Factors associated with general practitioners' routines and comfortability with assessing female genital cutting: a cross-sectional survey

Female Genital Cutting (FGC) refers to all traditional practices involving injuring the female external genitalia for non-medical reasons [1]. The World Health Organization (WHO) differentiates between four types of FGC that vary in severity, with type III (infibulation) being the most extensive form. Girls and women with FGC, type III, in particular, have a higher risk of experiencing a series of short- and long-term health problems than those who are not cut [2, 3]. Long-term health problems include genitourinary, obstetrical, and sexual health problems, such as cysts, keloids, dysmenorrhea, hematometra, urinary tract infections, poor urinary flow, perineal tears, prolonged labor, dyspareunia, reduced sexual desire and satisfaction, and symptoms of anxiety, and depression [2‐12].

Although FGC is primarily prevalent in 31 countries in Africa, Asia, and the Middle East, where more than 200 million girls and women have been subjected to FGC [13], it has also spread to other parts of the world. For example, in Europe, it is estimated that more than half a million immigrant girls and women have been subjected to FGC [14], of whom 17,000 live in Norway [15]. Many of these girls and women could need specialized healthcare. For example, those subjected to the most extensive form often require surgical intervention (deinfibulation) to facilitate sexual intercourse and childbirth [16, 17]. Moreover, recent evidence indicates that girls and women subjected to FGC, who live in a context where the majority condemn FGC, such as Western countries, are more likely to report psychosexual problems than those in countries of origin [10, 18‐22]. Consequently, many Western countries have established FGC specialized clinics to meet their affected immigrant population's potential healthcare needs [23]. These countries have also developed training modules and practical and clinical guidelines to help healthcare providers deal with FGC-related health problems and prevent and avert FGC [17, 23‐31].

Since 2000, Norway has had six action plans with earmarked funding to address FGC [32‐36]. Despite the predominant focus on preventive and protective measures, most action plans have also emphasized providing healthcare for those with FGC. Therefore, in 2004, as a national healthcare offer on FGC, several women’s outpatient departments started to provide specialized services for affected girls and women [23].

In Norway, general practitioners (GPs) are typically the first contact between patients and the healthcare system [37]. GPs make primary diagnoses, treat problems that do not require specialized healthcare, prescribe drugs, issue sick leaves, and assess whether the patients need a referral to specialized healthcare services. Upon referral from GPs, the hospitals' outpatient departments provide specialized healthcare services to the patients. To lower the threshold for patients with FGC-related health problems to access specialized healthcare, some hospitals allow women with FGC to contact the women's outpatient departments for appointments directly and thus forego referral from their GPs. However, some girls and women with FGC-related health problems do not benefit from self-referral. They either lack knowledge of the FGC-specialized healthcare services or are unaware of or uncertain whether there is a connection between these problems and FGC [38]. The GPs will continue to play a major role in helping these patients access the appropriate specialized services. Therefore, GPs need to proactively assess whether relevant health problems experienced by these patients are related to FGC. This proactive assessment would most likely entail that GPs take the initiative to ask women from FGC practicing countries about their FGC status when they present with health problems potentially related to FGC. They also need to feel comfortable to discuss FGC with their patients and consequently assess FGC thoroughly as a potential cause.

We do not know, neither in Norway nor other western countries, whether GPs assess FGC as a potential cause of a patient's health problems when such assessment is relevant. However, qualitative studies indicate a mutual silence on FGC during GPs' consultations [38‐40]. Therefore, we need to know more about factors that can improve GPs' practices in assessing FGC among relevant patient groups presenting with potential FGC-related health problems.

Many studies in Western countries have investigated healthcare providers' knowledge, attitudes, and practices concerning FGC [41‐59]. Most studies [41‐44, 46‐48, 52‐59] have included nurses, midwives, gynecologists, and obstetricians, followed by pediatricians [46‐49, 51, 55]. Only three studies [45‐47] included GPs. Furthermore, most studies have assessed whether healthcare providers have received training on FGC, their general knowledge of FGC (types, affected groups, reasons for the practice, health complications, and legislation), attitudes towards medicalization, experience with women subjected to FGC, and relevant practices (educating patients, reporting cases of FGC to child protection services, and performing deinfibulation). Almost all studies have concluded that healthcare providers' knowledge of FGC was insufficient for important FGC-related practices such as clinical management and prevention.

Nevertheless, only a few studies [46, 47, 50, 51, 53, 54, 60] have examined the association between the received training on FGC and the healthcare providers' knowledge or performance of certain FGC-related practices (e.g., identification of FGC cases and notification to child protection authorities). We identified only one [60] study that has investigated care provision. This latter study found a positive association between the healthcare providers' confidence in providing FGC-related healthcare and knowledge of health complications, experience with women with FGC, and more than five years of clinical experience. Still, none of the studies has assessed the association between received training and acquired knowledge and the GPs' routines and patterns of assessing FGC as a potential cause of relevant health problems. This article aims to fill some of the knowledge gaps.

Our main objectives are to examine: a) patterns of received training on FGC among GPs in Norway, their self-assessed knowledge, and their experiences with patients with FGC-related problems; and b) the association between these three factors and the GPs' assessment of FGC as a potential cause of patients' health problems. Our null hypotheis is that there is no statistically significant association between GPs' training levels, self-assessed knowledge, and experiences with patients with FGC-related health problems and the GPs' assessment of FGC as a potential cause of patients' health problems.

We conducted a cross-sectional anonymous online survey between June and July 2019.

