The report is availible in Norwegian only. English summary below.
The purpose of the study was to shed light on the service providers’ work on female genital mutilation/cutting (FGM/C). We mapped the inclusion of FGM/C in institutions for health education. We also mapped the systems established to ensure provision of information to the users, and explored the service providers experiences with providing information and healthcare to users. The users included asylum seekers and newly arrived quota refugees, as well as refugees who had lived for a longer period in Norway.
The study employed both quantitative and qualitative methods. A mapping of education on FGM/C was carried out through a questionnaire sent to 37 institutions providing health education. The main part of the study, however, employed qualitative methods with emphasis on in-depth interviews, document analysis and participatory observations.
In-depth interviews were conducted with 46 service providers who were responsible for disseminating information and/or health care post female genital mutilation. This included healthcare providers (28 individuals) and other service providers responsible for refugees and asylum seekers, here referred to as refugee consultants (18 individuals). Healthcare providers included gynaecologists, sexologists, school nurses, midwives and physiotherapists.
Refugee consultants included individuals who provided information in refugee camps, who conducted asylum interviews, and who provided information and support at refugee reception centres and in various municipalities. The interviewees worked in 20 different cities/places in the country. Participatory observations were conducted in settings where female genital mutilation was a focus, such as workshops, seminars and meetings.
Target groups for information services: Some groups of refugees received information about female genital mutilation repeatedly. Usually these are single information points where they are provided with the same information. Other user groups may fall completely outside the information system, and there is a large risk that many of these never will receive information about FGM/C from service providers. This imbalance highlights a correlation between how the information systems are organised and the criteria concerning who should get what information and when.
Female genital mutilation in health education: Out of the 27 health education institutions which responded to our survey, 17 reported that they provided teaching on FGM/C. This included all responding institutions for midwifery- and school-nurse training. We do not know whether the topic was taught at the non-responding institutions. On the other hand, two of the five medical schools responding, did not provide training on FGM/C. Results also showed that nursing schools provided training in less than half of the cases (8 out of 14 responding schools provided no training).
Considerable variation between time allotted to training (from 3 minutes to 3 hours), and that of content of training, was also brought to the fore from the research. We therefore recommend that training on FGM/C should be included in all relevant healthcare educations. Furthermore, we recommend a review of the content of such training to ensure its validity fits the needs of the service providers, and a greater level of compliance between the training within the same field at different institutions.
Three information systems: The report present how the information provided to refugees varies according to context and motivation for immigration by distinguishing between three information systems: The information system targeting quota refugees, the information system targeting asylum seekers and the information system that is directed to both these as well as other immigrant groups affected by FGM/C.
Information provided individually and in groups: Most of the routine information is given individually. However, there are also settings where information is provided in groups. This is usually single events where information is given in groups that are heterogeneous in terms of gender, age and ethnicity/linguistic background. In more rare cases information provided in discussion groups that provide a safe framework for reflection, dialogue and exchange of experience, which research suggests to be the most effective.
To provide the necessary trusting environment, such groups should be more homogenous with respect to gender, ethnicity and language. However, heterogeneous groups are also important as they can act as a conduit forward to changes in social norms.
Unclear responsibilities: The distribution of information tasks leads to a diffusion of responsibilities in some places. A consequence of this is that the tasks of providing information is not taken up by anyone, and therefore is not provided.
Experience of isolation and lack of technical support: Many service providers work part-time, and often alone or with very few colleagues. Thus many felt they were alone in taking difficult tasks and decisions, and missed opportunities for technical exchange and discussions with other service providers. Many saw their professional code of silence as a serious limitation for scientific exchange and discussions that they saw as fundamental for taking the right decisions. In a few communes there have been established routines of upheaval of code of silence so as to strengthen collaboration between the services to find the best solution for the users.
Collaboration with resourceful persons from affected communities: NGO’s and other knowledgeable persons from affected communities are probably to a low degree drawn into the public information work. This had structural, financial as well as practical reasons, particularly in smaller places with few immigrants from affected communities.
The objective of dissemination of information: While government guidelines equally emphasise prevention of FGM/C and provision of healthcare, in practice preventative measures are given the most attention. Official guidelines define three topics that should be included in the information disseminated: the illegality of the practice, the health consequences of FGM/C and the provision of health care. In reality, however, the main focus is on the illegality of the practice, after which some information is provided about the health consequences, whereas little information is given about the access to healthcare. In this report we suggest to strengthen the last two topics, as well as to add a new topic concerning the underlying socio-cultural motivations for FGM/C. Most importantly this concerns traditional perceptions regarding FGM/C as a tool for the sexual control of women. We consider it important to maintain an increased focus on stimulating discussions that consider these cultural views and their association with FGM/C critically. This discussion could both strengthen preventative messages as well as to increase the acceptability of the available health services.
Healthcare after FGM/C: The eight clinics with specialization in FGM/C differ to some extent in their surgical- as well as information techniques. Increased exchange between clinics could be beneficial for better harmonization of the healthcare offered. The study also found that there was limited attention concerning healthcare for minors with FGM/C, particularly prepubescent children. Neither were there any clinical guidance available for this group.
Medical registration and documentation: The specialized FGM/C clinics made active use of clinical codes for the registration of disease and treatment on FGM/C. However, it did not seem that the clinical codes for FGM/C were systematically used outside these clinics, such as in the management of pregnancy and childbirth. The gynecological codes for FGM/C were not used to register cases of children examined for suspicion of FGM/C. In these instances codes for abuse were used that do not specify eventual FGM/C.