Proposal for a Multidisciplinary Integrated Service Model for Taking Charge of Women Victims of Female Genital Mutilation

1. Introduction

From the sub-Saharan belt that extends from the Atlantic coast to the Horn of Africa, the mutilation phenomenon spreads globally, dotting the planet with ritual traditions perpetuated on the female body ^1,2.

Estimates portray a population of over 200 million girls and women victims of FGM/C worldwide, and more than 3 million girls each year are affected by the threat of mutilation ^3,4.

However, the illegality of the practice, harshly condemned by the European Union, is not sufficient to hinder its diffusion: there are in fact about 600,000 women living in Europe, on whose bodies the indelible marks imprinted by the observance of this practice stand out ⁵.

The European community, due to the substantial migratory phenomena, is steeped with a multi-ethnicity that understandably drags along its own and varied baggage of popular traditions which, in the case of FGM/C, result in partial or total ablation of the external genitalia.

These customs increase the risk of physical, mental and sexual complications in the short and long term ⁶, irreparably altering the anatomy and physiology of the body. The age of submission varies from the first week of life to adulthood but the excision tradition occurs above all on minors, especially between the ages of three and eight ^7,8.

In 2018, WHO published a clinical manual on female sexual mutilation to improve the knowledge, attitudes and skills of health professionals in the prevention and management of complications related to these practices ⁹.

In general, it must be noted that the political will of the international community has significantly growth in order to boost the actions toward a total end of the practice, dramatically spread worldwide.

The National and International Guidelines recommend the implementation of a multidisciplinary management (already tested in the rest of Europe) which is expressed, at the regional level, through the proposal of a model (Hub- Spoke) of integrated and multidisciplinary service to provide assistance to victims of Female Genital Mutilation, in order to fulfill the complexity of the needs expressed by the women assisted: a vulnerable and disadvantaged underprivileged female population in terms of access to care ^10,11,12.

2. Methodology

Taking into account the requests made by the Ministry of Health for the identification of reference centers for diagnosis, multidisciplinary treatment and the fight against mutilatory practices, together with the numerous initiatives that the ASL City of Turin has promoted, in November 2021 a service dedicated to FGM was opened at the new Multidisciplinary Center for Sexual Health (Ce. Mu.S.S.).

Ce.Mu.S.S. was born as the first and only center in Italy with this structure: based on the Anglo-Saxon Nurse-led model, it is organized starting from the unification of the three IST centers of the Metropolitan City of Turin with a multi-specialist footprint.

The FGM service, located within the Ce.Mu.S.S., fully adapts to the multidisciplinary model: it provides, in fact, the presence of two gynecologists, a coroner and a midwife who, in collaboration with the nursing staff, with psychologists and cultural mediators already present at the Ce.Mu.S.S., are able to provide high-level assistance in the prevention, diagnosis and treatment of FGM, as well as propose sexual health education interventions in the target population of women and in general.

The service aims to provide diagnostic and treatment services (de-infibulation and reconstruction of the genitals, coupled with psychological support for women victims of FGM), as well as to promote contrast to the practice through specific prevention activities for the population at risk, training courses for health workers, and with the production and spread of information material specific to citizenship.

The FGM center has a central role in defining relations with the local authorities that deal with the phenomenon and its main goal is to structure the implementation of a network between the territory and the birth centers, to be able to assist the women victim of FGM in their sexual and family life, during the period before and after delivery.

To fulfill this purpose, the five meetings held in Turin between April and May 2022 chaired by Amref Health Africa Italy in the framework of the project “P-ACT: paths of action against the cutting of rights” financed by the Asylum, Migration and Integration Fund (FAMI) of the Ministry of the Interior proved to be fundamental.

At the end of the aforementioned appointments, which were attended by the health and associative realities engaged in the fight against FGM at regional level, a first draft of the “Protocol for the launch of a territorial Network of prevention and contrast to FGM in Turin” was defined, which sets objectives, roles and responsibilities of the various local authorities as well as commitments, including economic ones, to be submitted to the attention of the institutions.

