Female genital mutilation and the Swiss health care system

World-wide, more than 120 million girls and women are estimated to have undergone
female genital mutilation (FGM), and each year 2 million more are subjected to these
practices in the name of traditional culture. FGM is practised mainly in 28 African
countries with a wide range of variation in prevalence rates between and within the
countries concerned. Increasing international migration from regions where FGM is
traditional has brought the practice to Europe. Receiving countries have been
unfamiliar with these traditional practices, and health care providers face multiple
questions in connection with FGM. Compared to other European countries, in
Switzerland official attention to the subject of FGM has been a very recent
phenomenon. Previous studies referring to FGM and health care in Switzerland only presented the
issue from the health care provider’s side. Objectives of this study were to analyse how
immigrant women with FGM experience gynaecological/obstetrical care in the Swiss
health care system, and to investigate if gynaecologists/obstetricians and midwives,
those health care professionals most directly concerned, are apt to treat and counsel
FGM related complications adequately. Based on these findings the aim was to
generate recommendations for the Swiss health care system. The quantitative part of
the study aimed to estimate the prevalence rate of girls and women concerned in
Switzerland, and to examine their distribution by country of origin, place of residence,
and age group in the host country. The quantitative part of the study consisted of data analyses concerning the current
number of women from 28 FGM practising countries living in Switzerland, as provided
by the Federal Office for Foreigners (2001) and the Federal Office for Refugees (2001).
This study’s emphasis was placed on the qualitative part that consisted of focus group
discussions and in-depth interviews with women (n=29) and men (n=3) of the migrant
communities from Somalia and Eritrea. Furthermore, in-depth interviews (n=37) with
Swiss health care providers (20 physicians and 17 midwives) were carried out. In 2001, there were more than 10,500 women and girls from FGM practising countries
officially living in Switzerland. A prevalence rate of 4,051/10,501 women (³ 16 years
old) concerned has been estimated. More than 2/3 of the women living in Switzerland
estimated to have undergone FGM are from Somalia, Ethiopia and Eritrea. 70% of the women concerned live in the large metropolitan areas, predominantly in the French
speaking part of Switzerland.
The main FGM-related health complications that women from Somalia and Eritrea
suffered from were a painful and prolonged menstruation, pain and reduced feelings
during sexual intercourse. In Switzerland obstetric complications play a smaller role
than in their countries of origin. Therefore, psychosexual complications become more
prominent consequences of FGM. The concern of being different from women of the
host society as FGM interferes with sexual pleasure, is a consequence that the migrant
women face particularly. However, participants who had undergone FGM expressed a
strong inter-individual variability with respect to sexual response. Generalisations that
having undergone FGM leads to sexual indifference, are not based on evidence and
might contribute to stigmatise women concerned. Consequently, the aspect of gynaecological/obstetrical care was found to be more
challenging in terms of a culturally sensitive interpersonal interaction between women
concerned and health care providers, than in relation to technical management of
FGM. The following aspects of the consultation concluded to be critical: the reactions of
several health care providers when first facing a mutilated vulva (FGM type III) ranged
from disclosing shock in front of the patient to totally ignoring the condition of FGM. A
complete medical history related to FGM, including probing for FGM related
complications, was not performed in most cases. Particularly, the sexual and social
complications were rarely discussed. Regarding prevention, only 8% of the
participating health care providers systematically addressed the future of concerned
women’s daughters. The issue of reinfibulation (re-establishment of infibulation or resuturing
the vulva after delivery to the antepartum state), a question specifically linked
to obstetrical care of women with FGM type III, presents an ethical conflict for the
gynaecologists/obstetricians and midwives. Ultimately all interviewed health care
providers give priority to the wish of an adult patient and support partially re-suturing
the vulva after delivery if requested. However, in respecting the interests of their
clients, some Health care providers clearly violated the patient’s rights by performing
the intervention without thoroughly informing the patient. While other European
countries ban reinfibulation (UK, Belgium) or clearly define degree and conditions
concerning this intervention (Denmark), partial reinfibulation without existing guidelines
is carried out at the obstetric services of all Swiss university hospitals participating in
this study. A striking lack of communication is a prominent finding in this study. This lack of
discussing FGM is obvious between women concerned and health care providers, the
women and their husbands/partners and even between the women of the same
migrant community. As to the gynaecological/obstetrical consultation, main obstacles
were the language barrier, the general delicacy of the subject and the fact that FGM is
a highly gender sensitive issue, which was a problem particularly for the male health
care providers perceiving the women’s reluctance to discuss FGM with a man. Among
the couple it is the taboo of talking about FGM that contributes to maintaining the
women’s unconfirmed assumption that men of their cultural background generally
prefer those women having undergone FGM. However, the young men of the migrant
communities included in this study opposed FGM. Finally, there is a striking lack of
exchange among the women concerned. This causes a difficult situation particularly for
the adolescent women who are often not able to talk with their mothers about physical
and social problems linked to FGM and thus carry the burden of secretly seeking for
medical help without any support of their families. Yet, even for several women of the
same generation and cultural background it was the first time they shared FGM related
complications with each other in the context of this study.Difficulties with FGM related gynaecological/obstetrical management were greatest in
the first half of the 1990s, the time when most Somali immigrants entered Switzerland.
Meanwhile, several gynaecologists/obstetricians and midwives at the university
hospitals developed a certain experience in the management of FGM. In the regional
hospitals however, where Health care providers are much less exposed to such cases,
the lack of experience is much more obvious. Thus, at several regional hospitals in
Switzerland to avoid vaginal deliveries in women with FGM type III, caesarean sections
have been carried out. FGM type III as such is no medical indication for caesarean
section. Moreover, with the perspective of migrant women to return eventually to their
home countries where subsequent caesarean sections may be difficult to realise in
resource poor areas, a previous caesarean section can then present a risk.
Furthermore, the majority of participating women opposed caesarean section as they
wished to maintain the option of many deliveries. Migrants from Sub-Saharan Africa are one of the most vulnerable populations in the
Swiss health care system. FGM means an additional burden for women from these
communities. This study reveals that gynaecological/obstetrical care in Switzerland
often does not meet the women’s specific needs with respect to FGM. This is not due
to lack of empathy or good will on the side of the Health care providers, but rather due to the fact that most Health care providers in Switzerland lack exposure, experience
and guidance on how to care for such women. However, considering that FGM is a
subject of great delicacy, inappropriate health care can even increase the women’s
burden by making them feel stigmatised. Gynaecological/obstetrical care for clients who have undergone FGM needs to be
adapted to a culturally more appropriate care and to a better management. Thus, FGM
should be included in pre-and postgraduate education for gynaecologists/obstetricians
and midwives in Switzerland. In order to improve the situation characterised by a
multilateral lack of communication, possibilities of networking should be initiated.
Exchange should be fostered between health care providers of different institutions in
the country, harmonising experiences and making use of resource persons. Moreover,
existing experience and instruments from other European countries should be included
in the elaboration of further measures in Switzerland. Finally, it is a priority to offer the
women concerned opportunities to share and discuss among each other their
experiences related to FGM, integrating thematic subjects about delivery, sexuality and
genital anatomy of a woman.
Women concerned are geographically concentrated in the large metropolitan areas of
Switzerland and predominantly consult in the large canton hospitals for
gynaecological/obstetrical care. Therefore, focussed efforts could make a great
improvement for the women from Sub-Saharan Africa and for their health care
providers in the Swiss health care system.