Midwife on dealing with circumcision: “The necessary trust comes through support”

taz: Ms. Groß, you teach midwifery science at the Hannover Medical School and also deal with the topic of circumcision, the technical term is Female Genital Mutilation/Cutting (FGM/C). When did you first encounter this?

Mechthild Groß: That was long before I started my midwifery training. In 1983 I visited a relative, Sister Therese Vogel, in her mobile clinic in Kenya. She worked there for over 60 years and did charitable work.

heads the research and teaching unit in midwifery science and the bachelor's degree program in midwifery science at the Hanover Medical School.

taz: Circumcision can also mean complications during birth [see info box]. What does this mean for the work of midwives with affected women?

Great: It takes time to build trust with women and reduce fears about childbirth. With FGM/C, it's not just the birth that counts, but also the special circumstances during the birth and the time afterwards. The necessary trust for these intimate and culturally sensitive conversations comes from constant support. That is why continuous care is a central aspect of midwifery science.

taz: What special circumstances are these?

Large: The degree of circumcision may vary. If there is an unhygienic situation, there is a risk of infection, so in rare cases the previously closed opening of the vagina should be opened during pregnancy.

taz: How often do midwives in Germany meet affected women?

FMG/C stands for Female Genital Mutilation/Cutting. FMG/C is mostly performed in childhood in western, eastern and northeastern regions of Africa, as well as in some Middle Eastern and Asian countries.

Type 1, the clitoridectomy: partial or complete removal of the clitoris with or without removal of the clitoral hood (fold of skin surrounding the clitoris).

Type 2, excision: partial or complete removal of the clitoris and labia minora with or without removal of the labia minora.

Type 3, infibulation: removal of the inner and/or outer labia and narrowing of the vaginal opening by stapling or suturing the edges of the wound together with or without removal of the clitoris and clitoral hood.

Type 4, all other non-medically justified procedures on the genitals.

UNICEF estimates that by 2025, at least 230 million girls and women worldwide would be affected by FMG/C.

FMG/C has been classified as a separate criminal offense in Germany since 2013 and can be punished with a prison sentence of up to 15 years. It doesn’t matter whether it is carried out in Germany or abroad.

Groß: That depends a lot on the location. In a big city this can happen once a month. In places with specialized women's shelters, those affected can meet and exchange ideas. This happens more often there. But midwives can also look after those affected in rural areas. Especially here the midwives have to know exactly what to do. According to figures from Terre des Femmes from 2020, there are an estimated 75,000 women affected by FGM/C and 20,000 girls at risk in Germany. According to an extrapolation, in Lower Saxony alone there were 8,168 affected women and 1,200 girls at risk in 2022.

taz: Vaginal examinations are often routine during childbirth. How can retraumatization of those affected be avoided?

Large: If it is determined early enough how big the child is and whether it lies comfortably in the pelvis, you can have the courage to forego a vaginal examination. However, when we carry out a vaginal examination on affected women, it is essential to have built up trust in them. The attitude and attitude of the midwife and the choice of words are important. Terms in the native language can be helpful. You should maintain eye contact and agree on signs beforehand that will stop immediately. In order to establish this sensitive contact, it is particularly important that affected women present themselves to the maternity clinics in good time.

Groß: This is something that has to be clarified in advance in several discussions with the women affected. For legal reasons, a woman cannot be sewn back up. Nevertheless, a culturally appropriate and sensitive solution must be found with which the woman is satisfied so that she can identify with herself.

Groß: We respond to the woman's wishes. We often show affected women a mirror after giving birth so that they can see the changes. But we also have to take the woman's family context into account and see to what extent the partner is involved and affirms a change. We cooperate with regional groups that carry out educational work and address partners directly. The aim is that women do not have any negative health consequences in the rest of their lives.

taz: To what extent can midwives do preventative work?

Large: By visiting women and their children at home for postpartum care. We can talk to the families and possibly find out what they are planning for the girls in the family. In Germany, circumcisions are a criminal offense, but home holidays are still organized during which they take place. The Lower Saxony project “Elikia” carries out prevention and educational work.

taz: Is education about FGM/C an integral part of the midwifery studies program at your university?

Big: Yes. Our aim is to train midwives to provide competent care for all women giving birth. If a woman affected by FGM/C shows up in labor at three in the morning, every midwife should know what to do. She shouldn't panic and should be able to make the woman feel safe.

taz: How do you organize teaching at your university?

Groß: We teach the students the facts and show them pictures of the different types of FGM/C. We always issue a trigger warning beforehand. We also teach how to deal sensitively and trustingly with those affected.

taz: Why is removing taboos about FGM/C so important?

Groß: So that it is clear that this is violence and a crime. Affected people should know that urination and the excretion of menstrual blood as well as conception do not have to be associated with pain.

taz: The literal translation of FGM would be “female genital mutilation,” which is also what organizations like Terre des Femmes call it. But you say “female circumcision”. Why?

Gross: The term “mutilation” should only be used in a political context to highlight the violence suffered by women. No one wants to be described as “mutilated,” and often those affected do not see themselves as “mutilated.”