also see:
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Introduction
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In their approach to clinical care, health professionals should:
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- Aim to provide holistic care with attention to psychosocial factors in a culturally sensitive non-judgmental manner
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| - Be aware of communities who may practice FGM , whilst making no assumptions on the basis of country of origin, race or religion
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| - Be aware of the practices which constitute FGM, their background and their consequences including medical, social and psychological aspects.
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| - Be aware of the influence of the Australian context including experiences relating to immigration
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| - Be aware of likely divergence between expectations and functioning of the health care system; explanation of the system is likely to be necessary
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| - Be aware of, and deal with, provider's own feelings and responses
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| - Involve interpreters if possible/appropriate
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| - Understand that husbands may play an important role in decision making: explore and respect the women's wishes
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| - Use terminology which is acceptable to the women and which avoids censuring the practices
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| - Respect difficulties in the discussion of intimate matters, and take time to develop a trusting professional relationship
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| - Explain and illustrate normal anatomy and the women's own situation according to her needs and wishes
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| - Explain reasons for examinations and procedures
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| - Document findings in detail to minimise need for repeat examinations As so that future difficulties such as catheterisation problems may be anticipated and planned for
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| - Be aware that pelvic examination may be difficult, painful or impossible and do not persevere if unduly uncomfortable/painful: careful angulation of instruments and one finger examination may be necessary
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Guide to asking women whether they have had genital surgery
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As with all maternity and gynaecology patients, women affected by FGM need to be accurately assessed with regard to their physical and social needs to ensure effective care.
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All women presenting in the Assessment Clinic can be asked whether they have had genital surgery as part of their medical assessment. This provides:
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- Accurate assessment of clinical needs
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| - Needs to be asked as a part of an overall medical and obstetric history
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| | - To entrench the question as part of routine assessment
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| - Enables Health professionals to develop critical pathways for care
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| - Enables women to develop birth plans
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| - Opens up avenues for negotiation re deinfibulation and resuturing
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| - Enhances opportunities for health promotion and information exchange
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| - Alerts health workers to women's needs for health education and counselling
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| - Raises opportunities for health professionals to reflect on practice, and professional learning needs
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Assessment:
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It is appropriate for the woman to be asked the question about her FGM status by a midwife or doctor in the assessment clinic. Should the woman require a physical assessment to confirm the nature and extent of ritual surgery, it would be appropriate for the examination to be carried out by the FGM liaison Officer for that ward or clinic area, or by a senior Medical Officer or midwife experienced in the care of women affected by FGM.
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The type of FGM should be documented clearly in the antenatal notes, using diagrams as necessary. Although many women and their partners prefer a female doctor to examine them, it is usually possible for consent to be gained for a male practitioner to attend them , so long as this is negotiated , using an interpreter as necessary. If this is not possible at the assessment visit, a further appointment will be necessary.
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Using Culturally Sensitive Language
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In our Western context, the language used to describe FGM or circumcision is complex. In line with WHO guidelines, the term "Female Genital Mutilation" is used by practitioners in Australia, particularly in the policy and Public Health arenas. It is a term used to emphasise the mutilating nature of the practice, as part of a worldwide campaign to eliminate the procedure.
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However, most women from affected communities would understand that the intent of their mothers and female relatives would have not been to mutilate, but to enhance their daughter's opportunities for marriage and economic security, and success in the world. Different communities may use different descriptors, therefore it is essential that health practitioners explore sensitively with clients the terminology that they understand, and are comfortable with.
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Terms that women may use include circumcision, cutting, traditional female cutting or surgery, or sunna. An interpreter or FARREP worker may be able to assist in finding a mutually meaningful term.
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There may be some anxiety amongst workers about:
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- who should be asked about genital surgery,
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- who should ask the question
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- how it should be asked without causing offence.
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The available literature, and comments from women interviewed in the Women's Individual Needs Project suggests that women affected by FGM prefer their status to be known to clinicians, to enable them to plan for antenatal care and delivery in conjunction with health care workers. They also feel more confident in the ability of the team to understand and recognise the needs of women affected by FGM if the health workers raise the issue as part of routine care.
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If the question is embedded in the framework of a routine medical and surgical history, it removes the onus from the workers of having to make a judgement about a woman's cultural or ethnic background, and from the woman of having to raise the question in an unfamiliar setting. It may also uncover other significant problems for non-infibulated women.
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Resources for health workers
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At the Women's, the Family and Reproductive Rights Project (FARREP) workers are able to offer support and advocacy to women accessing the hospital for antenatal care, and advice to workers providing their care.
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A FARREP worker is available every weekday on 8345 3058, or on a pager* and can assist with consultations, and follow up referrals. The role of the FARREP workers does not include interpreting rather supporting women and families to access the health care system as they are often new arrivals to the country and the health system. The FGM liaison Officer for each area may also be able to assist with practice questions.
Contact the Women's switchboard on (03) 8345 2000 and ask to have a FARREP worker paged.
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