GPs have a key role in the healthcare of girls and women subjected to FGC. This article first examined patterns of received training on FGC, self-assessed knowledge, and experiences with FGC-related health problems among 222 GPs in Norway. After that, it examined the associations between received training, self-assessed knowledge of FGC, and experiences with patients with FGC-related health problems and two outcome variables that we used as indicators for the GPs' assessment of FGC as a potential cause of patients' health problems. These two outcome variables were "feeling discomfort talking to patients about FGC" and "routines of asking about FGC in consultations with patients from FGC-practicing countries presenting during pregnancy or with urogenital, sexual, and mental health problems."

Almost two-thirds of our participants received training on FGC during either undergraduate or post-graduate training, which is a higher proportion than those reported elsewhere [46, 51, 53, 54, 57]. In Norway, three out of five medical schools provide training on FGC as part of their undergraduate training [62]. Nevertheless, training on FGC varies in content and duration (between 45–120 min). Considering the many aspects of FGC that need to be covered within such a timeframe, it is not surprising that just over half of the participants received training on FGC-related health problems. Similar to a French study [45], we found that female and younger GPs were more likely to report receiving training on FGC than male and older participants. This latter finding could reflect females' specific sensitization/interest in the topic [45, 47] and a relatively recent introduction of FGC into the medical curricula [62].

While most participants assessed their knowledge of the cultural aspects of FGC as adequate, they did not consider their knowledge adequate when it came to the medical codes. Further, over three-quarters of the participants expressed a need for more knowledge of FGC legislation and the WHO typology on FGC. Our findings are consistent with other studies on knowledge of typology [42, 46, 47, 63], legislation [42, 45, 52, 56, 63], and medical codes [51], but not cultural aspects [48, 52]. It is also possible that the cultural aspects of FGC are particularly emphasized in the training curricula on FGC in Norway. It is also possible that GPs in our study overestimated their knowledge of the cultural aspects of FGC. Previous studies [46, 47] indicate that healthcare providers tend to overestimate their knowledge of FGC. We did not assess the GPs' actual knowledge versus their self-assessed knowledge. Hence, the GPs' levels of actual knowledge of all aspects of FGC in Norway could be lower than those reported in this article. Regardless, our findings indicate that GPs in Norway need comprehensive FGC training, emphasizing typology, health problems, medical codes, and legislation.

In addition, we found female GPs to be more likely to have experience with patients with FGC-related health problems than male GPs, which might be related to a previous finding showing that some women with FGC prefer female healthcare providers [39, 52, 64]. Among the GPs who had experiences with patients with FGC-related health problems, 46% experienced that patients were unaware of the connection between their health problems and FGC. While we do not know the accuracy level of the GPs' diagnoses of health problems as FGC-related, this finding still indicates that the assessment of whether FGC causes the patients' health problems should not be left entirely to the patients. In addition, recent qualitative articles [38, 39] have revealed that some women subjected to FGC prefer their GPs to take the initiative to ask about their FGC status.

Feeling discomfort talking to patients about FGC could negatively affect the GPs' consultations with women subjected to FGC and the assessment of whether the women's health problems are due to FGC [65]. We found that feeling discomfort talking to patients about FGC was significantly higher among GPs who reported a need for more knowledge of the WHO typology than those who did not. In contrast, feeling discomfort talking to patients about FGC was significantly lower among those with knowledge of FGC medical codes than among those without such knowledge. Further, we found that the GPs with adequate knowledge of FGC medical codes were significantly more likely to ask about FGC in their consultations with patients from FGC-practicing countries presenting with urogenital, mental, and sexual health problems than their counterparts. These findings highlight the importance of clinical knowledge of FGC for the assessment of whether FGC is a cause of obstetrical, urogenital, sexual, and mental health problems experienced by girls and women subjected to FGC. We agree with Johnsdotter and Essén [66] that having a too strong focus on FGC as the presumed cause of such symptoms may lead to misdiagnosis. Nevertheless, failing to assess whether FGC is an underlying cause of symptoms could also lead to misdiagnosis and suffering. Careful consideration of whether FGC is an underlying cause for health problems, whenever relevant, is necessary to provide quality care for these women.

The study's low response rate challenges the external validity and generalisability of our findings. To recruit participants, we depended on an available list of valid e-mail addresses of GPs administered by IQVIA, constituting about 79.5% of all GPs in Norway. Selection bias regarding who accepted and reserved against inclusion in IQVIA's e-mail list is possible. Still, it is reasonable to assume that such decisions are unrelated to the aims of the current study. It is also possible that selection bias regarding experience with patients with FGC-related health problems influenced the participation in the study (i.e., those with experience were more likely to participate).

However, we recruited a substantial group (65%) of participants who reported no experience. Gender and age distribution of our participants were close to that of the target population [61]. Thus, even though we would be cautious about generalizing our findings to all GPs in Norway, we consider the knowledge produced by the current study to be a valuable addition to the research field and an important contribution to informing the Norwegian decision-makers and healthcare providers. To our knowledge, this is the first study to use statistical analyses to explore the association between GPs' training and self-assessed knowledge of FGC and their comfort and routines regarding the assessment of FGC as a potential cause of patients' health problems.

Our findings emphasize that GPs have a key role in the clinical management of patients with FGC-related health problems, particularly patients unaware of the connection between their health problems and FGC. Furthermore, we found that GPs were more likely to assess FGC as a potential cause of health problems when they had experience with patients having FGC-related problems and knowledge of FGC typology and medical codes. Therefore, to help GPs proactively assess FGC as a potential cause of patients' health problems, they should receive comprehensive training on FGC with emphasis on typology, health problems, and medical codes.

Finally, future research could benefit from adopting a qualitative approach that builds on our findings to provide a deeper and more insightful understanding of GPs experiences with the assessment with potential FGC-related health problems in Norway beyond the factors explored in this article.