Female genital mutilation/cutting (FGM/C) is a procedure by which all or part of the external female genitalia are removed or marred for non-medical purposes.1 FGM/C affects populations in Africa, the Middle East, Asia, and diaspora communities in the West. WHO describes FGM/C as a human rights violation and extreme form of gender-based violence. American Medical Association and American College of Obstetrics and Gynecologists align with WHO to condemn FGM/C and work toward its elimination.2,3 Condemning FGM/C is necessary yet insufficient to meet the needs of people who survive FGM/C. Effective healthcare for survivors must be respectful, competent, and not presume the patient’s attitude toward FGM/C. Since FGM/C occurs within a cultural paradigm, some survivors may not consider the practice aberrant and may be startled, insulted, disrespected, and more by healthcare worker (HCW) condemnation.4 Condemnation without compassionate and culturally humble care negatively affects survivors and may also curtail conversation with parents about FGM/C consequences – which in turn limits opportunities to prevent cutting in the next generation.
Nearly two decades ago, three conceptual approaches to cross-cultural medical education (awareness/sensitivity; multicultural/categorical; and cross-cultural) were published.5 We pose the question: Does addition of health humanities enhance cross-cultural medical education and promote learner preparedness to care for patients affected by FGM/C?
Emerging literature shows that using small group health humanities sessions when addressing multifarious topics allows for reflection and dialogue among learners and faculty.6
We created an FGM/C-focused health humanities session for second-year medical students at the Frank H. Netter MD School of Medicine at Quinnipiac University. We chose health humanities because of the attention to patient narratives, examination of perspectives, and capacity to promote self-awareness and compassion.7 Our health humanities session incorporated videos8,9 of FGM/C survivors telling their stories. The objectives are for learners to 1) recognize the influence of perspective and culture on attitudes, beliefs, and values, 2) reflect on how HCWs’ personal experiences and biases may help or hinder their ability to understand a patient’s story, and 3) personally experience the act of explaining a tradition, practice, or ritual to someone who is outside one’s culture group.
The session opened with acknowledgement that FGM/C can be a challenging topic. We then invited learners to discuss the Voices to End FGM/C videos, noting words or ideas that resonated with them or in some way caught their attention. Next, facilitators asked learners to respond to the writing prompt: “Write about a time you had to explain an aspect of your culture, religion, and/or family traditions to someone else.” The aim of the writing prompt is for respondents to have a personal experience of being an outsider and appreciate that the activities and beliefs they take for granted can appear strange to those beyond their culture group. Ultimately, the writing exercise aims to promote empathy and reduce othering of those exposed to FGM/C. Learners had the opportunity to share their writing with the group.
Learners completed anonymous, online, pre- and post-session surveys. The surveys used a Likert scale to enquire about familiarity with and general attitudes toward FGM/C, the affected populations, and respondent demographic information. The post-session survey additionally offered space for an open response to the question, “In what ways has your attitude changed?”
Of the 94 learners who participated in the FGM/C educational session, 82 completed the pre-session survey (85.4% response rate). Fifty-nine learners responded to the post-session survey (62.8% response rate). Survey data indicate the session favorably influenced learners’ knowledge and attitudes and helped shift their understanding of FGM/C to a culturally nuanced perspective. Here’s a sample of the open responses.
“I guess it gives me a perspective that maybe this is an issue that has deeper cultural roots that can’t be reduced to a knee-jerk reaction.”
“While my attitude was very negative at the beginning, the event helped me reflect on what practices my family does that I struggle to explain to other people but seem so normal to me. I can empathize with the individuals that have their daughters go through this procedure, even though I don’t agree with it.”
“I think it’s easy to pass judgement, but I think it’s important to recognize that in some instances it is a cultural practice. We need to approach it neutrally and with respect so we don’t offend patients, while also offering objective information for safety.”
“Talking through FGM as a cultural practice was important to me to be able to talk about ending FGM or supporting someone who may have been affected in a culturally competent and respectful way, rather than the initial shocked response I had.”
“I realized how pervasive the practice could be. In addition, I had a chance to think about how someone who has been cut might view what happened to them. There were many perspectives I hadn’t considered.”
