Tip 1
Develop understanding of the cultural and social complexity of FGM before the teaching session
FGM is a deeply embedded social norm, practised by communities and families for a variety of complex reasons and is often thought to be essential for a girl to become a proper woman and to be marriageable. In order to engage students in the topic and give them insight into this complexity, we ask them to watch a documentary commissioned by the International Federation of Gynecology and Obstetrics (The Cutting Tradition 2012) before the formal teaching session.
Tip 2
Acknowledge sensitivity of the topic and provide staff contact for debriefing and support
FGM can be a sensitive and upsetting topic. Students in the teaching session may know someone who has experienced FGM (a friend, relative, patient, NHS staff member), be concerned that they know someone is at risk of FGM or may have undergone FGM themselves. It is important to acknowledge this at the start of the teaching session and inform students that they can leave at any time. It is also worth reminding students that they should be mindful of this when discussing and asking questions about FGM in the session. Giving students warning of potentially sensitive content in advance allows them to deploy strategies for dealing with any difficult memories that may surface during the session (Collins, 2013).
Furthermore, Kennedy & Scriver (2016) stress the importance of providing a person to contact should students wish to discuss their emotional response to being taught about a sensitive and potentially upsetting topic. In our session, the facilitator makes themselves available to speak to students directly afterwards and provides contact information for those wishing to access further support.
We recommend all facilitators read the “Do No Harm” guidance produced by Girl Generation (2014) to help them gain understanding about how to avoid stigmatising or causing emotional distress to those who have undergone FGM: for example exercising caution around the use of graphic images of FGM.
Tip 3
Bring basic factual knowledge to the same level
Learners may come from very different cultural backgrounds and may have different educational and clinical experience, predisposing them to different levels of knowledge about FGM. Use of a quiz or similar learning tool can both assess and bring learners to the same baseline level of knowledge in an interactive and engaging way. A quiz can be completed individually or in pairs using a physical handout to stimulate peer discussion or via an online voting platform.
The quiz (see Appendix) ensures a group of diverse learners, who may practise in many different healthcare settings in the future, understand the fundamentals of FGM without overburdening them with specialist knowledge. Concerningly, a study of 45 healthcare professionals in a teaching hospital in London found only 4% could correctly identify the four types of FGM (Zaidi et al., 2007). The quiz addresses gaps in knowledge like this by including questions on basic information such as the WHO classification system (types 1-4). When going through the answers to the quiz the facilitator can evoke discussion on current law, prevalence, process, and complications of FGM.
Tip 4
Ensure understanding of potential complications of FGM
The consequences of FGM are variable and wide-ranging, including changes to women’s roles in their community and social standing, as well as effects on physical and mental health. It is essential doctors are aware of these potential physical and psychological consequences of FGM in order to provide appropriate treatment and support, especially as many women with FGM may not actively seek help for problems related to FGM.
There is currently nothing in the published literature regarding UK medical students’ knowledge about FGM. However, a study that assessed medical students’ knowledge about FGM in Egypt (Mostafa et al., 2006) found that less than half of the cohort of Egyptian medical students surveyed were aware FGM could lead to physical complications, even in the context of a high prevalence of FGM in Egypt.
Despite there being no data on medical students’ knowledge in the UK, there is evidence that qualified doctors in the UK have variable levels of knowledge. A study of obstetricians and gynaecologists showed that even though 92% of respondents were able to identify the long term physical complications of FGM, only 9% identified psychological complications (Purchase et al., 2013). Sex, pregnancy, and childbirth pose further challenges to women who have experienced FGM, and it is crucial to include these topics as part of core learning about FGM.
In our teaching session, the quiz ensures early understanding of the potential complications of FGM (Appendix, questions 7 and 8).
Tip 5
Critically evaluate justifications and explain facts
One of the biggest challenges to combating FGM worldwide is exposing and challenging misconceptions associated with the practice. Providing students with an understanding of the context and beliefs surrounding FGM and the justifications given for performing it not only enhances their understanding of the complex cultural processes involved but ensures they are adequately informed and prepared to refute justifications and explain facts to future patients from FGM-practising communities.
Common misconceptions are addressed in the quiz questions (Appendix, questions 10 and 11), and the reasons families allow their daughters to undergo FGM also discussed. These include justifications such as protecting chastity and fertility, improving marriageability and community belonging, and mistaken beliefs such as the clitoris will grow to the size of a penis if not removed and the baby will die if it touches the clitoris during childbirth. The common belief that FGM is a religious requirement is presented in a sensitive manner using quotations from prominent religious figures who have condemned FGM.
It can be challenging for some students to understand how parents could allow their daughters to undergo FGM and it is important the session addresses this so that students understand that unlike most forms of child abuse, loving parents can genuinely believe that having FGM is in their daughters’ best interests, and is essential for community belonging and marriageability.
Tip 6
Clarify current law and legal requirements
The law relevant to FGM in the UK is evolving. As with all medico-legal teaching, it is essential that updates to legislation are reflected in contemporary teaching materials so that students have a clear understanding of current law and their legal duties. Our session outlines the requirements of the Female Genital Mutilation Act 1985, as amended in 2003, and the Serious Crime Act 2015. Healthcare professionals’ legal duty to report all under 18s who disclose or have evidence of FGM to the police is emphasised, as is the requirement for health professionals to submit patient data to the FGM enhanced dataset. A discussion of the Whittington Health NHS Trust legal case, where a doctor was charged with performing FGM but later acquitted (Dyer, 2015), facilitates an appreciation of the complexities surrounding the legality of FGM relevant to clinical practice and stimulates some critical thinking about the law related to FGM (see Tip 10).
