUBLIC, KENYA defines female genital cutting 50-60% LIBERIA 80-90% MALI, EGYPT, SUDAN, ERITREA 10-20% YEMEN, UNITED REPUBLIC (FGC) as ‘all procedures that 40-50% GUINEA-BISSAU, CHAD OF TANZANIA 70-80% BURKINA FASO, GAMBIA, include partial or total removal 30-40% CÔTE D’IVOIRE of female genital organs or other ETHIOPIA 0-10% BENIN, IRAQ, TOGO, GHANA, injury to female genital organs for NIGER, CAMEROON, UGANDA non-medical reasons’. SOURCE: UNICEF global databases 2016, based on DHS, MICS and other nationally representative surveys ‘Female genital mutilation’ is the term used in Australian and TYPES OF FGC Victorian legislation, but the TYPE I Partial or total removal of the clitoris and/or prepuce. A. Prepuce removal only or preferred way to refer to the B. Prepuce practice using culturally sensitive removal and partial or total language is ‘female circumcision’ removal or ‘traditional cutting’. of the clitoris The practice is referred to as FGC throughout this document. TYPE II Partial or total removal of the clitoris and labia minora, with or EXCISION without excision of labia majora Removal of the The age at which circumcision clitoris plus part or all of the labia occurs varies from infancy to minora 15 years.

TYPE III Narrowing of vaginal orifice with creation of a covering seal by cutting Removal of part or all of the labia INFIBULATION and appositioning labia minora and/or labia majora, with or without minora, with the excision of the clitoris. labia majora sewn together, covering the urethra and and *DISCLAIMER; THESE PICTURES ARE leaving a small NOT REPRESENTATIVE AND CAN VARY. hole for urine and DRAWN IMAGES ARE FROM THE ‘CARE menstrual fluid PLAN FLOW CHART’ FAMILY PLANNING VICTORIA, 2012. TYPE IV All other harmful procedures, including pricking, piercing, incising. POSSIBLE HEALTH IMPLICATIONS HOW TO ASK ABOUT FGC? Metropolitan services for referral for women who Short term Long term › As a health practitioner you will need to use your judgement and experience to determine if and when to ask about FGC. have undergone type III › Severe pain › Reproductive tract › Difficulty in › While the practice of FGC may conflict with your own value infection undergoing cervical Royal Women’s Hospital › Excessive bleeding system, it is important for you not to show judgement in your › screening African Women’s Clinic › Shock Complication words or reactions. Do not use the term ‘mutilation’ or make during pregnancy › Scarring comparisons to ‘normal’ genitals. 20 Flemington Road, Parkville › Psychological and childbirth trauma › Sexual Telephone 8345 3037 or › Infertility complications 1800 442 007 (rural callers) › Infection SAMPLE QUESTIONS › Painful period › Urinary retention 1 Which country were you born in? Mercy Hospital for Women › Psychological › Death issues e.g. Cross check her country of origin with the prevalence of the Well Women’s Clinic depression/PTSD practice in her country. 163 Studley Road, Heidelberg

2 I understand that traditional cutting is a common practice in Telephone 8458 4880 your country, would you mind if I asked you if you have been circumcised or have had traditional cutting? It is important for Supporting women who have undergone FGC to have me to know before I examine you. a cervical screen Some women don’t know if they have been circumcised and when › If the woman discloses FGC during her preliminary appointment, it may have occurred. in order to build rapport and her trust, you may need to offer a subsequent appointment for return consultation. 3 Have you had a cervical screening test before? FURTHER READING The national education toolkit › Reassure the woman that the consultation is private and 4 Have you ever had an uncomfortable cervical screening for female genital mutilation/ confidential. experience in the past? If so, it may be helpful to let me know cutting awareness: › Use simple English to explain the importance of cervical why this was difficult for you? www.netfa.com.au screening and its purpose. 5 I will need to look at you then I can make a decision if I can do › Arrange for a female interpreter if required. the cervical screening test. THIS RESOURCE HAS › Let the woman know she can bring a friend or relative with her You will need to assess the level of difficulty performing the test; if BEEN DEVELOPED VIA A to the appointment. you are in doubt please don’t continue and refer her to a specialist hospital. COLLABORATION WITH CANCER › Encourage the woman to ask questions. COUNCIL VICTORIA AND WOMEN’S HEALTH WEST FARREP › Remind the woman she can stop the test at any time. Clinical considerations PROGRAM › Instruct the woman on calming and deep breathing techniques to help her relax. › Medium-sized Pederson speculum is the preferred option › Offer the woman written information in her language. › Select the most appropriate position for examination › Application of lubrication on the speculum edges may be useful JUNE 2017