Female Genital Cutting in Children Medical, Ethical, and Legal Considerations

1. Female Genital Cutting in ChildrenMedical, Ethical, and Legal Considerations Janine Young, MD, FAAP November 14, 2019

2. Financial Disclosures • CDC grant sub-recipient, MN Dept of Public Health, Refugee Centers of Excellence

3. What is FGM/C? • Medically unnecessary cutting of parts or all of the external female genitalia, including clitoris, prepuce, labia minora and majora • Associated with significant morbidity and mortality • Predates Judaism, Christianity and Islam • Not tied to any specific religion, ethnicity or race • Reasons for FGM/C vary by region and culture • Increases marriageability, preserves virginity, improves hygiene, rite of passage

4. Photo credit: USAID

5. FGM/C is a Pediatric Practice • However… • No national/international clinical practice guidelines for medical providers who care for children (UK for abuse) • No training slides • No standard training requirements for Peds, FPs, Child Abuse specialists, Peds Uro, Peds Urogyn, Peds surgeons, Adolescent Med docs, Mental health providers • No standard training of Child Protective Services workers, school nurses, teachers

6. WHY?

7. Photo credit USAID PRC, Accessed 9/16/19

9. Percentage of girls and women 15-49 years who have had FGM/C, by country WHO, FGM, https://www.who.int/reproductivehealth/topics/fgm/prevalence/en/, Accessed 9/16/19

10. Available at: http://www.strategiesconcertees-mgf.be/wp-content/uploads/Capture-d’écran-2013-07-09-à-23.22.37.png

12. Maternal report of age girls have undergone FGM/C WHO, Human Reproduction Program http://www.who.int/reproductivehealth/topics/fgm/prevalence/en

13. Girls at risk? How do we know? Population Reference Bureau, https://www.prb.org/us-fgmc/, Accessed 9/16/19

14. FY 2017: Illinois resettled 3,002 refugees Illinois Early Childhood Asset Map, https://iecam.illinois.edu/visual/15932/, Accessed 9/16/19

15. https://www.chicago.gov/content/dam/city/depts/mayor/Office%20of%20New%20Americans/PDFs/IL_Refugee_Resettlement_Program_FY18.pdfhttps://www.chicago.gov/content/dam/city/depts/mayor/Office%20of%20New%20Americans/PDFs/IL_Refugee_Resettlement_Program_FY18.pdf

16. Country of origin of at-risk refugee arrivals to ILL, FY2010-2015 https://iecam.illinois.edu/characteristics/other-factors/refugees/, Accessed 9/16/19

17. AAP Clinical Report, Young J, Narang S, et al, pending release

18. Photo credit: USAID

19. Standard of care practice? • “At each and every well-child check I examine private parts of all boys and girls to makes sure that everything is normal. I need your parent’s permission and your permission to do so. It takes about 5 seconds and I only check the outside, not the inside. You know that no one should examine your private parts except if a doctor gets permission, right? Do you know that you need to tell a trusted adult if someone is touching your private parts, correct?”

20. Physical Examination • Draped, frog-leg, parent at side for infants, young and mid-aged children • Teen with chaperone • Document permission and chaperone, as needed • Document physical findings • AAP: “A chaperone is recommended during…genital exams and should preferably be a nurse or medical assistant, not a friend or family member. However, offices are not required to have a chaperone. In certain situations, a chaperone may not be present because of patient choice or a chaperone from the office is not available. Pediatricians should develop their own office policy…..document in the patient’s medical record if and why they are unable to follow it.” Pediatric Patients and Chaperones in the Exam Room, AAP. Available at: https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Pediatric-Patients-and-Chaperones-in-the-Exam-Room.aspx

21. Visual diagnosis of child abuse, CD-ROM, 3rd Edition, AAP 2008

24. Visual diagnosis of child abuse, CD-ROM, 3rd Edition, AAP 2008

25. AAP, Visual diagnosis of child abuse, CD-Rom 3rd Edition, 2008

26. Abdulcadir J, et al. J Sex Med 2016

27. Abdulcadir J et al. Obstet Gynecol 2016.

31. Photo credit: USAID

32. Bright Futures, AAP, Physical Exam Recommendations • Newborn-5 days: “Genitals: Determine whether testes are fully descended. Determine whether labia are open.” • Infancy: “Genitalia/rectum: Determine that testes are descended; observe for penile anomalies or labial or vaginal anomalies.” • 6 days-6 years: No genital exam advised, besides asking for concerns in ROS. • 7-10 years: “Breast and genitalia: Assess for sexual maturity rating.” • 11-17 years: “Genitalia: Perform visual inspection for sexual maturity rating. A pelvic examination may be clinically warranted, based on specific problems.” • 18-21 years: “Genitalia: Female: Perform examination as indicated by patient or practitioner concerns. Male: Perform visual inspection and examine testicles for sexual maturity rates. Examine testicles for hydrocele, hernias, varicocele, or masses.” Bright Futures, Guidelines for Health Supervision of Infants, Children and Adolescents.

33. Young J et al, pending publication, J Imm Refugee Health

34. FGM/C Education, Knowledge, and Comfort in diagnosis among general peds and child abuse peds, n=132

36. CPT Code Defibulation(Not Specific to FGM/C) • 13131Defibulation (general procedure code) Repair, complex procedures on the Integumentary System (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet) • 56441 Lysis of labial adhesions • 56800 Plastic repair of introitus For complicated procedures, add the -22 modifier and document any additional physician work

37. Unpublished data, courtesy of Crista Johnson-Agbakwu, MD, MSc, FACOG

38. Visual diagnosis of child abuse, CD-ROM, 3rd Edition, AAP 2008

39. Visual diagnosis of child abuse, CD-ROM, 3rd Edition, AAP 2008

40. Graham, E https://ethnomed.org/clinical/womens-health/RFGCGrahamslides.pdf

41. Young J. et al. AAP FGM/C Clinical Report, pending release

42. Ethiopian 2 year old, new to US Photo credit: Young, J

43. Photo credit: Young, J

44. Graham, E. Reproduced with permission from UW Medicine/Harborview Medical Center for Sexual Assault and Traumatic Stress

45. Photo credit: M Toure, Bamako, Mali

46. Photo credit: Sy, ObGyn, Bamako, Mali

47. BMJ Open, Creighton S et al 2016

48. Photo courtesy of J. Abdulcadir

49. Photo credit: USAID

50. Timeline of International Legislation Against FGM/C Cameroon, The Gambia, Liberia, Sierra Leone and Indonesia do not have any laws or decrees that criminalize FGM/C https://www.unicef.org/media/files/UNICEF_FGM_report_July_2013_Hi_res.pdf. Accessed May 25, 2018