Introduction

Female genital mutilations (FGM), also reported as female genital cutting, are referred as to “all practices of partial or total removal of the external female genitalia or other induced alterations to the female genital organs, carried out for cultural reasons or other non- therapeutic reasons” [1]. In this regard, the World Health Organization (WHO) identifies 4 types of FGM based on the invasiveness of the practice: type I (clitoridectomy) that involves the partial or total removal of the prepuce and/or the clitoral gland; type II: partial or total removal of the labia minora and clitoral glans without the excision of the labia majora; type III (infibulation) that is the narrowing the vaginal canal by modifying the labia majora and minora and may also include the removal of the clitoral glans and type IV that includes any other nonmedical, harmful interventions (cauterization, pricking, and scraping) [2]. FGM are generally carried out on girls during infancy and adolescence and can cause severe acute and chronic health consequences ranging from life-threatening sepsis and hemorrhage to infectious diseases, genitourinary and sexual-reproductive disorders as well as psychological consequences [3-5]. Indeed, it is internationally recognized as a serious violation of human rights, with particular regard to the physical, mental, sexual and reproductive health and the relevance of the topic is underlined also by the UN commitment to ending FGM by 2030 under the 2030 Sustainable Development Agenda (SDG Target 5.3) [6]. Nevertheless, even if the global burden in largely unknown, estimates range from 100 to 200 million women and girls affected, and it is still documented in 92 countries worldwide, particularly in Africa (e.g. Egypt, Ethiopia or Nigeria), Middle east (e.g. Yemen, Iraq) and Asia (i.e. Indonesia) [7,8], where FGM is still a settled practice, rooted in traditional customs.

Indeed, the reasons for this practice appear to be due to a complex framework of causes: religious, social, and cultural factors [9]. Actually, the first should not be considered as critical issue. In fact, this practice is carried out by both Islamic and Christian believers and neither Islamic or Christian sacred writings advice or impose FGM in any way. In particular, the religious authorities often collaborate with institutional authorities in condemning these practices underlining the fact that FGM were out of the religious interests and the dictates of the sacred scriptures. Hence, the relevance of sociocultural traditions has been indicated as the unique “milieu” in which these dangerous and detrimental practice could take place.

FGM phenomenon in Italy is a fairly recent issue, related to the influx of migrants coming from Northern and Sub-Saharian Africa that Italy experienced during the last the last 20 years. The number of FGM women in Italy is still uncertain. However, estimates based on both direct and indirect methods [10, 11] reports around 60-80.000 women and 7.000 minors affected. To counteract the practice, in 2006, Italy issued a specific law (Law 9 January 2006, n. 7) - that included also the imprisonment for those who practice mutilations and the temporary prohibition of medical practice in case of physicians - followed by dedicated guidelines [12] on FGM prevention, care and rehabilitation of women and girls, published in 2007 and targeting health professionals as well as other professionals working with migrant communities from high FGM prevalence. Despite those guidelines emphasize the pivotal role of the training of health and social-health professionals, FGM knowledge and experiences among health professionals in Italy does not yet seem to have been adequately analyzed. Thus, our research Center aimed to investigate the FGM knowledge, experience and perception of those healthcare professionals that are more involved in prevention and care of women such gynecologists, obstetrician and pediatricians.

Methods

Study Design

A cross-sectional study has been designed aimed at ideally targeting all gynecologists, obstetrician and pediatricians - even in training - practicing in the Country via a web-survey using a semi-structured questionnaire. The survey has been launched after the approval of the protocol of the study by the Ethics committee of the “Fondazione Policlinico Universitario A. Gemelli – IRCCS” (Prot. No. 0018506/23 ID 5821, acronym IN-MGF).

Questionnaire Development

To structuring the survey questionnaire, a scoping review of literature was performed in 2022 using search string including keywords such as female genital mutilation/cutting, FGM/C, knowledge, attitude*, practice*, training, healthcare professional*, physician*, nurse*, midwife, midwives, paediatrician*, gynecologist* questionnaire, survey,” and variants, combined through the Boolean AND and OR operators and launched on Medline, Scopus and Google Scholar databases. The research did not identify any published questionnaires suitable for the research purpose. Thus, based on the literature research, the working group conceived a semistructured questionnaire of about 20 items with close and open-ended questions focusing on health professionals’ demographic profile (e.g. years of professional practice, workplace setting, the Italian region of health facility where they practice, etc). their knowledge of FGM (e.g. typology, clinical complications; demographic characteristics of FGM patients), their personal experience (e.g. number of patients visited; defibulation requests). Difficulties perceived by the professionals in interacting and communicating with the patients were also assessed as well as their perception regarding the need for FGM training and information in their category. Some of the questions were differently worded based on the specificities of the target population (e.g., pediatricians versus other physicians). The questionnaire developed was validated through focus groups with Pediatrc, Gynecology and Obstetric scientific societies members to assess its clarity and relevance and incorporating any other inputs. Moreover, a pre-test on 10 representatives per category (pediatricians, Gynecologists and obstetricians) was also performed to check questionnaire questions and answers formulation - besides estimating time for its completion resulting in a final version.

