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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.16 no.45 Murcia ene. 2017  Epub 01-Ene-2017

http://dx.doi.org/10.6018/eglobal.16.1.263331 

Originales

Proposal for Nursing Diagnosis: Post Female Genital Mutilation Syndrome

Ismael Jiménez-Ruiz*  , Pilar Almansa Martínez**  , Lynda Juall Carpenito*** 

*Nursing department. Faculty of Health Sciences. University of Alicante. España. E-mail: ijimenez@ua.es

**Nursing department. Faculty of Health Sciences. University of Murcia. España.

***Family Nurse Practitioner, ChesPenn Health Services, Pennsylvania , USA. Author, Consutant, LJC Consulotants, New Jersey, USA

Abstract

Objective

To develop a nursing diagnosis for the detection and prevention of FGM.

Methods

The creation of this diagnosis is based on exhaustive bibliographic research of databases such as LILACS, CUIDEN, TESEO y Web of Sciencie; as well as other documentary sources from international entities.

Results

Post Female Genital Mutilation Syndrome is defined as: Deterioration of a range of health domains as a result of female genital mutilation.This diagnosis belongs to domain 11: safety/protection and class 3: violence.

The following defining characteristics are established for this diagnosis: Acute phase, chronic responses physical, sexuality, chronic obstetric alterations and psychological responses.

Conclusions

Via the diagnosis presented herein, early detection might be procured by nursing professionals of those women and young girls having undergone this traditional practice, thereby being able to treat any possible resultant sequelae.

Keywords Female Genital Mutilation; Female Circumcision; Nursing Diagnosis

Identifying the problem

Female Genital Mutilation (FGM), according to UNICEF1, affects some 200 million women and girls around the world, mainly in 30 sub-Saharan African countries, as well as areas of the Middle East, Indonesia and among certain ethnic groups of Latin America. Current migratory movements make it possible for cases to be found in western countries. As such, FGM is recognized internationally as a global issue2.

FGM is considered worldwide as an act of violence and an affront on the human rights of women and girls since it involves the removal of healthy sexual organs with no medical justification and has harmful effects on their physical health, as well as severe psychological, sexual and obstetric consequences. It is the result of strongly rooted gender discrimination which perpetuates inequality and denies them the right to physical and psychosexual integrity.

The International College of Nursing (ICN) urges nurses all over the world to be vigilant of any FGM being performed, taking into account the movement of migrant populations and the cultural diversity such displacement generates. Towards this aim, they must have the necessary knowledge and capacity to detain it wherever it may take place and to be aware of culturally-friendly alternatives such as "circumcision through words" 3.

Autonomous and independent nursing intervention, aimed at treating the complications, or possible complications, for the health of women and young girls who have undergone the mutilation of their genitals, must be based on a standardized nursing language. Thus, the objective of the present manuscript is that of developing a proposal for a new Syndrome Nursing Diagnosis, aimed at detecting and treating the aforementioned issues.

Methodology

This Nursing Diagnosis has been established via a two-stage process:

The first stage consisted in creating a committee of professional experts in FGM, made up of researchers from the Nursing, Women and Care Research Group of the Faculty of Nursing at the University of Murcia, Spain.

The second stage began with an integral review of the available literature with a view to performing an in-depth conceptual analysis of the proposal, in order to achieve theoretical consistency in all aspects of the diagnosis. Towards this aim, a diverse range of strategies were utilized in the search for documents:

Free-text descriptors were used for the bibliographic review, as displayed in Table 1, combined via the Boolean operators "AND, NOT and OR".