Tip 7
Develop skills to identify and support women who have undergone FGM
It is essential that doctors have both the knowledge and communication skills to identify women from FGM-practising communities so that they can effectively treat current medical issues and offer/signpost to support. Our teaching concentrates on this, firstly acknowledging that evidence shows that healthcare professionals often find it difficult to know how to approach FGM in a culturally sensitive manner (Hussain & Rymer, 2017) and thinking about why this might be. Students participate in a role-play where they sensitively ask whether the person sat next to them has undergone FGM. Respectfully raising the topic of FGM in consultations is discussed, using verbatim phrases such as, ‘Have you ever had any operations on your genitals or genital piercings or had FGM, or cutting or circumcision?’ Questions that identify physical and psychological consequences and support needs are discussed and examples given, including questions about flashbacks and nightmares.
In order to reinforce learning points and increase their confidence to ask about FGM, students watch a short video of a medical student speaking to a woman from Sierra Leone in a general practice surgery who has symptoms of a urinary tract infection. The video demonstrates how, even as students, HCPs can sensitively and effectively ask a woman about FGM and help support her. The video is freely available online as a learning resource (UCL Medical School, 2017).
Drawing students’ attention to relevant clinical guidance, for example on procedures for de-infibulation and re-stitching after childbirth and on post-maternity conversations on safeguarding (RCOG, 2015; RCN, 2019) will help them learn how to support women with FGM in maternity care and identify girls are risk of FGM (see Tip 8).
Tip 8
Develop skills to indentify and support girls at risk of FGM
As well as identifying and supporting women who have experienced FGM, learners must also be equipped to identify girls at risk of FGM. We describe useful questions for risk assessment to use in consultations and outline good safeguarding practice when clinicians identify an immediate risk of FGM. We also discuss what clinicians can say to people from FGM-practising communities to help prevent future FGM. The video mentioned in Tip 7 reinforces these learning points.
Tip 9
Involve women with experience of FGM
The opportunity to hear from a woman who has personally undergone FGM is an incredibly valuable learning experience for students. Existing literature suggests that narratives tap into several key learning processes in medical education, including providing a relevant context for understanding, engaging learners, and promoting memory and empathy (Easton, 2016).
Hearing a first-hand account of the cultural significance of FGM in a specific community and the detrimental impacts of FGM on an individual’s health and wellbeing, as well as personal experience of encounters with healthcare professionals reinforce the importance of everything students have learned in the session. Our speaker, SKK, discusses her experiences freely with students and encourages them to ask any questions, helping break down taboos and concerns about discussing FGM with patients. The passion with which she speaks about ending the practice and how doctors can help with this, as well as how to support women who have undergone FGM promotes understanding and empathy in the students and inspires them to be competent and caring clinicians with a desire to help tackle the issue. As one student said, “Really brilliant teaching, particularly the opportunity to hear from [a] survivor of FGM”. Another student reports, “I’ll never forget it”; and another, says “Hearing women's personal stories about FGM…was very touching and so helpful for us to understand why these things happen and what we can do to help”.
It is important to note that not everyone who has undergone FGM is happy to share their experience with students and to ensure that those who are willing to speak out are supported, in order to minimise the risk of being re-traumatised.
Tip 10
Discuss ethical issues
Ensuring students are familiar with legal and professional guidance on FGM is integral to the session. However, aspects of current law and certain statutory duties regarding FGM such as mandatory reporting (Creighton et al., 2019) and data sharing (Kelly, 2016) are ethically controversial. Our session gives students the opportunity to critically appraise FGM legislation and policy and discuss this in relation to legal duties, confidentiality, best interests and unintended consequences of legal requirements.
These discussions help students understand that sensationalising of the issue and ‘zero tolerance’ approaches that encourage clinicians to consider patients solely through a ‘safeguarding lens’ may demonise women who have experienced FGM and risk unintended consequence of alienating them from accessing physical and psychological care (Creighton & Bewley, 2018).
Time permitting, it can be enlightening to expand discussion to more political issues such as the motivation for FGM-related prosecutions and how the warning that quantification of the numbers of women and girls in the UK who have experienced FGM is not possible has largely been ignored (Macfarlane, 2019). Additional discussion around similarities and differences with male infant circumcision and intersex surgery and the increasing medicalisation of FGM in countries including Egypt and Sudan (where some doctors perpetuate the practice), can be both challenging and instructive.
Tip 11
Use expert facilitators
The ideal facilitator for an effective and comprehensive teaching session on FGM for medical students is a clinician with experience of caring for women/girls from FGM practising communities who also has experience of teaching healthcare professionals/students on sensitive topics, including medical ethics and law. However, it may be difficult to find all these skills and experience in one person. Identifying a number of facilitators with some of the above skills and qualities and further training them to deliver these sessions, in combination with co-facilitation and constructive peer-review of teaching sessions, can provide good training and support to facilitate effective learning.
Tip 12
Highlight students’ potential to be an advocate for change
At the end of our session, we remind students that as future medical professionals, often held in high esteem by local communities, they could play a pivotal role in education and approaches to FGM, both at a local level with individual patients, but also at a wider political level. By harnessing their medical expertise to demystify myths around FGM, and working with other agencies, academics, the government and policy makers they have potential to become key proponents for promoting change and ending this harmful practice.