Can+you+feel+the+pain+if+you+were+me?

=Topic: "Can you feel the pain if you were me?” Health consequences and associated factors of female genital mutilation=

**__//Cultural//__ **//**__Artifact__** // ====It is a front cover photo on Bristol Safeguarding Children Board (BSCB) factsheet and took from Amnesty International – Sweden (2011). The main function of Bristol Safeguarding Children Board (BSCB) is to co-ordinate and lead work on child protection within Bristol. BSCB is made up of organisations and people working together to promote children's welfare and keep them safe (Bristol Safeguarding Children Board, 2011). This artefact demonstrates a clear and concise representation of Female Genital Mutilation. The photo shows a red rose which petals are bound by wires. The red rose is delicate and beautiful signifying the traits of a female and representative of the female genital. The red colour of the rose is also symbolic of the bleeding female genital and the pain of female genital mutilation portrayed through the wires in the rose.====

**//__Public Health Issue__//** ====The term “Female Genital Mutilation” also called “female genital cutting" refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. According to the World Health Organization (2011), around 140 million women across the globe are affected by FGM, with around 3 million girls undergoing the procedure every year. Estimates suggest that there are around 120,000 migrant women in Australia who have undergone the practice in their countries of birth. (Australian Bureau of Statistics, 2007) Moreover, there are specific laws banning FGM in the majority of Australian states and territories. (Toubia and Rahman, 2000) Dr Ted Weaver (2010)from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists said that, “there is some evidence to suggest that it does happen in certain parts of Australia. It's very hard to gauge the actual numbers because obviously this is often, because it's prohibited by legislation, and it's something that is performed in an underground way.”====

Type 2 – excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (Figure b).
====Type 3 – infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris (Figure c).====

Type 4 – other: all other procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping or stretching the labia (Figure d).
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**//__L__////__iterature Review__//** ====Research from the last 10 years has shown that Female Genital Mutilation is an important issue affecting women’s health. It is not only a short term hazard but also results in long-lasting physiological and mental damage. In addition, the obstetric costs of FGM are a huge burden for society and the government.====

====In today’s issue of The Lancet, Lars Almroth (2005, P.385-391) and colleagues did a case-control study in Sudan enrolling 99 women with primary infertility not caused by hormonal or iatrogenic factors, to investigate the possible association between female genital mutilation and primary infertility. 48 women had appendages of organ pathology indicative of previous inflammation (Almroth et al., 2005, P385-391). The authors conclude that primary infertility was associated with the actual anatomical extent of FGM, and not whether the vulva had been sutured or closed(Almroth et al., 2005, P385-391). Therefore, infections that occur after FGM in childhood might affect the internal genitalia, causing inflammation, scarring, and subsequent tubal-factor infertility.====

====For thatreason, Female Genital Mutilation is a harmful traditional practice with severe health complications. In Gambia, the prevalence of FGM is 78.3% in women aged between 15 and 49 years (Hechavarría, Kaplan, Bonhoure& Martín, 2011, p. 26). The data was collected on types of FGM and health consequences of each type of FGM from 871 female patients who consulted for any problem requiring a medical gynaecologic examination and who had undergone FGM (Hechavarría et al. 2011, p. 26). This study shows that FGM is still practiced in Gambia, the most common form being clitoridectomy (Type 1), followed by excision (Type 2). All forms of FGM, including clitoridectomy (Type 1), produce significantly high percentages of complications, especially infections (Hechavarría et al. 2011, p. 26).====