Table 1 Keywords or Free-text descriptors 

Spanish English
Excisión Excision
Ablación Ablation
Infibulación Infibulation
Clitoridectomía Clitoridectomy
Mutilación Genital Femenina Female Genital Mutilation
Complicaciones Complications
Enfermería Nursing

Utilizing these keywords, a review was made of internet search engines such as Google and Academic Google, via which access was achieved to a number of documents of great interest to the research at hand, available in the web pages of organizations such as International Amnesty (IA), the United Nations (UN), the United Nations High Commissioner for Refugees (UNHCR), the World Health Organization (WHO), the United Nations International Children's Emergency Fund (UNICEF) and the national Union of Family Associations (UNAF).

Subsequently, a more exhaustive search was performed using the databases: LILACS, Cochrane Library Plus, SciELO, TESEO and Web of Science. The search in these databases was performed using the MeSH and DeCS descriptors "circuncisión femenina (female circumcision)" as displayed in the following flowchart (Figure 1).

Figure 1 Search Flowchart  

Development and discussion of the proposal

Based on the definition for syndrome diagnoses by NANDA-I: "A clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions"4 we developed the following diagnosis proposal:

  • Diagnosis Label: Post Female Genital Mutilation Syndrome.

  • Definition: Deterioration of a range of health domains as a result of female genital mutilation.

  • Defining Characteristics: The nursing diagnosis associated with this syndrome are grouped as follows

Acute phase

Acute pain (00132): The large amount of nerve endings present in the genital area and the insufficient, on occasion inexistent, use of anaesthesia mean the cutting procedure produces extreme pain, which gradually subsides over the healing period5)(7.

Risk of Infection (00004): Infection, together with haemorrhage and anaemia are the most frequent acute complications associated with FGM 5),(7. Moreover as an additional complication, the damage to genital tissues produced by the cutting procedure and consequential microbial contamination creates a risk of recurring vaginal infections and pelvic inflammatory disease (PID) which can lead to infertility8),(9.

Urinary retention (00023) and Rick for urinary retention: This can appear due to the intense pain produced during urination or resultant from inflammation secondary to a lesion in the urethral conduct5),(6.

Chronic responses physical

Impaired urinary elimination (00016): Due to the presence of recurring urinary tract infections8)(10 as well as symptoms in the lower urinary tract11 as a consequence of anatomical changes to the vagina and the urinary conducts resultant from FGM.

Chronic pain (00113). Associated with the modification of the genitals as a result of this practice5)(7.

Chronic pelvic infection6),(10

Sexuality

Sexual dysfunction (00059): Due to the possible presentation of dyspareunia, vaginal dryness or the lack of lubrication during coitus, as a consequence of the structural changes produced in the external genitalia and the loss of elasticity due to the creation of scar tissue12. Furthermore, the existence of one or more of these consequences has negative repercussions on the quality of sexual relations in those women affected13 and may lead to varying degrees of sexual phobia and dysfunction in sexual excitation.

Ineffective Sexuality Patterns (00065): In a great number of cases this is either diminished or completely omitted. The removal of erogenous zones of great importance to female sexuality, such as the clitoris and genital labia; the resultant scar tissue and pain-related phobias, are merely a few of the factors which can affect such women's ability to experience sexual arousal and pleasure during coitus12),(13.

Chronic Obstetric Alterations

Episiotomy: The pressure generated in the birthing canal by the foetus can lead to perineal tearing and severe haemorrhage requiring surgical intervention14);(15. In these cases, episiotomy is necessary due to the loss of elasticity of the vaginal vestibule as a result of scarring14),(16. In addition, Birthing efforts are usual prolonged and extenuating in infibulated women, which promotes the appearance of obstetric fistulas as a result of the pressure of the foetus' head on the vaginal walls and adjacent organs15),(17.

Labour pain (00256)5.

Psychological responses

Post-trauma syndrome (00141): The consulted bibliography describes a significantly greater prevalence of post-traumatic stress disorder in women subject to FGM18),(19. The complexity and chronicity of this diagnosis will require the expertise of a mental health specialist (nursing, psychiatry).

Anxiety (00146): There is a significantly greater prevalence of psychiatric syndromes, such as anxiety, in women who have undergone FGM than in those who have not18.

