**1. Introduction**

Female genital mutilation/cutting (FGM/C) is practised beyond the borders of countries where it is traditionally reported. Through the influx of asylum seekers and refugees to host countries such as Australia, FGM/C is increasingly creating challenges for healthcare professionals, who may have no or few culturally specific skills to work with its presentation in migrant women [1]. The sexual and reproductive needs of migrant women living with FGM/C are unique, and without culturally specific healthcare frameworks, meeting the healthcare needs of these women may be inhibited by cultural, environmental, and language barriers [2].

The World Health Organisation (WHO) classifies FGM/C into four categories: Type I, Type II, Type III and Type IV. Type III is described as the most severe, whilst Type IV is described as only symbolic and not a ritual [3]. There are two forms of Type I. Type Ia involves the intentional removal of the hood of the clitoris and seldomly occurs on its own [4, 5]. Type Ib results in clitoridectomy—a procedure requiring the removal of the clitoral hood. Type Ib is more common and may also include the partial or complete removal of the clitoris together with that of the prepuce [6]. In Type II (excision), the clitoris and labia minora are partially removed with sharp objects, although some cultures partially cut out the labia majora and may apply ashes or herbs to stop the ensuing bleeding [5, 7]. FGM/C Type III (infibulation) involves the removal of all external genitalia, after which the wound is fused with cat gut, thorns or surgical threads (see [8, 9]). The clitoris may be pricked, pierced and scrapped to let blood in FGM/C Type IV. The practice represents the ritual of FGM/C in communities where FGM/C is outlawed ([10, 11]; for other forms of the practice, see [12, 13]).

An estimated 200 million women and girls globally have undergone the FGM/C procedure, with populations with the highest percentages residing in Africa, including 1% in Cameroon, 4% in Ghana and Togo, and above 91% in Egypt and 98% in Somalia UNICEF [5]. In Europe, it is estimated that half a million women and girls are living with FGM/C [14], mostly due to the mobility of women and girls from countries that practice FGM/C [15, 16].

The prevalence of FGM/C in Australia is difficult to determine, although some speculate that it has been around since 1994 [17]. Whilst there appears to be a lack of research and literature around FGM/C in Australia, the increase of migrants into the country from nations where FGM/C is practised may be an indication that FGM/C prevalence is increasing in Australia [18]. It is believed that women who have experienced FGM/C arrive in Australia after the procedure has been done [19]. Tellingly, statistical analysis shows that Australia received 38,299 migrants from 11 African countries where FGM/C is highly prevalent such as Sudan (24,082), Egypt (6258), Somalia (2736) and Ethiopia (5223), with the remainder from other African nations, as reported by Bourke [20, 21]. In 2010, the Melbourne Royal Hospital reported that it had seen 600–700 women living with FGM/C [20, 21]. Mathews [18] argues that the challenge of accurately establishing the prevalence and occurrence of FGM/C in Australia also stems from secrecy of the practice when compared to how it is symbolically portrayed in public ceremonies in countries that observe FGM/C (see also [16]).

A 2010 US survey revealed that sexual and reproductive healthcare professionals (SRHPs) may have knowledge about the presentation of FGM/C amongst migrants, but lacked culturally competent skills and adequate information to provide competent healthcare for women living with FGM/C [22]. Hess et al. [22] also found that negative attitudes and cultural insensitivity in SRHPs reinforce stigmatisation and isolation, resulting in poor sexual health amongst migrant women. Further, Berggren et al. [23] conducted a study in Sweden revealing that midwives attending to women living with FGM/C did not have adequate knowledge, which was evident during labour of women with infibulation. They also revealed that cultural insensitivity by healthcare professionals, poor cross-cultural communication and poor management of the labour process resulted in caesarean sections in women with FGM/C more often than was necessary.

Zaidi et al. [24] found that there is a need for healthcare professionals working with women living with FGM/C to be aware of their own cultural prejudices that may affect the wellbeing of their patients. Other researchers investigating healthcare professionals' knowledge and management of FGM/C revealed that cross-cultural training of healthcare professionals working with migrant women is imperative to

**33**

potentially end the practice [11, 42].