The achievement of the key objectives of the Territorial Network was made possible through the active involvement of the various participating entities that took part in the training events co-organized and scheduled during the meetings and provided by the Distance Learning (DL) system.

The appropriate training of those involved plays a key role in early risk interception, laying the foundations for the structuring of a more sustainable, fairer, less precarious social and health system, in which the right to health is not disregarded but assumes a priority role in the system of resource allocation. Significant in this regard is the example of the Parisian health context: despite the absence of a standardized system for taking charge of women with FGM, it emerges
that the proposal for a personalized, multidisciplinary and multi-specialized service to women living with FGM is a public health duty, as stated by the GAMS Federation (Groupe pour l’abolition des Mutilations Sexuelles Féminines) ^{11, 13, 14}.

3. Outcomes

The international examples supported by the International Guidelines show that the only possible approach to FGM is multidisciplinary and integrated. Taking into account the urban context of Turin and the territorial structures that already exist and already operate in the field of FGM, the center opened at Ce.Mu.S.S. plays the role of a hub and manages activities aimed at stakeholder involvement, staff training and medical and surgical care, if needed, for women victims of FGM.

The services present in the territory (Spoke) allow for a two-way system that sees the convergence of women towards the health center and the divergence from it towards the other entities that are part of the model. This enhances and facilitates not only users’ access to the center but also the opportunity to connect with FGM victims by offering them valuable support and assistance at various times and stages of their lives.

In particular, the health services responsible for the first level of assistance and interception of women victims of FGM are consultors, general practitioners (GP), hospitals and services against sexual violence.

Ce.Mu.S.S.’s FGM service aims to act as a HUB to be referred to in case territorial services need a specialized intervention such as surgical repair (e.g. deinfibulation and/ or clitoral reconstruction). In addition, community services may respond to a specific need of the woman in terms of social assistance or psychological support for that requires more in-depth and structured long- term management and for which the hub center is available for referral.

Parallel to the health services, associative bodies are structured entities that come into contact with women also through the Anello Forte, anti-trafficking network of Piedmont and Valle d’Aosta ¹⁵.

This project, funded thanks to the national action plan against trafficking and serious exploitation, has allowed the construction of a system of services such as mobile units, the toll-free number, the counters, the Extraordinary Reception Centers (Cas) and the Protection System for asylum seekers and refugees (Sprar).

These have been involved, on various levels, in the project of Amref Health Africa – “P-ACT: paths of action against the cutting of rights” – thus allowing a fruitful exchange of contacts and the definition of standardized procedures for sending and receiving women victims of FGM, as well as for reporting any risk of recurrence of this practice on newborns.

The territorial services that took part in the meetings chaired by Amref proposed to delegate a figure that could interface systematically with the MGF Service of Ce.Mu.S.S. in order to define relationships of constant updating, exchange and sharing.

One of the closest collaborations of the FGM Center has been defined with the social workers of the Corporate Social Service of the ASL City of Turin for which a contact person has been appointed. This person will be dedicated to the activities of the FGM Center, and will be consulted in case of particularly sensitive issues, involving minor or underlying situations of gender violence.

Due to the implication of FGM with the application for political refugee status, the role of social workers and coroners is crucial in order to best manage the relationship with the woman and her family, ensuring the protection not only of her safety and rights but also of compliance with Italian legislation.

The FGM Service is thus placed at the center of an ideal graph (Figure 1) at whose extremes we find, like petals of a flower, the territorial services that can intercept and consequently bring to the attention of the Service a particular case or, vice-versa, receive from Ce.Mu.S.S. specific reports for standardized social or health interventions intended for the patient.