Disturbed personal identity (00121) and Risk for disturbed personal identity (00225): The young or adult women who have been "cut" and later emigrated to western countries, may experience a number of psychological problems related with the differences between the cultures of their host country and country of origin, realizing that FGM is not only not a universal tradition, but considered in an extremely negative light in other cultures. This can result in serious internal conflicts regarding identity and loyalty towards one's own culture, leading to feelings of humiliation, confusion, powerlessness, a sense of being betrayed by their family and shame6.

Dysfunctional Family Processes(00063) and Risk for Dysfunction Family Processes. The consequences of FGM can affect family relationships6.

Figure 2 Summary of the Diagnosis 

Multiaxial Structure of the Diagnosis

Following the multiaxial structure of Nursing Diagnoses, seven dimensions of the human response have been defined which must be considered during the diagnostic process in the following manner:

Axis 1 The Diagnostic Focus: Female Genital Mutilation. As an essential and primordial element of the syndrome presented herein, "Female Genital Mutilation" is considered an inseparably unique element since it defines in an unequivocally specific and concrete manner the act via which the aforementioned human responses are produced and which may appear concomitantly as a result of FGM. Each separate term does not imply sufficient significance on its own in order to satisfy the description of the human responses comprising this syndrome.

Axis 2 Subject of the Diagnosis: Individual woman or girl (Female). The subject of the diagnosis is described in the diagnostic focus as the women or young girls having undergone Female Genital Mutilation.

Axis 3 Judgement. Deterioration of a range of a range of health domains as a result of female genital mutilation.

Axis 4 Location. Female genitals.

Axis 7 Status of the Diagnosis. Problem-focused. This syndrome is characterised by concomitant unwanted human responses resulting from genital mutilation.

Conclusions

This new Nursing Syndrome Diagnosis denominated Post Female Genital Mutilation Syndrome is born from the need to improve the healthcare services provided to girls and women who have undergone FGM. Through its application the early detection by nursing professionals of women and girls having suffered this traditional practice is foreseeable, and thus the treatment of the consequences of FGM made possible.

Implications for Nursing Knowledge

In this sense, from a viewpoint which recognizes the intrinsic dignity and inalienable equal rights of all human beings, it can be vouched for that the nursing profession, focused on transcultural care planning and motivated by the recognition of the consequences of FGM, can endeavour in furthering the creation of specific nursing interventions centred on the palliative care of complications arising from, as well as the earlier detection of new cases of FGM, in order for them to be treated in a timely and appropriate manner.

In addition, the nursing community worldwide must be aggressive to openly discuss the issue of FGM as a human rights violation.

Referencias

1. UNICEF. UNICEF´s data work on FGM/C. [Online]. 2016. Advailable at: http://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdfLinks ]

2. Grande Gascón, M; Ruiz Seisdedos, S & Hernández Padilla, M. El Abordaje Social y Político de la Mutilación Genital Femenina. Portularia. 2013; XIII(1): 11-18. Advailable at: http://rabida.uhu.es/dspace/bitstream/handle/10272/6742/El_abordaje_social_y_politico.pdf?sequence=2Links ]

3. CIE. Declaración de posición del CIE: Eliminación de la mutilación genital femenina. 2010. Advailable at: http://www.icn.ch/images/stories/documents/publications/position_statements/A04_Eliminacion_mutilacion_genital_femenina-Sp.pdfLinks ]

4. NANDA International. Diagnósticos Enfermeros. Definiciones y clasificaciones 2015-2017.Barcelona: Elsevier. 2015. p.464 [ Links ]

5. Royal College of Obstetricians and Gynaecologists. Green-top Guideline Female Genital Mutilation and its management. 2015; (53): 1-26. Advailable at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-53-fgm.pdfLinks ]