*Experiences of Sexual and Reproductive Healthcare Professionals Working with Migrant Women…*

address the knowledge gaps that hinder efficient service delivery to women living with FGM/C [25, 26]. Widmark et al. [27] suggested that the systematic involvement of infibulated women in pregnancy and birth planning frameworks could ultimately

Cultural competence amongst healthcare professionals working with women

The WHO defines FGM/C to include 'all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons' ([3], p. 3). FGM/C is performed on children between 0 and 15 years [28]. Traditionally, it is performed at 8 years of age on average but can occur at any age. Kolawole [29] argued that FGM/C is infused with cultural, legal and medical implications, making it difficult to adequately define. Debates regarding terminology and definitions continue across all societies, social groups and cultures. Almroth et al. [30, 31] pointed to concerns amongst scholars regarding the use of terminology and the ritual of FGM/C; in particular, some scholars consider 'mutilation' (p. 457) a medically acceptable term for the practice, as it involves the removal of healthy tissue and organs without medical indication, whilst others have argued that this term denotes negative connotations and attitudes towards the procedure,

We have argued elsewhere [33] that the term 'female circumcision' implies an analogy with male circumcision, which is misleading from an anatomical aspect as male circumcision only involves the removal of the glans, which by no means corresponds to the cutting of female genitalia (see also [31, 34])—FGM/C could only be compared with male circumcision if the penis were completely amputated and the surrounding tissue removed, as the cutting experienced by girls is severe, with irreversible effects that inhibit both sexual and reproductive capacities [29].

According to Bibbings [35], 'female genital mutilation' (p. 139–149) suggests torture and violent bodily injury forced on children and unwilling women by men and women from their cultural groups for the benefit of men and their communities or groups. This study shares this viewpoint, and both the term female genital mutilation and cutting (FGM/C) have been used concurrently to take a strong stand against the procedure, whilst acknowledging the theoretical debates on the definition of FGM/C

as well as cultural, social and health implications of the procedure (see [36]). Several scholars have argued that FGM/C is a strategy that exploits female sexuality for the sexual pleasures of men [37–39]. Some authors have postulated different reasons for the occurrence of FGM/C, including marriage [39], religion [26], cultural reasons [40], ethnicity [41], maternalism [23], patriarchy, and social pressures [37]. Additionally, community attitudes towards the continuance of the practice are reported to slow and frustrate measures designed to address and

living with FGM/C can also decrease stigmatisation towards these women, ultimately leading to better health outcomes for them and their families [22]. Further, Zaidi [24] cited communication between the healthcare professionals and women living with FGM/C as a major drawback to the achievement of better health outcomes for women living with FGM/C in host countries. This study aimed to investigate the experiences of healthcare professionals providing sexual and reproductive healthcare to women living with FGM/C in Western Australia. A secondary aim of this study was to contribute to the wider body of knowledge regarding healthcare professionals working with women living with FGM/C in

establish efficient service delivery and address knowledge gaps.

and may be offensive to some cultural groups [31, 32].

*DOI: http://dx.doi.org/10.5772/intechopen.93353*

Western Australia.

**2. Literature review**

### *Experiences of Sexual and Reproductive Healthcare Professionals Working with Migrant Women… DOI: http://dx.doi.org/10.5772/intechopen.93353*

address the knowledge gaps that hinder efficient service delivery to women living with FGM/C [25, 26]. Widmark et al. [27] suggested that the systematic involvement of infibulated women in pregnancy and birth planning frameworks could ultimately establish efficient service delivery and address knowledge gaps.

Cultural competence amongst healthcare professionals working with women living with FGM/C can also decrease stigmatisation towards these women, ultimately leading to better health outcomes for them and their families [22]. Further, Zaidi [24] cited communication between the healthcare professionals and women living with FGM/C as a major drawback to the achievement of better health outcomes for women living with FGM/C in host countries. This study aimed to investigate the experiences of healthcare professionals providing sexual and reproductive healthcare to women living with FGM/C in Western Australia. A secondary aim of this study was to contribute to the wider body of knowledge regarding healthcare professionals working with women living with FGM/C in Western Australia.