====Following increased global mobility, it has also become a common medical issue in many countries where an increasing number of immigrants from regions where Female Genital Mutilation is still traditional. Johnstone and Kanitsaki (2007) argue that the health status of racial and ethnic minority groups, including immigrants and refugees, is poorer than that of the local population of the country they are living in. In Australia there are disparities in health among minority racial, ethno-cultural and Indigenous groups, and most recently, new immigrants and refugees (Allotey, 2003., ABS, 2007. , AIHW, 2005). This is despite the fact that Australians are one of the healthiest populations and have access to a world class health system (AIHW, 2007., ABS & AIHW, 2008, Department of Health South Australia, 2004).Further research ( Elgaali, Strevens & Mardh, 2005 ) supported that FGM isperformed in immigrant women even after settling in areas where this practise is legally banned. Circumcised immigrant women experience medical and sexual problems which have to be dealt with in their new domicile country. Many African Islamic women, who have migrated to other countries, still seem to be in favour of the continuation of circumcision for varying reasons. A questionnaire was distributed to 220 immigrant women (16–42 years old), who belonged to an African community in Scandinavia and who had all been circumcised (Elgaali et al., 2005). Information was also gathered concerning 76 of their daughters (aged 1–13 years) (Elgaali et al., 2005). Of the women's husbands, 95 were asked about their attitudes to FGM. For the results, 140 women had been circumcised in their home country before they migrated, 78 (35%) had undergone clitoridectomy (Type 1), 38 (17%) had been subjected to genital excision and 24 (11%) to infibulations (Type 3) (Elgaali et al., 2005).====

====In Canada, a 36-year-old woman, who underwent FGM at the age of four, was presented to the colposcopy unit which is a medicaldiagnosticprocedure to examine an illuminated, magnified view of the cervixand the tissues of thevaginaandvulva ( Chase, 2009 ), with increasing swelling of the vulva (Hamoudi & Shier, 2010). Examination revealed a large cystic mass in the midline of the vulva, and MRI identified two well-defined cystic lesions (Hamoudi & Shier, 2010). The mass was excised, and histological examination confirmed an epidermal inclusion cyst. The author concluded that an epidermal inclusion cyst can develop as a long-term consequence of FGM (Hamoudi & Shier, 2010). Although it grows slowly and usually without symptoms, it may require excision because of inflammation, secondary infection, or, in rare cases, malignancy developing within the cyst (Hamoudi & Shier, 2010). Canada’s immigrants are increasingly from non-English-speaking countries with different medical issues. Female genital mutilation is a procedure performed for non-medical reasons that is not traditionally encountered in Canada and that has serious health implications for women.====

====Moreover, the cost to the health system of obstetric complications due to female genital mutilation is high (Bishai et al., 2010). A multistate model depicted six cohorts of ten thousands 15-year-old girls who survived until the age of 45 years in the six African countries (Bishai et al., 2010). Cohort members were modelled to have various degrees of FGM, to undergo childbirth according to each country’s mortality and fertility statistics, and to have medically attended deliveries at the frequency observed in the relevant country (Bishai et al., 2010). The risk of obstetric complications was estimated based on a 2006 study of 28 393 women (Bishai et al., 2010). The costs of each complication were estimated in purchasing power parity dollars for 2008 and discounted at 3 %(Bishai et al., 2010). The model also tracked life years lost owing to fatal obstetric haemorrhage (Bishai et al., 2010). The annual costs of FGM-related obstetric complications in the six African countries studied amounted to $ 3.7 million and ranged from 0.1 to 1% of government spending on health for women aged 15–45 years (Bishai et al., 2010). In the current population of 2.8 million 15-year-old women in the six African countries, a loss of 130 000 life years is expected owing to FGM’s association with obstetric haemorrhage (Bishai et al., 2010). This is equivalent to losing half a month from each lifespan. Beyond the immense psychological trauma it entails, FGM imposes large financial costs and loss of life. The cost of government efforts to prevent FGM will be offset by savings from preventing obstetric complications.====

====The researchers note that their study has a number of limitations. First, it did not address the medical complications of the initial procedure--pain, bleeding and infection--or any psychological or psychosexual consequences. Second, the data were collected from a small number of each country. Third, some studiesare based on self-reporting of the participants.====

**//__Cultural and Social Analysis__//**

1. Religious Reasons
====It is a common misconception that it is an exclusively Muslim practice. Female Genital Mutilation is also practiced by many secular and religious groups; including Egyptian Christians,( Reymond, Mohamud & Ali, 2000) Ethiopian Jews, and non-believers.(Reymond et al., 2000 & World Health Organization, 1997) In fact, FGM predates Islam(Reymond et al., 2000). Some Muslim communities practice FGM because they believe that their faith demands it(Trueblood, 2000).====

