TWEET CONFERENCE SCRIPT: Disseminating the 2018 World Health Organisation (WHO) guideline: “Care of women and girls living with FGM: a clinical handbook – 17th January 2019”

FGM stands for Female Genital Mutilation, and is defined as all procedures that involve the partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.  

There are four types of FGM, as classified by World Health Organisation (WHO) in 1997 and subdivided in 2008, and they are:   

Type I: partial or total removal of the clitoris and/or the prepuce (Clitoridectomy).  

Subdivisions of FGM Type I are: FGM Type Ia, removal of the clitoral hood or prepuce only and FGM Type Ib, removal of the clitoris with the prepuce.

Type II: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Subdivisions of FGM Type II are: IIa, removal of the labia minora only; IIb, partial or total removal of the clitoris and labia minora; and IIc, partial or total removal of the clitoris, labia minora and labia majora.

Type III: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Subdivisions of FGM Type III are: FGM Type IIIa, removal and apposition of the labia minora; and FGM Type IIIb, removal and apposition of the labia majora.

Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation, for example after childbirth when defibulation is necessary.

 Type IV: unclassified – All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, pulling, piercing, incising, scraping and cauterization.

It is estimated that over 200 million girls and women worldwide are living with or at risk of suffering the associated negative health consequences of FGM. Every year 3 million girls and women are at risk of FGM and are therefore exposed to the potential negative health consequences of this harmful practice.  

FGM has no known health benefits, and those girls and women who have undergone the procedure are at great risk of suffering from its complications throughout their lives.  

The procedure of FGM is painful and traumatic, and is often performed under unsterile conditions by a traditional practitioner who has little knowledge of female anatomy or how to manage possible adverse events.  Moreover, the removal of or damage to healthy genital tissue interferes with the natural functioning of the body and may cause severe immediate and long-term negative health consequences.  

The practice of FGM is prevalent in 30 countries in Africa and in a few countries in Asia and the Middle East, but also present across the globe due to international migration  

FGM practice is deeply rooted in a strong cultural/social framework. It is endorsed by the practicing community & supported by loving parents who believe that undergoing FGM is in the best interest of their daughter.  

The beliefs sustaining the practice of FGM vary greatly from one community to another, although there are many common themes such asending promiscuity or the maintaining culture tradition of the community.  

Despite its cultural importance, we need to acknowledge the fact that FGM is a harmful traditional practice that violates the rights or girls and women.  Therefore, FGM has to be eliminated.  

For more information about FGM you can visit http://www.who.int andwww.endcuttinggirls.org or watch https://www.youtube.com/watch?v=f0-dYD9cYKo&t=80s  

Now let us talk about “the 2018 World Health Organisation (WHO) guideline: “Care of women and girls living with FGM: a clinical handbook”. it is estimated that over 200 million girls and women worldwide are living with FGM, which can affect multiple aspects of a woman’s health and well-being, despite the high prevalence of FGM in many settings and the health consequences associated with it, many health-care providers have limited knowledge on FGM and limited skills for preventing and managing related complications. To address this gap, WHO continues to develop evidence-informed guidelines and tools to ensure that affected girls and women receive the highest quality care possible.   

what is new about this Clinical Handbook is that it distils the evidence-informedrecommendations into a practical and user-friendly toolfor everyday use by health-care providers, this Clinical Handbook covers a wide range ofhealth topics in nine chapters, ranging from basic knowledge andcommunication skills to management of a range of complications. moreover, this Clinical Handbook describes how to offer first-line mental and sexualhealth support as part of comprehensive care to address multipleaspects of women’s health and well-being.   

this handbook is for health care providers involved in the care of girls and women who have been subjected to any form of FGM. This includes obstetricians and gynaecologists, surgeons, midwives, nurses and other country-specific health professionals health-care professionals providing mental health care, and educational and psychosocial support, such as psychiatrists, psychologists, social workers and health educators, will also find this handbook helpful.

thisclinical handbook is based on the WHO Guidelines on the management of health complications from female genital mutilation, 2016. It also draws on other WHO publications, in particular the four listed hereafter…:

(i) the teacher’s guide and student’s guide versions of Female genital mutilation: integrating the prevention and the management of the health complications into the curricula of nursing and midwifery, 2001;

(ii) Eliminating female genital mutilation: an interagency statement, 2008;

(iii) Global strategy to stop health-care providers from performing female genital mutilation, 2010;   and

(iv) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP) – version 2.0, 2016.

This Handbook is divided into four major sections based, namely, 1) Guiding principles for the handbook; About this handbook; Chapters 1-9; & Annex: Job Aids. The sections will be presented in the coming tweets.   

First, let us discuss the “Guiding principles for the handbook”.

this handbook is based on three important guiding principles.The1st Principle:Girls and women living with FGM have experienced a harmfulpractice and should be provided with high-quality health care.

