How do I discuss FGM/C with my patient?

Female genital mutilation/cutting (FGM/C) is an enormously sensitive topic for some women, while others are comfortable talking about it. Some women want to treat the symptoms, while others see FGM/C health consequences as a normal part of life. As you would with anyone else, pick up cues from your patient as to how she feels about living with FGM/C. Does she feel ashamed? Indifferent? Comfortable or nervous discussing health consequences? The tips below are a starting point on how to navigate a thorny topic. 



Use the same words your patient relies on to describe her experience with FGM/C.1 Use the word "mutilation" with your patient.2
Ask if your patient is willing to talk about their FGM/C.1 Insist on discussing FGM/C if the patient doesn’t want to.
Provide a professional interpreter/translator.3 Let a family member serve as the interpreter/translator.4
Limit the number of providers in the room when examining her.* Invite other providers from the practice in the middle of a vaginal examination.
Use a nonjudgmental tone when discussing health consequences.4 React with shock and horror. 
Keep an open mind about how your patient feels about life with FGM/C. Assume all patients are necessarily unhappy living with FGM/C. Some may see consequences such as painful periods or infections as a normal part of life.*
Ask if your patient would like to be accompanied by family members.5  Discuss FGM/C with family members in the room unless the patient brings up FGM/C first.
Make FGM/C care a recurring part of your patient's routine visits in order to help her overcome her embarrassment.6  Assume the patient will bring up FGM/C care during visits. 
Explain why some requests may not be legally or ethically possible (i.e. reinfibulation following deinfibulation is outlawed in some countries).7 Assume your patient knows FGM/C is illegal in the United States. 
Give referrals to specific mental health services or other specialized physicians such as adolescent gynecologists and urogynecologists.8  Assume your patient will seek out these resources on her own. 


* George Washington University Milken Institute School of Public Health original study, 2018-19.

Cultural Sensitivity

When discussing FGM/C with patients, it’s important to remain culturally sensitive and to practice cultural awareness in various scenarios. Cultural sensitivity and awareness exercises an appreciation for another culture’s values and practices.1 Culture is not limited to one’s ethnic background, but also includes other racial and social groups that differ from yours. Health care providers should not make assumptions about a patient's cultural practices, and should not assume every patient with links to a country that practices FGM/C, has had or is at risk of FGM/C. 

Why cultural sensitivity is essential when dealing with FGM/C

A qualitative study of a Somali community in the United Kingdom found that FGM-safeguarding practices often translated into stigmatization and traumatizing experiences.9 The community members in the study were committed to ending FGM, but still reported the challenges that came out of the hyper-focus on one’s culture. Key findings from the study included experiences with health practitioners, where FGM-safeguarding was found to occur in various settings, such as with midwives and general practitioners. While some women felt their health providers approached the topic of FGM in a fine manner, others felt the questions and probing were inappropriate, based on outdated information, and some interactions were re-traumatizing for the patients.9 Much of the differences in perspectives were noted to be related to whether the provider approached the topic in a culturally sensitive manner or not. Additionally, the cultural stigmatization was also seen in school settings, at the community level, or when traveling. These negative experiences led to feelings of alienation, fear, and trauma. Despite being active in working against FGM, the Somali community in Bristol felt their voices and actions were being ignored.9

This example provides an important lens to look through when practicing FGM/C safeguarding within your clinic. There is a delicate balance to strike between ensuring you are picking up on risk factors or behavior changes, while also remaining culturally sensitive.


In their own words: health care providers talk about FGM/C

"When it’s an accepted practice in one culture and the provider is from a culture where it is not acceptable, then we have to be really careful not to judge. Because the person may not have a problem with the fact that they’ve had this procedure. Some may feel terrible about it. Some may think it’s a good thing. As a provider, I need to evaluate where [patients] are with this issue."

"FGM needs to be integrated into screening, pap smears and for when patients are preparing for children. There is a lot of self-blame and embarrassment. For many women, this was not a choice. For many women talking about it was not common."

"If [our patients] come from a place where 95% of women had FGM [and] it is a part of their growing up and what is normal in their society, you don’t want [to] re-traumatiz[e] someone. If it is an issue for them [they] know they can come to you and not have you judge them.And that’s one of the hardest parts--making sure [you] don’t come across [as] “oh my god, what happened to you.” You don’t have to accept everything, but you [do] need to understand."