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Abstract
Background:
Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal.
Objectives:
We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision.
Methods:
This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method.
Results:
There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor’s choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals’ awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families.
Limitations:
Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation.
Conclusions:
In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision.
Future work:
Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services.
Trial registration:
Current Controlled Trials ISRCTN14710507.
Funding:
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.
Plain language summary
Female genital mutilation (or cutting) involves changing or removing parts of a girl’s or woman’s genitalia when there is no medical reason to do so. Many women and girls who have been cut live in the United Kingdom, where female genital mutilation is illegal. Some girls and women who have been cut experience problems in getting pregnant and having their baby. There are four types of cutting. Type 3 involves cutting and sewing together the genitalia, leaving only a small hole. Women and girls with type 3 mutilation can have a small operation to open their vagina. We do not know when the best time is to have this operation. We would also like to know more about how NHS female genital mutilation services can best help women.
To answer these questions, we talked to 141 people, who were women who have been cut, men and health-care professionals. They told us that there is no ideal time to have the operation. Women who have been cut would like the operation before they get pregnant, but health-care professionals would like women to have it during their pregnancy. Men were not sure when it should happen. They all agreed that the operation should take place in a hospital and be carried out by a skilled professional.
The way that we support women and men could be better and we need to improve the help that is offered. Sometimes women and men did not know where to go for help or how to ask for help. Women, men and health-care professionals sometimes found it hard to talk about cutting. Some health professionals did not have the right skills to undertake the operation. They told us that they need more training and clearer guidance to ensure that women feel cared for and safe.
Contents
- Scientific summary
- Chapter 1. Introduction and background context
- Chapter 2. Methodology and methods
- Chapter 3. Results: themes
- Chapter 4. Results: silences
- Chapter 5. Discussion, implications and recommendations
- Chapter 6. Conclusions
- Acknowledgements
- References
- Appendix 1. The hybrid framework method stage alignment
- Appendix 2. Overview and alignment of themes and silences
- Appendix 3. Exploration of quantitative and qualitative data sets
- Glossary
- List of abbreviations
About the Series
Declared competing interests of authors: Kate Jolly is part funded by National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands and is a subpanel chairperson of the NIHR Programme Grants for Applied Health Research programme.
Disclaimer: This report contains transcripts of interviews conducted in the course of the research and contains language that may offend some readers.
Article history
The research reported in this issue of the journal was funded by the HTA programme as project number 16/78/04. The contractual start date was in May 2018. The draft report began editorial review in November 2020 and was accepted for publication in May 2021. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
Last reviewed: November 2020; Accepted: May 2021.
- NLM CatalogRelated NLM Catalog Entries
- Preferences for deinfibulation (opening) surgery and female genital mutilation service provision: A qualitative study.[BJOG. 2023]Preferences for deinfibulation (opening) surgery and female genital mutilation service provision: A qualitative study.Jones LL, Costello BD, Danks E, Jolly K, Cross-Sudworth F, Byrne A, Fassam-Wright M, Latthe P, Clarke J, Adbi A, et al. BJOG. 2023 Apr; 130(5):531-540. Epub 2022 Dec 26.
- Exploring the views of female genital mutilation survivors, their male partners and healthcare professionals on the timing of deinfibulation surgery and NHS FGM care provision (the FGM Sister Study): protocol for a qualitative study.[BMJ Open. 2019]Exploring the views of female genital mutilation survivors, their male partners and healthcare professionals on the timing of deinfibulation surgery and NHS FGM care provision (the FGM Sister Study): protocol for a qualitative study.Jones L, Danks E, Clarke J, Alidu L, Costello B, Jolly K, Byrne A, Fassam-Wright M, Latthe P, Taylor J. BMJ Open. 2019 Oct 17; 9(10):e034140. Epub 2019 Oct 17.
- Review Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews[ 2019]Review Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviewsEvans C, Tweheyo R, McGarry J, Eldridge J, Albert J, Nkoyo V, Higginbottom G. 2019 Sep
- A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England.[BMJ Open. 2016]A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England.Moxey JM, Jones LL. BMJ Open. 2016 Jan 7; 6(1):e009846. Epub 2016 Jan 7.
- Review Woman and girl-centred care for those affected by female genital mutilation: a scoping review of provider tools and guidelines.[Reprod Health. 2022]Review Woman and girl-centred care for those affected by female genital mutilation: a scoping review of provider tools and guidelines.Dawson A, Assifi A, Turkmani S. Reprod Health. 2022 Feb 22; 19(1):50. Epub 2022 Feb 22.
- Views of female genital mutilation survivors, men and health-care professionals ...Views of female genital mutilation survivors, men and health-care professionals on timing of deinfibulation surgery and NHS service provision: qualitative FGM Sister Study
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