FGM/C is a global issue that affects many communities, including diaspora communities in the West. HCWs in western countries may struggle to provide care for affected populations because of unfamiliarity with FGM/C and conscious and unconscious biases about a practice outside their cultural paradigm.4,10 Unless HCWs bridge the cultural divide, communities affected by FGM/C are likely to receive suboptimal care.
Health humanities education may heighten learners’ awareness of the varied perspectives incurred by survivors of FGM/C and contribute to learners’ appreciation of the dual role health professionals have as social justice advocates who condemn gender-based violence practices and culturally astute caregivers to FGM/C survivors and those at risk for FGM/C.
References
- World Health Organization. WHO guidelines on the management of health complications from female genital mutilation. 2016. https://www.who.int/publications/i/item/9789241549646 Accessed January 3, 2023.
- American Medical Association. Expansion of AMA policy on female genital mutilation H-525.980. 2017. https://policysearch.ama-assn.org/policyfinder/detail/Expansion%20of%20AMA%20Policy%20on%20Female%20Genital%20Mutilation%20H-525.980?uri=%2FAMADoc%2FHOD.xml-0-4716.xml. Accessed January 3, 2023.
- American College of Obstetrics and Gynecologists. Female genital mutilation. 2022. https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2019/female-genital-mutilation. Accessed January 3, 2023.
- Milken Institute School of Public Health and George Washington University. FGMC Toolkit. How do I discuss FGM/C with my patient? No date. http://fgmtoolkit.gwu.edu/are-you-health-care-provider/how-do-i-discuss-fgmc-my-patient. Accessed January 3, 2023.
- Betancourt JR. Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Acad Med. 2003; 78(6):560–569. doi: 1097/00001888-200306000-00004
- Charon R, Irvine C, Ngozi Oforlea A, et al. Racial justice in medicine: Narrative practices toward equity. Narrative. 2021; 29(2):160-177. https://doi.org/10.1353/nar.2021.0008
- Williams A. Integrating health humanities, social science, and clinical care: A guide to self-discovery, compassion, and well-being. New York and London: Routledge, Taylor & Francis;
- Voices to end FGM/C. 2020. https://sahiyo.com/voices-to-end-fgm-c/. Accessed January 3, 2023.
- Digital Stories. No date. https://www.storycenter.org/stories. Accessed January 3, 2023.
- Brottman MR, Char DM, Hattori, RA, Heeb R, Taff SD. Toward cultural competency in health care: A scoping review of the diversity and inclusion education literature. Acad Med. 2020; 95:803-813. doi: 10.1097/ACM.0000000000002995
-Anna-leila Williams, PhD, MPH
-Zahra Qaiyumi, MD
Anna-leila Williams, PhD, MPH is Professor of Medical Sciences at the Frank H. Netter MD School of Medicine at Quinnipiac University where she leads the curriculum content in behavioral and social sciences, public health, social, structural, and political determinants of health, and health humanities. Her textbook, Integrating Health Humanities, Social Sciences, and Clinical Care: A Guide to Self-awareness, Compassion, and Well-being, was published by Routledge, Taylor & Francis in 2019. Dr. Williams advances diversity, equity, and inclusion initiatives to honor her ancestors’ struggles and help realize the Beloved Community. LinkedIn page: https://www.linkedin.com/in/anna-leila-williams-834155b/
Zahra Qaiyumi, MD is a resident physician specializing in Family Medicine at Mercy Medical Center in Redding, CA. She completed medical school at Frank H. Netter MD School of Medicine at Quinnipiac University. Dr. Qaiyumi grew up in a community in which girls and women are impacted by FGM/C. She is interested in the role of health care providers in caring for those affected by the practice, and as such has been involved with developing training for resident physicians on necessary surgical care that improves quality of life for those affected by the most severe forms of FGM/C. She has also implemented curricular changes at her medical school to introduce physicians in training to the cultural nuances surrounding FGM/C with the goal of increasing cultural humility. Additionally, Dr. Qaiyumi works on various projects focused on community engagement through Sahiyo, an organization dedicated to working with practicing communities to end FGM/C. LinkedIn page: https://www.linkedin.com/in/zahra-qaiyumi-608b9069/