Listen to the audio file of the interview of Dr. Kathy LaFavor by Dr. Haddad. Read the articles by Litrop, et al., Ahmuda and Shweder, and Londono Sulkin that are on e-reserve for this session to provide background information on female genital cutting. Discuss how the observations of Dr. LaFavor regarding a troubling trend in her clinical practice could lead to involvement of the ethics committee and in what ways. How could or should the ethics committee assist Dr. LaFavor and her colleagues?
Instructions
Examples of criteria are completeness, correctness, clarity, and lack of ambiguity. During the week, reply to at least two other posts. Review criteria for citations and quotations when these are appropriate for the initial post or responses. Generally, keep quotations to a minimum. Emphasize using your own words.
275 words. State word count (citations excluded). Cite sources for comments and quotations with abbreviated forms for the text and other assigned readings. Use full citations for other sources (You must use APA format).
Required text book
REQUIRED TEXTS:Post, L.F., Blustein, J., & Dubler, N.N. (2007). Handbook for Health Care Ethics Committees. Johns Hopkins University Press, Baltimore, MD.
Hester, D.M. & Schonfeld, T. (Eds.) (2012). Guidance for Healthcare Ethics Committees. Cambridge University Press, New York, New York.
Read and answer questions.
TRANSCRIPT: Haddad/LaFavor
Haddad: Alright. This is Dr. Amy Haddad, and I’m director of the center for health policy and ethics. And I have a wonderful opportunity of talking to Dr. Cathy LaFavor, who is a fourth-year medical resident in obstetrics and gynecology, in school of Medicine here at Creighton University And we’re gonna be talking today about a roundtable presentation that we’re gonna be doing late this afternoon. And I thought I would try and go back and re-create the first time that we had the opportunity to talk about the topic that you’re gonna discuss. And, I started my question by saying when did you first encounter a patient who had a genital mutilation? And I don’t know if that’s the place to start the story, if it was a clinical encounter. But maybe you can just take it back to the first time that you encountered this in clinical practice or why you became interested in taking care of patients with this.
LaFavor: I probably encountered it a lot earlier than when I discovered what it was. We have a high Somalian population here at Creighton, and so we do often see them in our clinics. And it took me probably several months before I knew. I’ve never heard of the procedure, even during medical school, before I’d heard. And we refer to it as female genital cutting or circumcision in our clinics. And it was probably at least half way through my 1st year residency, when I became familiar with it, and would be able to identify patients who would have the procedures. I was asked to do a grand rounds about a year ago, and had e-mailed the Ethics department to see if there is any policy in regards to re- infibulation at the time of delivery for a hospital. And that’s kind of where we made the first contact, and, speaking with the department, there really was nothing in place of, how do we deal with these patients as physicians when they want a re- infibulation And so that’s kind of where all of this round table has spurred from.
Haddad: Alright, so that you, so, I’m gonna back up. Because there’s probably terms that people are not through familiar with. So, and even when you improperly corrected me with how this is referred to in the literature, even using the word mutilation and circumcision makes a difference in how we even talk about this. So could you kinda take that umbrella term of female genital circumcision, and say what different things might be in there, and then, of course, one of those is the term re-infibulation. So maybe you could take us through what that might entail.
LaFavor: The way that most literature likes to refer to it is female genital cutting, just because female genital mutilation has kind of a poor connotation, where many women don’t feel that their genitalia is mutilated. it’s just part of their culture. And so, the female genital cutting is just a more friendlier way to phrase the procedure. Most women don’t have any problems with it referred to as circumcision, but they also wanna know that it is something different than a circumcision because many will think that it’s analogous to a male circumcision. So that’s kind of why we use the topic female genital cutting. And basically it refers to any destruction to the tissue of female genitalia. And we’ll go over, there’s 4 different types. Some is just removing the skin around the genitalia called the prepuce. Some is destroying the clitoris, which is the orgasmic organ in females, and some involved removing more extensive part of the genitalia, like the labia. And then sewing that tissue together and basically creating a very small hole, through which urine and menstrual flow pass through, and then also, intercourse, is done through this opening.
Haddad: So that’s the infibulation part?
LaFavor: Right. And so defibulation is just removing that. Some women will want that procedure reversed if they’re having problems. And then re- infibulation is actually, where we see it is after delivery, if they would have torn along that scar, or if we had to cut the scar during labor. Typically, some women may want that sewn back together because that’s what they are used to. Whereas, some women will just leave it. After you’ve, so there’s some studies that show that when the people are educated about the harmful effects of the procedure, then they are more likely to just leave it open and not have it re-infibulated.
Haddad: So just, ’cause anatomically, I’m trying to understand, could you deliver a baby with an intact, or would it have to be open..?
LaFavor: It all depends on what type of cutting that they have. There are more mild ones like type 1 and 2, a lot of times, they can deliver without having any problems. Usually, at type 3,which causes a very small opening, will either tear or need to be cut during the labor process.
Haddad: And so this specific question was regarding the re-infibulation .So, after delivery, if this is put back together or not. And your initial question was do we have a policy at the hospital that says one way or the other about it. Again, I’m gonna backup a little bit, because I think the medical and health implications of this, you mentioned, if a woman is educated and understands what sort of health implications there are. Is there any medical reason to do any of this to begin with?
LaFavor: No. There’s no medical justification for this procedure at all. It’s all based on culture and religious beliefs.
Haddad: And then are some of the health problems that can result by having this done. And then maybe additionally, what re-infibulation, what might result from that?
