Ethically sensitive approach: reframing the concept of ‘harm’
Few topics elicit such a strong, visceral reaction among women and men from non-practicing countries, as do FGC practices. The fact that many women are the keepers of this tradition, that the practice is so widespread among some groups, given the sub-optimal conditions under which the practice occurs, and the fact that it mostly affects girls creates challenges for health care and community-based providers to give ethically, gender sensitive, non-judgmental care; this is key to the success of SERC’s community-based work as change is progressively and carefully promoted. The issues raised above are key ‘ingredients’ in the training sessions that SERC is engaged in with a diversity of providers along with women themselves, while core information about FGC, diverse cultural meanings and social constructions are shared.
In order to be non-judgmental and ethical, to avoid further marginalization of newcomer women, SERC’s providers had to reflect upon their own feelings and reactions as well as beliefs and values, recognise them and suspend judgement. The presence of an in-community facilitator was essential in these teachings, as she modelled how to reflect the normalcy of FGC in practicing cultures. In addition to this most valued presence, the briefings that were held allowed providers to move away from error-inducing dichotomies such as ‘freedom’ vs. ‘oppression’, and ‘them’ vs. ‘us’ as well as ‘sensitive’ vs. ‘insensitive’ towards quality of service and care for everyone within an environment that would be as bias free as possible [
45]. As providers become progressively aware of the continuum of beliefs and thoughts about the traditional practices, group discussions about a possible shift in these thoughts are held as information is shared with a diversity of women and men.
Similarly, a partnership in Switzerland, between community providers, professional actresses and amateur actors with a migration background have devised a play in English, French and Somali to increase public awareness, without accusing or judging, thereby building trust for the rounds of discussions that follow the performance [
46].
In its mission to establish trust and freedom of conduct while sharing information and training women and providers, one of the challenges SERC faced was to carefully manage potential backlashes within and between members of community groups. SERC has begun to integrate issues associated with sexuality in general while increasing the time allocated to the training in order to allow for sharing and building constructively on potential emotional reactions. As discussed above, the involvement of statutory agencies such as child protection services and the police during selected training sessions have been perceived as an added value anchored in the principles of ethical collaborative strategies. Several initiatives are underway in Winnipeg to build a proper understanding of the role these agencies play in prevention, protection and support as newcomers are simultaneously encouraged to express their views about these institutions. Of interest, no such institutions have yet participated in SERCs’ group discussions so as to not affect the trusting relationships.
Working partnerships between the public health sector and community based organisations with a true involvement of women and men from practicing communities will allow for more sensitive and congruent clinical guidelines. In order to honour the fundamental principles and values of Canadian medical ethics, such as compassion, beneficence, non-malfeasance, respect, and justice and accountability, the complex nature of socio-cultural interactions at the interface of health and migration will continue to require proper attention.
One of the most telling prescriptions from the Canadian Medical Association (CMA) Code of Ethics, article 12, states: “to practice the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect” [
19], p. 1. It entails a commitment to recognise the intrinsic value and dignity of women’s context. It has been argued earlier that selected, at times unintended, reactions from health care professionals may lead to perceptions of stigmatization by some women from practicing communities.
As a final note, it is therefore not superfluous to reiterate the importance of the obligation of health care professionals to provide compassionate and ethical care, especially when clinical situations are complex involving personal, community and legal consequences of a single clinical decision.
‘ … It is unacceptable that the international community remains passive in the name of a distorted vision of multiculturalism. Human behaviour and cultural values, however senseless or destructive they may appear from the personal and cultural standpoints of others, have meaning and fulfil a function for those who practice them. However, culture is not static but is in constant flux, adapting and reforming. People will change their behaviour when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture…’
Joint Statement (August 2007)
UNFPA, UNICEF and WHO at the Global Technical Consultation in Addis Ababa, Ethiopia
‘ … Culture is a matrix of infinite possibilities and choices. From within the same culture matrix we can extract arguments and strategies for the degradation and ennoblement of our species, for its enslavement or liberation, for the suppression of its productive potential or its enhancement…’
Wole Sovinka, Nigerian Nobel Laureate