By applying the system expressed in Figure 1, conceived through the ideas that emerged within the workshops organized by Amref and from the discussion with international services already working in the field, it is therefore possible to ensure the personalization of patient care. Moreover, the system will ensure the long-term sustainability of the intervention (educational, health, psychological, social) implemented and comprehensiveness regarding all the needs that such a complex phenomenon as FGM entails.

Fig. 1. Multicentre and Multidisciplinary Service Model for Women with FGM.

Some of the achievements include training activities organized by the FGM Service and targeting different categories of health and social workers.

These allowed for the improvement of awareness and sharing of content and stimulus for a less superficial and more competent approach to healthcare. Specifically, the involvement of the GP and obstetrical-gynecological emergency room staff has allowed the construction of pathways not only for diagnosis and treatment, but also for prevention. In this way, attention is drawn to the mutilatory phenomenon as early as during the first contact with the woman, so that she can have the time and tools to consciously and freely reflect, remember and decide respecting her own body and health. It is essential to de-link the “first contact = urgency” association typical of FGM women’s access, and also to set the foundation for a constructive and welcoming dialogue on the topic of FGM. These foundations should be laid as early as adolescence and, in any case, hopefully before the onset of sexual activity.

This “preventive” rather than “interventional” approach expresses its value not only towards women already victims of FGM but also in newborns and in all generations of girls at risk of perpetuation of the phenomenon, both in the countries of origin and in Europe.

At the social level, on the other hand, the training of educators, psychologists, social workers, and in general all those involved on the local level within cooperatives or associations in contact with the migrant population, contributed exponentially to the increase in the number of accesses and visits provided by the FGM Service in the second half of 2022. This fact confirms the success of the Hub-Spoke dialogue in the management of FGM.

4. Limitations

The topic of FGM is still little known and most professionals, especially in the healthcare field, lack the skills to deal with it. This lack leads to an inadequate and deficient service, as well as an inherent and concrete difficulty in building significant diagnostic-clinical pathways. Although in Turin there is a very specialized service such as the one opened at the Ce.Mu.S.S., at the territorial level this does not translate with as much immediacy. This delays – if not compromises – the definition of integrated pathways and the management of less complex cases by the services already existing.

This limitation can be overcome through to the wide-ranging training interventions organized by the FGM Service and Amref Health Africa, but will significantly delay the implementation of the hub-spoke model.

In addition, the formation of a territorial network is not sufficient for the long-term functioning of the relations between the territory and the institution. Therefore, it is also necessary to define roles in relation to the need to interact with institutions to enable discussion on the allocation of funds dedicated to combating FGM. To this end, the definition of a supra-local/regional lead subject and the formalization of a multi-departmental and inter-institutional standing committee for the prevention and combating of FGM is essential. These objectives are also mentioned in the draft protocol drawn up by the actors who participated in the meetings with Amref Health Africa in Turin between April and May 2022.

5. Conclusion

National plans and regional investment to open a dedicated service to fight and manage FGM at the Sexual Health Center need an area context to interface with.

The Ce.Mu.S.S. is an excellent example of a multidisciplinary reality from which to define paths for sharing the burden resulting from the management of this phenomenon.

Within the FGM service there are specialists responsible for managing the most complex clinical cases and organizing training and consulting courses aimed at local authorities.

The implementation of this service designed on the basis of the Hub-Spoke model and described in the results of the research project, concretely responds to the needs that emerged from the careful analysis of needs conducted at regional level on FGM. The territorial context with which to interact is the resource identifiable in the capillary territorial services (Spoke) that allow the convergence of women to the health center (Hub). The Hub is recognizable by the multidisciplinary team of gynecologists, obstetricians, urologists, forensic doctors, sexologists, psychologists, and cultural mediators that make up the FGM outpatient clinic located within the Ce.Mu.S.S.

Taking charge of these cases would be personalized, sustainable- able and complete with respect to all the needs that such a complex phenomenon implies.

A phenomenon, that of FGM, which ultimately reflects a profound and atavistic gender inequality at the worldwide level between man and woman and violence against women and girls.