LaFavor: The most common complication, long-term complication, anyway, would be just chronic infection, whether that’s chronic urinary tract infection, chronic vaginal infection, sometimes when the procedure is performed, it’s not performed in a surgical and sterile environment, and so there may be holes that communicate between the vagina and the bladder, and so urine can pass to the vagina or through the vagina and the rectum. And so feces can pass through the vagina .Acutely, after this procedure is done, you may have infections, sepsis, those are the most common, acute, hemorrhage also because this isn’t done sterilel ,they don’t have the right instruments or equipment to prevent the bleeding. So those are probably the most common. But then, long-term, you’re also gonna have psychological problems, like some have evidence of post-traumatic stress disorder. Some may have keloid formation, which is large scarring, which can cause problem like obstruction, and discomfort just simply with walking.
Haddad: That was, I have read something about that, and I thought, well, if it’s done under conditions because very often lay people not medical professionals perform these procedures initially. And that the scarring would be so bad that it might affect someone’s gait. It was kind of surprising, thinking how badly someone might heal after something like this. And you mentioned a little bit at the beginning that that you encountered this in Omaha with refugee populations that, Somali, and Sunnis too, or..?
LaFavor: Yes, both.
Haddad: So, would you say that it is a common incidence with refugees from those countries?
LaFavor: I’d say it’s very common. A lot of times, you may be to tell in an exam that they’ve had a procedure, and you’ll ask the patient about it. I was at first thought it was uncomfortable and how to ask your patient if they had a female genital cutting and a lot of times, they don’t understand that, and so I would ask have you had any surgery down here? And a lot of them would say no, but you know that they did. I think some are scared that they’ll be repercussions because they are now here in another country.
But, you know, I don’t press on. I just note it and know that there could be complications with delivery and whatnot.
Haddad: And that would be, I mean, I’m sure you’re dealing with all the issues, not only in being worried about this, but language issues and just, I was wondering if you’d had to deal with this on delivery if people didn’t come in for prenatal care and you didn’t have the opportunity to see, you know, what sort of issues this would mean for delivery. It’ll be kind of hard to encounter this in the delivery room.
LaFavor: A lot of our patients, they may come in just for delivery, and so you don’t have that opportunity during their prenatal care to discuss what their wishes are at delivery. So, in reading a lot of the literature, the biggest thing you could do is educate your patient on complications from this procedure. And whether or not they are going to want to have a re-infibulation at the time of delivery. So just educating, and sometimes that means not only your patient, but maybe their spouse, or even the mother-in-law or the mothers in their culture, because sometimes they are the strongest proponents of it because they see as the introduction into womanhood. And, to be a woman, you have to have this done, whereas the man, you know, it’s, sometimes it’s not as important for them. But just educating the patient, telling them that, you know, we don’t typically repair this at the time of delivery, what are your thoughts on it. I personally have not had anyone that was adamant about having the procedure done at the time of delivery, but I think it’s just a matter time before that.
Haddad: So you’re being a little bit proactive about what, in these circumstances, and if you don’t have the benefit of any kind of relationship where someone ahead of time to doing any teaching at all,that is probably most difficult situation. You answered a lot of the other questions that I had, but one of those was, as you did your research on this, is there a position statement that the American College of Obstetrics and gynecology has on this? Or anything to say, here is where we stand or here’s how you should approach this?
LaFavor: I haven’t found anything clear cut, and that’s kind of why I’ve been searching out different avenues for guidance, but I think, as a physician, with any procedure that you perform or any request that a patient makes to you, you have to kind of kind of have your stance as to I’m absolutely not going to do this, but I will provide you physicians that will. Or maybe, OK I feel comfortable may be re-infibulating part of the genitalia, but not to a point where it can cause chronic long-term effects like the chronic infections, blocking of the urethra or the vagina. But it also still, the debate is, even though it is not medically indicated, you’re still doing harm. Whereas you’re kind of allowing this, you’re saying it’s okay to continue the procedure. So there’s nothing clear-cut as far as the college states, and it’s just something that you have to develop on your own.
Haddad: And I’m sure you’ve encountered in your reading, people who have very strong feelings about this. About what kind of position OB/GYN physicians should take on this. And not only to do what you’re saying, but saying maybe I personally would not feel that I could participate in this. But there may be colleagues who would. That would be one place, but then, I’ve read a few things where it’s like, no, it should be even stronger that we work to try and prevent this.
LaFavor: And that’s what, they do encourage not preventing, not continuing on the procedure, because it is harmful in trying to put an end to it. But I think, in some special situations where, by not re-infibulating, you may cause more harm to the patient being exiled from their community, or being sent home or divorced, things like that, that maybe, and you have to weigh that in each different situation.
Haddad: And you’d be weighing this in the delivery room? I mean, would you do this at the time of delivery?
LaFavor: Well, yes, it would, that’s really the only time that it would be okay to do it is at after delivery. So that’s what a lot of other people will run into, the physicians that haven’t been faced with this, and this patient come in, didn’t know they had a circumcision, and they’re dealing with all of these thoughts, after delivery, what do I do?
Haddad: So this has been, and, I don’t know if this was your assignment to look at this, but the whole idea of looking at this and presenting your grand rounds, and now, presenting here with us. It does raise awareness, I think, and that’s always a nice about ethics, to have a quiet moment when you’re not in the throes of the situation, to think about what the different options might be and all of that. I think you’ve answered all the questions that I had, and I really appreciate you taking the time to do this today.
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