**4.1 Communication difficulties**

Anis et al. [64] argued that placing patients at ease in an environment so they are able to speak about their FGM/C is a key to provide consistent care and positive outcomes. Participants expressed concerns regarding poor communication between their patients and themselves. The difficulties in communication were both verbal and non-verbal, which included the refusal by patients to respond to questions when asked if they lived with FGM/C. Participants reported that they also refused examinations when they presented at the sexual and prenatal clinics. This led to the late discovery of the presence of FGM/C in women who had presented with pregnancy and labour. The following excerpts are from the interviews conducted with the SRHPs:

*They don't talk about it … but they don't talk about it … they know what is happening to them … the very first one that I saw I was really shocked, because there was only an opening you could only let a finger in … she knew she had a problem … but she didn't talk of what had happened to her …*

Another midwife made the following statement: 'they would refuse all vaginal exams … they don't tell anyone that it has been done to them … and they just arrive … here!' Another participant commented:

*Well … hopefully, that should be identified at the antenatal clinic … but as it goes … don't tell us … if they refuse examination at the antenatal, which a lot of them do, we don't find out until they are in labour …*

The professional health workers expressed how some of the patients were not aware of the FGM/C themselves, that it had been done when they were too young and that they may not have even known that they had it. One of them reported that she saw no need to talk about FGM/C with these patients. She also expressed her view that it was not her place to talk about FGM/C as she feared there could be implications in speaking about it with her patients. She expressed a deep lack of confidence in communication with her patients living with FGM/C:

*I wonder if it is helpful for me to point out to them that they have a problem which is not in one of my problem categories … yeah … They would be as how they have always been … they won't actually know any difference … I don't know what intervention is of benefit … Maybe that is what I need to learn more about … what evidence is there towards intervention? … asking those questions is important but I don't know how … but I do feel that even if someone says that, this is ok to talk about it … I can still get myself into a lot of trouble … and I think I … bring up a subject that is very sensitive and very difficult … that I actually don't have very much skill to help with … then I would cause harm … and so often I won't mention whether they may or may not perceive they have a problem is sometimes more harmful than good … and yet I recognise that I may be missing an opportunity … to discuss … but they may not have the courage to discuss …*

Participants reported that they felt inadequately equipped to communicate effectively with women living with FGM/C and suggested that healthcare professionals with the same cultural background as their patients would be appropriate to provide services to women living with FGM/C. It was also suggested that

**37**

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

culturally specific healthcare to women living with FGM/C would promote efficient communication between healthcare professionals and their patients. A

*I guess my thinking is that someone who is from the same culture or background would understand that background and would have more ability to … perhaps ask the right questions … so it is that sense of someone who understand me … so I won't go to a man for a pap smear … someone who understands women's health … I think the similar would be the case … to talk to someone who thinks this is barbaric … to do that to my daughter … how can I go to that person for help? I need to speak to* 

Additionally, participants reported that they were concerned about their patient's capacity to comprehend the medical information and advice provided. One midwife expressed concern about the ability of the patients to clearly understand

*I'm not 100% sure women will know what we are asking them … you know … have you been cut? … they may not understand what we are asking … and they may not have knowledge of what has been done … a youth worker … had FGM … and she didn't know because she didn't know how a normal vagina would look like … She didn't know she had been cut … a doctor had to examine her to see if she had been* 

Another participant strongly emphasised the importance of efficient communication between patients and healthcare professionals: 'Yes. Communication is

Communication difficulties between participants and their patients were discussed by participants as barriers to efficient sexual and reproductive health service delivery. The reasons for these communication barriers were reported to stem from

Several of the participants reported that they viewed the procedure of FGM/C in their patients as barbaric, incomprehensible, oppressive and dangerous and expressed sadness and anger at the pain that women with FGM/C have to endure during delivery. However, despite these feelings of sympathy, they experienced frustration, shock and anger that these women do not speak about FGM/C even

*it makes me sad that that happens … to people who don't have the ability to step out of their culture … they don't go, 'Oh my God, we are cutting a baby on a sensitive area! That can't be right!' And yet, I have days I reflect on tradition and things that have been done for a long time … then there must be some reason behind it even though to my … outsider position I am looking at it, and it is completely* 

*The sensitivity is of course related to sexuality; it is related to cultural identity and that whole sensitivity is multiplied by the fact that we are medical professionals from the other culture … And I think if it was my culture, I would feel I have the* 

cultural conflict between healthcare professionals and their patients.

when they are asked. A doctor made this statement:

*someone who understands the background and the pressure …*

what was being communicated to them during service delivery:

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

doctor made this statement:

*cut.*

**4.2 Cultural conflict**

*wrong.*

Another participant stated*:*

the key.'

