Model protocol medical care for women and girls with FGM

FGM as a very serious and damaging form of child abuse

Dutch policy towards violence against women (VAW) adopts a gender neutral approach. As a consequence, there are no specific rules in place on data collection of VAW incidents, and no specific national strategy is implemented targeting VAW. The legal framework on violence in the Netherlands criminalises rape (Art. 242 criminal law), sexual assault and stalking (law from 28 June 2000). No separate criminal offence exists for sexual harassment outside of the workplace.

In Netherland FGM is prosecutable under general criminal legislation (section 300-304, 307, 308 of the Penal Code), with a maximum imprisonment of 12 years or a fine of maximum € 76.000. In case FGM is done by one of the parents, imprisonment can be increased with one third. In case the parent(s) gave the assignment, pay for it, provide means that will be used for FGM or assist during FGM, they will be punishable as well. This is seen as instigation, aiding and abetting. An adjustment of the law in February 2006 makes FGM performed abroad punishable too, in case the suspected person has a Dutch nationality or lives in the Netherlands. In July 2009 the period of limitation is prolonged. The period of limitation takes effect with the 18th birthday and amounts to 20 years with serious forms of FGM.

FGM data estimation

Since the 90s, women and girls are living in the Netherlands, who emigrated from countries where female genital mutilation (FGM) - or circumcision - is practiced. According to estimation studies[1], out off the number of women living in the Netherlands in 2012 and originating from countries where FGM is traditionally practiced (almost 70.000, 1% of the Dutch female population), an estimated 40% have undergone FGM. Next to that, 2.000 women originating from these countries live at the asylum reception centres (35% of the total number of women in the reception centres), of whom an estimated 74% have undergone FGM. In total, there are an estimated 29.120 women with FGM living in the Netherlands. The majority of these women fall within the reproductive ages.

An integrated chain approach

Several projects have been implemented in the Netherlands and national policy has been developed in order to prevent FGM among young girls and to offer relevant medical and psycho-social health care for women who have been circumcised.

Activities against FGM in the Netherlands started with short-term projects aimed at breaking the taboo through awareness raising, education and development of expertise. In 1993 the Dutch government takes a clear position: all forms of FGM are forbidden. Gradually, projects are implemented aimed at prevention and education. Activities are interconnected, targeting African communities, the Dutch health care sector and fostering dialogue between these two groups. In 2005, on advice of the Council for Public Health and Health Care, the government increases the sense of urgency to end this form of violence by an intensive approach with a number of tangible measures.

Dutch policies on FGM focus on prevention, mainly through an integrated (chain) approach. The approach developed with ‘key persons’ (persons from African communities, living in the Netherlands) and community based migrant organisations, who after training made FGM a subject of discussion in their community, becomes part of the intensive preventive approach of the government during 2006 - 2009.

Medical and psycho-social care is vital

Since 2010, attention for medical and psychosocial care for women with FGM also increased. To this end, several protocols have been developed, mostly within the social and medical sector, to signal and handle cases of FGM. Youth Health Care developed a Statement on the Prevention of FGM and implemented a Communication Protocol[2] from 2005 regarding genital mutilation of girls, to support early signalling of cases. An Action Protocol on genital mutilation of minors[3] was also implemented in 2013 informing police, the Focal Points Child Abuse and the Council for Child Protection and providing information on ways to act.

Within this context, a Model protocol on medical care for women and girls[4] with FGM was developed by the Dutch Association for Obstetrics and Gynaecology in 2010. The Protocol is aimed at presenting recommendations on how professionals can deliver medical, psychosocial and sexual care to girls and women who are victims of FGM covering following a multi-dimensional approach.

The Model protocol medical care for women and girls with FGM describes the role of different professionals being confronted with (potential) cases of FGM. It also informs professionals on the position of several professional organisations regarding FGM and recommendations concerning ways to act in case of (risk of) FGM.

Health professionals’ role in the protocol

Obstetricians and gynaecologists role in the chain of prevention is the following. During intake, they declare if the woman has undergone FGM or of she originates from a country where FGM is prevalent. During pregnancy, the professional discusses FGM in relation to possible physical consequences and impact on delivery. When a girl is born, the issue of FGM is addressed, including the health risks for girls and women, legal regulations in the Netherlands and the role of youth health care workers in preventing FGM.

Health care workers are also urged to report (potential) cases of FGM to the Inspection for Health Care (Inspectie Gezondheidszorg IGZ). Since 2011, youth health care workers register the risk of FGM in a digital file. They gather information concerning several risk factors regarding FGM. They register for example if the mother or sisters of the child have undergone FGM, if the parents originate from a country where FGM is prevalent, etc.

Several actions regarding national registration, signalling and reporting of cases of FGM, for professionals from different sectors (youth health care workers, general practitioners, obstetricians, gynaecologists, professionals working in the field of child abuse etc.) are described. All cases of FGM among pregnant women should be registered in the Perinatal Registration Netherlands database. The Perinatal Registration Netherlands (PRN) is an organisation that brings together the different Dutch professional organisations working in the field of perinatal care, and is responsible for collection of perinatal data. At the request of the Ministry of Public Health, Welfare and Sports (VWS), being responsible for policies on FGM, the registration of FGM was included in their registration system. The PRN dataset 2014 includes codes on ‘FGM status’ and ‘type of FGM’, providing insights on the number of women with FGM in the Netherlands. PRN cooperates with several (inter)national institutions including the Ministry of VWS and the Central Bureau for Statistics (CBS).

The Protocol main success factor is related to the fact that it is a joint initiative of several medical professional organisations for registering and reporting of (potential) cases of FGM. Moreover, the protocol is not only aimed at prevention, but also at urgent aid and long-term care following the Dutch chain approach from prevention to treatment.

[1] Maria Exterkate, Female Genital Mutilation in the Netherlands. Prevalence, incidence and determinants, January 2013, Pharos Centre of Expertise on Health for Migrants and Refugees

[2] Gespreksprotocol JGZ.

[3] Handelingsprotocol VGV bij minderjarigen (AMK 2013 Pharos De Jager).

[4] Modelprotocol medische zorg voor vrouwen en meisjes met VGV NVOG (2010) Nederlandse Vereniging voor Obstetrie en Gynaecologie.