Survey Features and Launch

The questionnaire was made available for self-administration on three different links per category of professionals on Google Moduli platform, jointly with the study and privacy policy description and the informed consent form for participation in the survey. Indeed, the participation in the survey has been designed in order that before starting the survey participants were asked to give their consent, otherwise the filling of the questionnaire was denied. Access to the platform did not involve any registration or provision of email addresses and results were available and downloadable in Excel format. Time for completion has been estimated in less than 10 minutes.

The survey has been launched on 20 June 2023 and remained available until the 20 november 2023. Recruitment of participants, whose participation was voluntary and for free, were spurred involving scientific societies and professionals associations such as the Italian Society of Gynecologists and Obstetricians (SIGO) and the territorial working groups of  gynecologists  (AGITE), the  Italian  Society  of  pediatricians  (SIP)  and  the  various professional associations of obstetric personnel. Those associations shared the link for the online survey to their members mailing list. Moreover, the link has been also shown during scientific conferences organized by the supporting scientific associations highlighting its aim to deepen the knowledge of the phenomenon and gain information regarding any training need of the healthcare operators.

Data Analysis

Descriptive analyses of the variables under consideration were carried out on both total sample and stratification (e.g., occupational type, length of time in the profession; region, prevalent area of practice etc.), using absolute and relative frequencies for describing qualitative variables and central tendency and dispersion indices for quantitative variables.

Results

The survey was completed by about 300 physicians. Main characteristics of the participants regarding their experience, the Italian region of work and their work setting (e.g. private or public healthcare systems) are reported in Figure 1A, Figure 1B and Figure 1C, respectively. Focusing on the regions of work, all Italian regions were covered with Lazio and Lombardia that resulted to be the most represented regions.

Figure 1A: Participants’ Years of Experience

Figure 1B: Participants’ Italian Regions of Work

Figure 1C: Participants’ Work Setting

The first question raised was referred as to the possible experience of gynecologists ostetricians and pediatricians with FGM. Specifically, Figure 2 indicates the experience with FGM declared by the participants, differentiated according to their medical specialization (Figure 2A gynecologists and obstetricians, Figure 2B pediatricians). Their answers clearly indicated that whereas the formers (gynecologists and obstetricians) had experience of FGM, recognizing FGM in their patients (more than 85%, Figure 2A) more than 90% of pediatricians never encountered young patients with FGM (Figure 2B). Some insight also derived from the question asked to gynecologists concerning the reason of the visit: more than 80% was associated with pregnancy or delivery whereas for less than 20% of patients the visit was due to the campaigns against FGM and only small percentages were due to pathological conditions such as infections or other pathological conditions (see Figure 3). Unfortunately, despite the campaigns performed in Italy in order to counteract the FGM practices, more than 70% of health professionals found that the number of patients with FGM was substantially stable, about 30% of them found that was decreased whereas about 20% responded that that was even increased.

Figure 2: Experience with FGM

Figure 3: Reason of the Visit (Gynecologists)

A further point was referred as to the understanding of the knowledge by all the health professionals regardless their specialization of the “reason” of FGM for their patients: do they believe that the FGM practice was due to a cultural or a religious background? The answers appeared as quite uncertain: the cultural reasons were considered as causative for about the 90% of professionals but, when the question was proposed in a different way, i.e. if FGM were performed in order to respond to religious reasons, more than 50% of respondents indicated religion as the causative reason for FGM practice (Figure 4 A, B).

Figure 4: Your Thought About the Causative Reasons of FGM.

To better characterize that awareness of Italian professionals interviewed, the survey proposed the same question to gynecologists, obstetricians and pediatricians: what type of FGM do you have noticed the most? As state above the types of FGM from I to IV differ substantially and they could/should be recognized by healthcare workers. However, at least among the responders, the knowledge appears quite sufficient being about 35- 40% capable of recognizing type I injuries and more than 50% able to recognize type II injuries. Type III injury resulted to be as the most commonly recognized by obstetricians, presumably in patients undergoing delivery, and barely by padiatricians (see Figure 5). However, the need for a more accurate training dealing with FGM appears mandatory to more than 60% of respondent professionals, without significant differences between the three different professional skills considered here (Figure 6A). The need for a specific training during the degree Courses or with specific update Courses after degree is shown by the percentages reported in Figure 6B.

Figure 5: Type of FGM Most Noticed by Participants. as the most commonly recognized by obstetricians, presumably in patients undergoing delivery, and barely by padiatricians (see Figure 5). However, the need for a more accurate training dealing with FGM appears mandatory to more than 60% of respondent professionals, without significant differences between the three different professional skills considered here (Figure 6A). The need for a specific training during the degree Courses or with specific update Courses after degree is shown by the percentages reported in Figure 6B.

Figure 6A: Do you believe you are Adequately Trained to Recognize FGM?

Figure 6B: In which Period of Medical Training the Formation on FGM is More Appropriate?