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

culturally specific healthcare to women living with FGM/C would promote efficient communication between healthcare professionals and their patients. A doctor made this statement:

*I guess my thinking is that someone who is from the same culture or background would understand that background and would have more ability to … perhaps ask the right questions … so it is that sense of someone who understand me … so I won't go to a man for a pap smear … someone who understands women's health … I think the similar would be the case … to talk to someone who thinks this is barbaric … to do that to my daughter … how can I go to that person for help? I need to speak to someone who understands the background and the pressure …*

Additionally, participants reported that they were concerned about their patient's capacity to comprehend the medical information and advice provided. One midwife expressed concern about the ability of the patients to clearly understand what was being communicated to them during service delivery:

*I'm not 100% sure women will know what we are asking them … you know … have you been cut? … they may not understand what we are asking … and they may not have knowledge of what has been done … a youth worker … had FGM … and she didn't know because she didn't know how a normal vagina would look like … She didn't know she had been cut … a doctor had to examine her to see if she had been cut.*

Another participant strongly emphasised the importance of efficient communication between patients and healthcare professionals: 'Yes. Communication is the key.'

Communication difficulties between participants and their patients were discussed by participants as barriers to efficient sexual and reproductive health service delivery. The reasons for these communication barriers were reported to stem from cultural conflict between healthcare professionals and their patients.

### **4.2 Cultural conflict**

*Psycho-Social Aspects of Human Sexuality and Ethics*

Anis et al. [64] argued that placing patients at ease in an environment so they are able to speak about their FGM/C is a key to provide consistent care and positive outcomes. Participants expressed concerns regarding poor communication between their patients and themselves. The difficulties in communication were both verbal and non-verbal, which included the refusal by patients to respond to questions when asked if they lived with FGM/C. Participants reported that they also refused examinations when they presented at the sexual and prenatal clinics. This led to the late discovery of the presence of FGM/C in women who had presented with pregnancy and labour. The following excerpts are from the interviews conducted with

*They don't talk about it … but they don't talk about it … they know what is happening to them … the very first one that I saw I was really shocked, because there was only an opening you could only let a finger in … she knew she had a problem …* 

Another midwife made the following statement: 'they would refuse all vaginal exams … they don't tell anyone that it has been done to them … and they just arrive …

*Well … hopefully, that should be identified at the antenatal clinic … but as it goes … don't tell us … if they refuse examination at the antenatal, which a lot of them do,* 

The professional health workers expressed how some of the patients were not aware of the FGM/C themselves, that it had been done when they were too young and that they may not have even known that they had it. One of them reported that she saw no need to talk about FGM/C with these patients. She also expressed her view that it was not her place to talk about FGM/C as she feared there could be implications in speaking about it with her patients. She expressed a deep lack of

*I wonder if it is helpful for me to point out to them that they have a problem which is not in one of my problem categories … yeah … They would be as how they have always been … they won't actually know any difference … I don't know what intervention is of benefit … Maybe that is what I need to learn more about … what evidence is there towards intervention? … asking those questions is important but I don't know how … but I do feel that even if someone says that, this is ok to talk about it … I can still get myself into a lot of trouble … and I think I … bring up a subject that is very sensitive and very difficult … that I actually don't have very much skill to help with … then I would cause harm … and so often I won't mention whether they may or may not perceive they have a problem is sometimes more harmful than good … and yet I recognise that I may be missing an opportunity … to* 

Participants reported that they felt inadequately equipped to communicate effectively with women living with FGM/C and suggested that healthcare professionals with the same cultural background as their patients would be appropriate to provide services to women living with FGM/C. It was also suggested that

confidence in communication with her patients living with FGM/C:

*discuss … but they may not have the courage to discuss …*

*but she didn't talk of what had happened to her …*

*we don't find out until they are in labour …*

here!' Another participant commented:

**4.1 Communication difficulties**

**4. Findings**

the SRHPs:

**36**

Several of the participants reported that they viewed the procedure of FGM/C in their patients as barbaric, incomprehensible, oppressive and dangerous and expressed sadness and anger at the pain that women with FGM/C have to endure during delivery. However, despite these feelings of sympathy, they experienced frustration, shock and anger that these women do not speak about FGM/C even when they are asked. A doctor made this statement:

*it makes me sad that that happens … to people who don't have the ability to step out of their culture … they don't go, 'Oh my God, we are cutting a baby on a sensitive area! That can't be right!' And yet, I have days I reflect on tradition and things that have been done for a long time … then there must be some reason behind it even though to my … outsider position I am looking at it, and it is completely wrong.*

#### Another participant stated*:*

*The sensitivity is of course related to sexuality; it is related to cultural identity and that whole sensitivity is multiplied by the fact that we are medical professionals from the other culture … And I think if it was my culture, I would feel I have the* 