====In 1994, the Sheikh of Al-Azhar, Sunni Islam's highest authority, persuaded the Egyptian Ministry of Health to issue a decree, which permitted hospitals in Egypt to perform the procedure (Trueblood, 2000). However, three years later, the Sheikh changed his opinion on the issue, and "reaffirmed" his support for the Egyptian Health Ministry's ban on FGM (Trueblood, 2000). Sheikh Mohammed Sayyed Tantawi also made a statement in support of the ban, "I support the Health Ministry's decision to ban excision because it is a medical and not a religious matter. (Trueblood, 2000)" The Sheikh added, "all the hadith on excision are weak," a reference to the sayings of the prophet Mohammad, one of the foundations of Islamic legislation(Trueblood, 2000). However, many clergy continue to support the practice, and religion continues to be a primary motivation for FGM among Muslim populations(Trueblood, 2000).====

2. Sociological Reasons
====Female Genital Mutilation is an ancient practice cloaked in tradition allowing women to identify with their cultural heritage. The sociological reasons supporting FGM are the strongest as they are imbedded in the daily lives of these women. FGM is performed as a rite of passage to womanhood(Trueblood, 2000). An elaborate ceremony may surround the event where songs and dance are performed to teach the young girl her duties as a good wife and mother. The girl may even receive gifts, such as gold, clothes and food (Hassan, 1995).====

====If a girl does not undergo the procedure society may shun her; she may be ostracized from her family, and may never marry (Hassan, 1995 & Reymond et al., 2000). In Kenya, a sixteen-year-old girl, Regina Muakaria, was chased away from her home because she refused to undergo the procedure before entering secondary school(Trueblood, 2000). Failure to be circumcised can lead to tremendous social pressure and harassment. In the Sabiny culture in Uganda, an uncircumcised woman cannot speak in front of elders, hold any position of responsibility, or even marry(Reymond et al., 2000). The impact of social pressure from peers, husbands and other extended family members towards female circumcision is expressed by a nineteen-year old woman who was circumcised the previous year. She explains the social pressures she experienced:==== ====I dropped out of school and decided to get married. I did not like to undergo circumcision, but was compelled to accept it. My friends are circumcised, so I was isolated, a social outcast and not respected. I was told by in-laws that if I did not undergo circumcision, dowry would not be paid(Reymond et al., 2000).==== ====Another pressure women endure comes from mothers-in-law and other wives in polygamous marriages, who want uncircumcised women to look like them and to be respectable(Reymond et al., 2000).Interestingly, most women who have been subjected to FGM strongly favour it for their daughters(Reymond et al., 2000).==== ====FGM is most common in the western, eastern, and north-eastern regions of Africa, in some countries in Asia and the Middle East, and among certain immigrant communities such as Australia. Between 100 and 140 million girls and women worldwide are living with the consequences of FGM (World Health Organization, 2010). Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. In summary, FGM is mired in tradition, culture, and religion. Thus, there exist numerous complexities. Religions may reinforce this practice, tacitly or explicitly. History and poor education about women's reproduction and sexuality combine to make FGM difficult to stop. Solutions are not easy and enforcement is even more difficult.====

**//__Reflection on Cultural artefact__//** ====This artefact has shown a clear and concise representation of Female Genital Mutilation. As this essay mentioned about it is shown a red rose which petals are blinded by wires. The red rose is delicate and beautiful which is represented female and that is intimated the female genital. The red rose is delicate and beautiful signifying the traits of a female and representative of the female genital. The red colour of the rose is also symbolic of the bleeding female genital and the pain of female genital mutilation portrayed through the wires in the rose. FGM can cause immediate complications including pain, bleeding and infection and long term complications such as obstetric and psychological problems. Several factors have been associated with an increased likelihood of FGM. It sounds dangerous to females and hurts them severally. It is hard to imagine how young women who have undergone FGM could overcome this trauma. In the meantime it is hoped that the contemporary medical system would help those who undergo FGM to recover. ====

