Registration of FGM in hospitals

National strategy and action plans on violence against women

The way prevention and repression of gender-based violence are dealt with in Belgium is influenced by the country’s federal administrative structure dividing responsibilities between the Federal, Regional and Community authorities. Coordination and dialogue between entities are therefore crucial. This is why since 2001, Belgium has pursued a policy to combat gender-based violence by means of national action plans (NAP), supported by the federal government, the communities and the regions. This plan is coordinated by the Gender Equality Institute (Institut pour l’égalité des femmes et des hommes).

Several plans were drawn up: the first NAP 2001-2003, the second NAP 2004-2007, a third NAP 2008-2009 and a fourth NAP 2010-2014. The topics addressed under each NAP have varied over time; the current NAP 2015-2019 choose a broad approach of gender based violence. The goal of the NAP 2015-2019 is to banish all forms of gender-based violence and it covers intimate partner violence, female genital mutilations, forced marriage, honour based violence, sexual violence and prostitution.

One of the current NAP overall objective is to pursue an integrated policy to gather quantitative and qualitative data about all forms of violence. Also, an interdepartmental group bringing together representatives of the federal, community and regional institutions involved in the battle against gender-based violence is in place in order to attain a joint and coherent policy. The group is coordinated by the Gender Equality Institute. 

Currently, collection of administrative data is organised under the general regulatory framework for penal offences: all complaints and cases are systematically registered by the relevant services (police and the judicial system). The classification is based on the type of offence. However, for intimate partner violence an administrative circular (Col 3) adopted in 2006 provides that every complain should be registered with a specific code by the police and the judicial system indicating the relationship between the victim and the author. It was adopted notably the put an end to a practice of « main courante » (daybook); all cases should systematically be recorded to get a better view on the phenomenon.

FGM as a penal offence

There is no law specifically on violence against women, all forms of gender based violence are addressed as gender neutral except for Female Genital Mutilation (FGM). FGM is thus considered as a penal offence and therefore registered when women and girls are victims of such practices.

Female genital mutilation (FGM) is considered as inhuman and degrading treatment and may lead to protection under asylum. Thus, Belgium may grant the quality of refugee to a victim of FGM or woman / girl at risk in order to ensure her protection and to preserve her physical and mental integrity.

Excision is also punishable by law since 2001 (Article 409 Penal Code). The law can be applied even in the case of an excision performed abroad if the perpetrators reside in Belgium. Indeed, for families established in Europe the practice of FGM continues, albeit to a lesser extent, while they are on holidays in the country of origin or even in the territory of the host country.

The importance of carrying out studies on FGM phenomenon

In order to conduct a proper policy for medico-social care and prevention it is important to estimate the number of women and girls concerned by FGM in Belgium. This, firstly to protect girls at risk of undergoing the practice, and secondly to deal with the gynaecological and obstetric complications as well as psychosexual issues for circumcised women and to be able to respond to growing demands for reconstructive surgery.

A fist study was concluded in 2012 (based on 2010 data) in order to appreciate the prevalence of FGM in Belgium. It was then based on the population registers and of foreigners. A subsequent study to update data was conducted in 2014. A more comprehensive approach was developed, using 2012 data from population registers and foreigners (no data by ethnicity), but also from asylum seekers and departments in charge of childhood.[1]

Although this study was not based on a clinical diagnosis (it remains a statistical estimate of the prevalence of FGM in Belgium by combining different data sources), it showed that prevention and care needs are important in Belgium.

Mandatory registration system in hospitals

Within this context, hospitals in Belgium have to register medical acts in a mandatory registration system. Through this system clinical data on each patient are collected. Data entered by doctors in the patient file are standardized using the ICD classification system of the World Health Organisation. The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence of diseases and other health problems, providing a picture of the general health situation of a country and its population. Since 2015, the registration system in Belgium is progressively using the ICD-10–CM and ICD-10-PCS classification (before it was ICD-9-CM).

To ensure an accurate registration of pathologies linked to female genital mutilation (FGM), it is important that doctors and those in charge of coding in hospitals have adequate knowledge. The National Action Plan to combat different types of gender violence adopted for 2010–2014 contains one measure relating to "ensuring registration of facts of FGM by professionals who have to deal with the problem and a routine recording of detected cases".

Pilot test in 10 hospitals

Following an observation of underreporting of FGM by hospitals, in 2012 the Federal administration in charge of public health (FPS Health) organised awareness raising and training sessions in 18 hospitals in the country.

In 2013, FPS Health launched monitoring of the registration of FGM in hospitals that had previously followed the mentioned training. Of the 18 hospitals concerned, 10 participated in the pilot study on registration. All participating hospitals received some information by leaflets highlighting what specific elements should be incorporated into a file in order to optimise the registration of FGM cases. These were available in both Dutch and French.

To monitor the number of registered cases of FGM, FPS Health contacted, on a monthly basis, all participating hospitals and asked that a form be completed. This form mainly included fields relating to the date of registration of a FGM case in the hospital, the type of FGM, the type of hospitalisation and, if relevant, type of surgery performed. The monitored period started on 1 January 2013 and ran until 31 December 2013.

The aim of this pilot study was to assess whether existing registration procedures in hospitals are sufficient to ensure adequate recording of FGM cases. A number of cases were monitored for a period of 12 months. As mentioned above, only 10 hospitals were chosen for this monitoring study, the criterion for selection being to have previously followed a training session organised in 2012.

Improvements in the pilot hospitals

The results of the study show that the number of recorded FGM cases after awareness raising/training sessions is 2.5 times higher than the average of the previous years (1.6 times higher than in 2011), which seems to confirm the suspected under-registration in past years. This was echoed by doctors involved in the participating hospitals: it was after the sensitisation – as well as fact sheet on FGM – that more attention was paid to the correct registration of cases.

The hypothesis that trained professionals will register FGM cases more systematically and accurately was confirmed. The study reveals clear links between information on FGM and how to deal with it (leaflets) and the correct implementation of existing registration instruments.

Therefore, to improve the correct registration of FGM in hospitals, training and awareness sessions are the first steps to be implemented. Existing instruments (classification, leaflets) are adequate to ensure a proper registration if doctors in hospitals are properly trained.

As positive success factors, the following can be mentioned. Hospitals in Belgium have to register medical acts in a mandatory registration system. Through this system clinical data on each patient are collected. Data entered by doctors in the patient file are standardised using the International Classification of Diseases (ICD) system of the World Health Organisation.

So, the use of use of international standard is to be considered as a success factor in collecting comparable data on FGM.

Moreover, the collection of FGM data in connection with general health data could ensure, in the future, that data will be accessible to all health care providers.

[1] French link: http://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/mgf_etude_de_prevalence-_version_longue_11-11-2014_final.pdf

Dutch link : http://www.health.belgium.be/nl/gezondheid/zorgberoepen/multidisciplinaire-themas/vrouwenbesnijdenis