*right to ask … in the same way a woman can ask a woman about periods and talk about sex in a way that a man doctor can't ask that question … But I come from a different culture and I am asked questions about a practice that people from that culture, which is new to this country, they realise that the practice is forbidden and that there is overriding condemnation of it. And they may even feel that me asking a neutral question could sound like condemnation.*

A midwife described with profound sadness how she witnessed a woman suffer during childbirth: 'Oh, I was upset … when I saw the poor girl … I told you she had an opening only one centimetre. We couldn't even find her urethra … It is very sad.' Another midwife was clearly psychologically disturbed by FGM/C in her patients:

*It makes me mad … it makes me very sad that the woman has had to endure it … especially if it was done in countries with basic tools … knives, and I think, that is a small child that it was done to and I … the pain and why you do it?*

#### **4.3 Re-infibulation and the medicalisation of FGM/C**

Re-infibulation occurs after childbirth and returns de-infibulated women back to the previous state of infibulation; it is argued to have no benefits (e.g., [51, 65]). Statements were made by participants that women requested re-infibulation after childbirth. One midwife described how a doctor carried out re-infibulations after birth, giving him a large clientele of patients who preferred his services, which is in contrast to the typical cultural practice of women who are living with FGM/C, who usually have a preference for female healthcare providers [22, 66]. This midwife said:

*I know … when I worked at XXXX hospital, one of the doctors used to look after a number of Middle Eastern ladies because he spoke their language, and there was a high proportion of FGM/C in these ladies … and at one stage, I know he was sewing them back as they were … because they were requesting it … before he was talked to about all the legalities …*

In non-traditional rituals, as occurred in Western societies, clinicians who support the practice of FGM/C often perform re-infibulation, creating a situation where FGM/C is medicalised [18]. This has been highly controversial within the WHO [52], which has called for prosecutions of clinicians who perform FGM/C, in line with the rationale that there is no excuse whatsoever for the facilitation of any form of FGM/C by medical practitioners [52]. Whilst the campaign against FGM/C has been highly visible within the traditional locations where FGM/C is practised (e.g., sub-Saharan Africa), in Western countries, clinicians are still faced with poor training. A lack of access to and knowledge of clear clinical guidelines for the treatment of women living with FGM/C is evident, which may increase the likelihood of re-infibulation occurring [67, 68].

Participants in this study described how some women would travel for long overseas holidays to perform re-infibulation and also have their newborn daughters circumcised. The following statements were made by participants:

*XXXX hospital now refer women, any women who have had daughters, to social workers to ensure they don't disappear for long to circumcise their daughters … and they are trying to introduce it here: any woman that has a female baby is followed up … they have training for social workers … because they have specific training … to ensure these women do not disappear for long periods of time so the same thing is not done on them.*

**39**

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

Some of the statements made by the participants identify the need for culturally specific sexual and reproductive healthcare to meet the needs of women living

The participants expressed the need for women living with FGM/C to have access to culturally specific healthcare, reporting that this was lacking in the public health system in Western Australia. Participants described how healthcare professionals find it difficult to understand the culture of FGM/C and therefore feel inadequate in their capacity to provide sexual and reproductive health services in an efficient manner to women living with FGM/C. A doctor expressed how culturally specific healthcare would minimise conflict in the relationship between women living with FGM/C and healthcare professionals by training professionals with a similar cultural background as the patients to provide efficient healthcare:

*it is a specialised area and accessing specialised services is important by those people who are fairly trained to help … even within gynaecology, you wouldn't refer them to any gynaecologist … just those who are more experienced, those who are more able to help. Psychologists would have very little experience within that area, counselling and some would be very well experienced … I think there needs to be more conversations about it, and probably more training by people who are very much from that culture and understand all the in's and out's. And then give good advice as to how someone who is not from that culture might approach the issue. Because within our own culture we have many ideas of healthcare, even within one culture every person is different. It isn't helpful if doctors are trained to provide the* 

It appears therefore that clinicians with experience and backgrounds where FGM/C is traditionally practised can offer invaluable support to women presenting with FGM/C at sexual and reproductive health services in Western Australia. These clinicians could be targeted for specialised training in numbers that can appropriately cater for sexual and reproductive health needs of women

**5. Complications of FGM/C in sexual and reproductive health provisions**

All participants stressed the importance of consistently screening pregnant women for FGM/C and clearly recording the information at the antenatal care stage before women go into labour. The participants stated that this could help prevent complications during childbirth, such as prolonged labour and unplanned caesarean sections and episiotomies. Routine screening and the correct use of information were reported to facilitate appropriate planning and the prevention of trauma during childbirth. However, it was reported that this was often hindered by women's refusal to be physically examined and by the poor recording of information. This is

*One of the doctors is the one who usually do … the anterior cuts … they actually do cut where they have been stitched … the registrar would decide where the cut's gonna* 

has got two daughters and we want to make sure she doesn't cut them?"'