6. Abdulcadir, J; Margairazb, C; Boulvaina, M & Iriona, O. Care of women with female genital mutilation/cutting. Swiss Medical Weekly. 2011: 6. doi:10.4414/smw.2010.13137 [ Links ]

7. Kaplan, A; Hechavarría, S; Martín, M & Bonhiure, I. Health consequences of female genital mutilation/cutting in the Gambia, evidence into action. Reproductive Health. 2011; 8(26): 1-6. doi:10.1186/1742-4755-8-26 [ Links ]

8. Almroth, L; Bedri, H; El Musharaf, S; Satti, A; Idris, T;M SIR K & .Bergstrom, S. Urogenital Complications among Girls with Genital Mutilation: A hospital-Based Study in Khartoum. African Journal of Reproductive Health. 2005; 9(2): 118-123. [ Links ]

9. Khaled, K; Samy, S; Abed El-Aziz, E & Haytham, H. Impacts of Female Genital Mutilation on Women's Reproductive Health. Comumunity Medicine & Health Education. 2012; 2(3): 1-4. [ Links ]

10. Iavazzo, C; Gkegkes, I & Sardi, T. Female genital mutilation and infections: a systematic review of the clinical evidence. Archives Gynecology Obstetrics. 2013; 287(6): 1137-1149. doi:10.1007/s00404-012-2708-5 [ Links ]

11. Amin, M; Rasheed, S & Salem, E. Lower urinary tract symptoms following female genital mutilation. International Journal of Gynecology and Obstetrics. 2013; 123(1): 21-23. doi:10.1016/j.ijgo.2013.06.010 [ Links ]

12. Elnashar, A & Abdelhady, R. The impact of female genital cutting on health of newly married women. International Journal of Gynecology and Obstetrics. 2007; 97(3): 238-244. doi:10.1016/j.ijgo.2007.03.008 [ Links ]

13. Andersson, S; Rymer , J; Joyce, D; Momoh, C & Gayle, C. Sexual quality of life in women who have undergone female genital mutilation: a case-control study.BJOG: An International Journal of Obstetrics and Gynaecology. 2012; 119(13): 1606-11. doi:10.1111/1471-0528.12004 [ Links ]

14. WHO. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. The Lancet. 2006;367: 1835-1841. doi:http://dx.doi.org/10.1016/S0140-6736(06)68805-3Links ]

15. Berg , R & Underland, V. The Obstetric Consequences of Female Genital Mutilation/Cutting: A Systematic Review and Meta-Analysis. Obstetrics and Gynecology International. 2013; (1): 1-15. doi:http://dx.doi.org/10.1155/2013/496564Links ]

16. Frega, A; Puzio, G; Maniglio, P; Catalano, A; Milazzo, G; Lombardi, D & Bianchi, P. Obstetric and neonatal outcomes of women with FGM I and II in San Camillo Hospital, Burkina Faso. Archives of Gynecology and Obstetrics. 2013; 288(3): 513-519. doi:10.1007/s00404-013-2779-y. [ Links ]

17. Chibber , R; El-Saleh , E & El Harmi, J. Female circumcision: obstetrical and psychological sequelae continues unabated in the 21st century. Journal of Maternal-Fetal and Neonatal Medicine. 2011; 24(6): 833-836. doi: 10.3109/14767058.2010.531318 [ Links ]

18. Behrendt, A & Moritz, S. Posttraumatic Stress Disorder and Memory Problems After Female Genital Mutilation Female Genital Mutilation. The American Journal of Psychiatry. 2005; 162(5): 1000-1002. doi:10.1176/appi.ajp.162.5.1000 [ Links ]

19. Vloeberghs E, Van-der-Kwaak A, Knipscheer J, Van-den-Muijsenbergh M. Coping and chronic psychosocial consequences of female genital mutilation in The Netherlands. Ethnicity & Health. 2012; 17(6): 677-695. doi:10.1080/13557858.2013.771148. [ Links ]

Received: July 12, 2016; Accepted: September 09, 2016

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