The 2nd Principle:Medicalization of FGM violates medical ethicsbecause: (a) FGM is a harmful practice; (b) medicalizationperpetuates FGM; and (c) the risks of the procedure outweighany perceived benefit.

the 3rd Principle: All stakeholders should initiate or continue actions directedtowards primary prevention of FGM. Health-care providers inparticular should play a key role in the prevention of FGM.

Second, let us highlight the “About this handbook”.

this handbook is an easy-to-use tool that contains all the essentialinformation you need in order to provide care to girls and womenwho have been subjected to any type of FGM, either recently or inthe past.

(i) In particular, this Clinical handbook offers advice on how to manage the following six issues listed below:

(ii)how to communicate effectively and sensitively with girls and womenwho have developed health complications due to FGM;

(iii)how to communicate effectively and sensitively with the husbands orpartners and family members of those affected;

(iv)how to provide quality health care to girls and women who have healthissues due to FGM, including immediate and short-term obstetric,gynaecological or urogynaecological complications;

(v)how to provide support to women who have mental and sexual healthconditions related to FGM;

(vi)how to identify when and where to refer patients who need additionalsupport and care;   

(vii) work with patients and families to prevent the practice of FGM.

third, let us enumerate the topics under “Chapter 1-9”. within the 9 chapters,symbols and coloured elements help readers navigate the text andprovide further information relevant to daily clinical practice. They symbols are described in tweets 21b (i to viii).  

(i) “Navigation”:The symbols indicate that readers should go to other chapters andsections for further information.  

(ii)“Note of Referral”: the Use of this blue symbol and/or boxed text signifies that a referralmay be necessary.  

(iii) “Important!”: Use of this red symbol and/or boxed text (example below) highlightsimportant information.  

(iv) “Remember”: Boxed text, and side panels using the word“REMEMBER” highlight important information that readers shouldkeep in mind during clinical practice.  

(v) “Note on follow-up”: Use of this grey symbol and/or boxed text indicates follow-upactions that may be necessary.

(vi) “Assessment Pages”: take readers through the clinical assessmentprocess step by step. Users should go rough all the steps to develop acomprehensive clinical assessment before moving to themanagement phase.  

(vii) “Management Pages”: provide step-by-step instructions on howto provide clinical care. Users should start at number 1and go through all the steps and implement all that areappropriate for your patient.  

(viii) “Icons”:  icons are used throughout the handbook for illustration instructions such as Assess, Take a history, Ask, Reassure/explain, Listen, Record, Refer, Important, Follow-up, Child/minor, etc.

This handbook is organised into 9 chapters that are listed in the tweets 21c (i to ix).  

(i),The Chapter 1 of the Clinical handbook is:Understanding female genital mutilation (FGM)

(ii),The Chapter 2 of the Clinical handbook is:Communicating with girls & women living with FGM  

(iii),The Chapter 3 of the Clinical handbook is:Immediate & short-term physical complicationsarising from FGM

(iv),The Chapter 4 of the Clinical handbook is:Gynaecological & urogynaecological care  

(v),The Chapter 5 of the Clinical handbook is:Caring for women with FGM during pregnancy, labour,childbirth & postpartum

(vi),The Chapter 6 of the Clinical handbook is:Deinfibulation  

(vii),The Chapter 7 of the Clinical handbook is:Mental health & FGM  

(viii),The Chapter 8 of the Clinical handbook is:Sexual health & FGM

(ix),The Chapter 9 of the Clinical handbook is:Additional considerations

Fourth, the section on “Annex: Job Aids”listed:I) Classification of FGM; II)Visual recording of FGM; III)Deinfibulation procedure, IV)Problem management in five steps; and V)Diagrams of the female genitalia

All the recommendations on treatment, care and protection from FGM provided in this handbook apply in conflict, emergency and humanitarian settings, just as in other settings.  

theoutcome 3: of the Phase III of the UNFPA/UNICEF Joint Programme on Eliminating FGM: accelerating change is “Girls and women receive appropriate, quality and systemic services for FGM prevention, protection and care”.  

The Outputs3.1 under Outcome 3 of UNFPA/UNICEF Joint Programme on Eliminating FGM is “Improved availability and quality of FGM services in Joint Programme intervention areas”.   to achieve output 3.1, the UNFPA/UNICEF Joint Programme on Eliminating FGM will continue to mainstream FGM into the curricula of medical and paramedical schools in participating countries like Nigeria.  

An activity under output 3.1 will include Disseminating the “Care of women and girls living with FGM: a clinical handbook(WHO 2018) toimprove care for millions living with the consequences of this practice.

26. To download the “Care of women and girls living with FGM: a clinical handbook (WHO 2018), please visit http://apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1  

27. To learn more about the  Social Media Campaign to end FGM, please visit endcuttinggirls.org and follow our social media handles on Facebook, Twitter, Instagram and YouTube, using  

28. At this point, I will end the presentation to give room for questions and contributions from participants. Thank you all for reading our tweets

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