Another midwife made the following statement: 'she had previous Type III FGM … and the social worker sent me an email saying, "Can you talk to her about it, she

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

**4.4 Culturally specific healthcare**

*wrong approach.*

living with FGM/C.

exemplified in this excerpt from one midwife:

with FGM/C.

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

Another midwife made the following statement: 'she had previous Type III FGM … and the social worker sent me an email saying, "Can you talk to her about it, she has got two daughters and we want to make sure she doesn't cut them?"'

Some of the statements made by the participants identify the need for culturally specific sexual and reproductive healthcare to meet the needs of women living with FGM/C.

### **4.4 Culturally specific healthcare**

*Psycho-Social Aspects of Human Sexuality and Ethics*

*a neutral question could sound like condemnation.*

**4.3 Re-infibulation and the medicalisation of FGM/C**

*about all the legalities …*

re-infibulation occurring [67, 68].

*not done on them.*

*right to ask … in the same way a woman can ask a woman about periods and talk about sex in a way that a man doctor can't ask that question … But I come from a different culture and I am asked questions about a practice that people from that culture, which is new to this country, they realise that the practice is forbidden and that there is overriding condemnation of it. And they may even feel that me asking* 

A midwife described with profound sadness how she witnessed a woman suffer during childbirth: 'Oh, I was upset … when I saw the poor girl … I told you she had an opening only one centimetre. We couldn't even find her urethra … It is very sad.' Another midwife was clearly psychologically disturbed by FGM/C in her patients:

*It makes me mad … it makes me very sad that the woman has had to endure it … especially if it was done in countries with basic tools … knives, and I think, that is a* 

Re-infibulation occurs after childbirth and returns de-infibulated women back to the previous state of infibulation; it is argued to have no benefits (e.g., [51, 65]). Statements were made by participants that women requested re-infibulation after childbirth. One midwife described how a doctor carried out re-infibulations after birth, giving him a large clientele of patients who preferred his services, which is in contrast to the typical cultural practice of women who are living with FGM/C, who usually have a preference for female healthcare providers [22, 66]. This midwife said:

*I know … when I worked at XXXX hospital, one of the doctors used to look after a number of Middle Eastern ladies because he spoke their language, and there was a high proportion of FGM/C in these ladies … and at one stage, I know he was sewing them back as they were … because they were requesting it … before he was talked to* 

In non-traditional rituals, as occurred in Western societies, clinicians who support the practice of FGM/C often perform re-infibulation, creating a situation where FGM/C is medicalised [18]. This has been highly controversial within the WHO [52], which has called for prosecutions of clinicians who perform FGM/C, in line with the rationale that there is no excuse whatsoever for the facilitation of any form of FGM/C by medical practitioners [52]. Whilst the campaign against FGM/C has been highly visible within the traditional locations where FGM/C is practised (e.g., sub-Saharan Africa), in Western countries, clinicians are still faced with poor training. A lack of access to and knowledge of clear clinical guidelines for the treatment of women living with FGM/C is evident, which may increase the likelihood of

Participants in this study described how some women would travel for long overseas holidays to perform re-infibulation and also have their newborn daughters

*XXXX hospital now refer women, any women who have had daughters, to social workers to ensure they don't disappear for long to circumcise their daughters … and they are trying to introduce it here: any woman that has a female baby is followed up … they have training for social workers … because they have specific training … to ensure these women do not disappear for long periods of time so the same thing is* 

circumcised. The following statements were made by participants:

*small child that it was done to and I … the pain and why you do it?*

**38**

The participants expressed the need for women living with FGM/C to have access to culturally specific healthcare, reporting that this was lacking in the public health system in Western Australia. Participants described how healthcare professionals find it difficult to understand the culture of FGM/C and therefore feel inadequate in their capacity to provide sexual and reproductive health services in an efficient manner to women living with FGM/C. A doctor expressed how culturally specific healthcare would minimise conflict in the relationship between women living with FGM/C and healthcare professionals by training professionals with a similar cultural background as the patients to provide efficient healthcare:

*it is a specialised area and accessing specialised services is important by those people who are fairly trained to help … even within gynaecology, you wouldn't refer them to any gynaecologist … just those who are more experienced, those who are more able to help. Psychologists would have very little experience within that area, counselling and some would be very well experienced … I think there needs to be more conversations about it, and probably more training by people who are very much from that culture and understand all the in's and out's. And then give good advice as to how someone who is not from that culture might approach the issue. Because within our own culture we have many ideas of healthcare, even within one culture every person is different. It isn't helpful if doctors are trained to provide the wrong approach.*

It appears therefore that clinicians with experience and backgrounds where FGM/C is traditionally practised can offer invaluable support to women presenting with FGM/C at sexual and reproductive health services in Western Australia. These clinicians could be targeted for specialised training in numbers that can appropriately cater for sexual and reproductive health needs of women living with FGM/C.