====Almroth, L., Elmusharaf, S., El Hadi, N., Obeid, A., El Sheikh, Mohamed A A, Elfadil, S. M., & Bergström, S. (2005). Primary Infertility After Genital Mutilation in Girlhood in Sudan: A Case-Control Study. //Lancet//, 366(9483), 385-391.====

====Australian Bureau of Statistics. (2007). //Country of Birth of Person by Age by Sex - Australia//. Retrieved from http://www.censusdata.abs.gov.au/ABSNavigation/prenav/ViewData?breadcrumb=POLTD&method=Place%20of%20Usual%20Residence&subaction=-1&issue=2006&producttype=Census%20Tables&documentproductno=0&textversion=false&documenttype=Details&collection=Census&javascript=true&topic=Birthplace&action=404&productlabel=Country%20of%20Birth%20of%20Person%20by%20Age%20by%20Sex&order=1&period=2006&tabname=Details&areacode=0&navmapdisplayed=true&====

====Australian Bureau Statistics (ABS) & Australian Institute of Health and Welfare (AIHW). (2008). //Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples//. ABS Cat.No.4704.0 and AIHW Cat. No.IHW21. Canberra: ABS & AIHW.====

====Bishai, D., Bonnenfant, Y., Darwish, M., Adam, T., Bathija, H., Johansen, E. (2010). Estimating the Obstetric Costs of Female Genital Mutilation in Six African Countries. //Bulletin of the World Health Organization//, 88(4), 281-288. doi:10.2471/BLT.09.064808====

====Bristol Safeguarding Children Board. (2011). Factsheet //for Professionals - Female Genital Mutilation [leaflet].// Bristol, UK. Retrieved from http://www.bristol.gov.uk/sites/default/files/documents/children_and_young_people/child_health_and_welfare/FGM%20Leaflet%20for%20Professionals%20printable%20version%5B1%5D.pdf====

====Elgaali, M., Strevens, H., & Mardh, P. (2005). Female Genital Mutilation -- An Exported Medical Hazard. The European Journal of Contraception & Reproductive Health Care : //The Official Journal of the European Society of Contraception,//10(2), 93-97. doi:10.1080/1362518040020945====

====Hechavarría, S., Kaplan, A., Bonhoure, I., & Martín, M. (2011). //Health Consequences of Female Genital Mutilation/cutting in the Gambia, Evidence into Action. Reproductive Health//, 8(1), 26-26. doi:10.1186/1742-4755-8-26====

====Johnstone, M., & Kanitsaki,O.(2007).An Exploration of the Notion and Nature of the Construct of Cultural Safety and Its Applicability to the Australian Health Care Context. //Journal of Trans-cultural Nursing,// 18(3), 247—256.====

====Toubia, N., Rahman, A., Center for Reproductive Law &, Policy, & RAINBO (Organization). (2000). //Female Genital Mutilation: A Guide to Laws and Policies Worldwide//. London: Zed in association with CRLP and RAINBO.====

====Trueblood, L. A. (2000). Female genital mutilation: A Discussion of International Human Rights Instruments, Cultural Sovereignty and Dominance Theory. //Denver Journal of International Law and Policy//, 28(4), 437.====

====World Health Organization. (2011). //Eliminating Female Genital Mutilation – an Interagency Statement. OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCE, UNICEF, UNIFEM, WHO//. Retrieved from http://whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf ====



http://healthculturesociety.wikispaces.com/Doctor-Patient+Relationships

I think service providers should be aware of how personal beliefs and perceptions make objective assessment and treatment of patients’ pain difficult. When working cross-culturally, the first step is to understand the perspective of the patient, especially their treatment goals. The next step is to identify a treatment plan that is acceptable to the patient and to the health care team. Undertreatment or overtreatment of pain may result if service providers are not familiar with the cultural backgrounds of patients or make stereotypical assumptions. The most effective way to address cultural difference is through open and balanced communication.

Thanks.