Knowledge, attitudes and practices of Swiss reproductive health and paediatrics professionals regarding female genital mutilation/cutting: a cross-sectional study

Demographic

Our survey included 21 demographic questions including individual and clinical practice characteristics, and previous exposure to FGM/C. For analysis, responses of “No” and “I don’t know” on prior exposure to FGM/C were combined into a single category.

Knowledge

The knowledge section included 27 items covering six key areas: general FGM/C knowledge, vulvar anatomy, ethical and legal aspects, communication, health complications and management approaches. Reproductive health workers had four additional items on defibulation and pelvic examination.

Each item had a single correct answer plus an “I don’t know” option to reduce guessing; correct answers were scored 1 and incorrect 0. A total knowledge score, calculated only for participants completing all items, was created to facilitate comparisons across different groups, ranging from 0 to 27 for paediatrics and from 0 to 31 for reproductive health workers.

Attitudes

The attitudes section contained 23 items, plus an additional 5 items for reproductive health workers (concerning defibulation). Attitude items were scored on a Likert scale (from 0 “Strongly disagree” to 4 “Strongly agree”) and are reported at the item level as each item measures a distinct aspect of attitudes rather than a single underlying construct.

Practices

There were 29 practice items in total, following a branching logic depending on specialty but also professionals’ previous exposure to FGM/C or to minor patients. Five items targeted only practitioners who had ever performed defibulation. Items in this section had different response formats (multiple-choice question, Yes/No question or 5-point Likert scale), making it hard to calculate total scores.

Confidence

Four items assessed confidence regarding visual identification of FGM/C, management of health concerns of women with FGM/C and coding capacities. One additional item targeted only reproductive health workers and enquired about their confidence levels in defibulation.

Reproductive health workers

A total of 127 reproductive health workers completed the survey. Most were women and physicians, and the majority worked in the French-speaking region of Switzerland. Midwives accounted for just over one quarter of respondents, while only six nurses completed the form. Despite different scopes of practice, nurses and midwives working in the same department are likely exposed to similar reproductive and sexual health care and FGM/C-related training, so they were grouped together for analyses.

Paediatrics workers

In total, 76 paediatrics workers participated, the majority of whom were female physicians. Most worked in French-speaking hospitals. Additional demographic characteristics are shown in table 1.

Reproductive health workers

Most reproductive health workers had cared for women and girls with FGM/C, with around a third having seen more than 20 cases. Despite this experience, only about half had received training, mainly via full lectures or independent reading. Familiarity with local regulations for reporting FGM/C in children was low. Nearly all reported at least some interest in learning more about FGM/C. Table 2 summarises prior exposure.

Regional comparisons of prior exposure and training among reproductive health professionals are presented in table 3. Overall, prior clinical exposure and interest in further training were high in both regions. Previous training and awareness of workplace guidelines were significantly higher in Swiss French reproductive health workers than in their Swiss German counterparts.

Paediatrics workers

Only a third of paediatrics workers had cared for a girl with FGM/C. Most lacked prior training, with independent learning and brief mention in a class being more common than full lectures. Nearly all expressed some interest in learning about FGM/C. Only a third were familiar with local regulations on reporting cases in children. Regional comparisons of prior exposure and training among paediatrics professionals are also presented in table 3. Prior clinical exposure, training and interest in further learning were similar across regions. The main regional difference was lower awareness of workplace guidelines among Swiss German paediatrics professionals as compared to their Swiss French colleagues.

Reproductive health workers

Overall, reproductive health workers knew the definition of FGM/C and its potential health consequences and answered anatomy questions adequately. The lowest scores were seen for identification of WHO FGM/C types, indication for caesarean in type 3 FGM/C, and clitoral reconstruction, with around three quarters mistakenly believing FGM/C could involve removal of the entire clitoris. Table 4 shows correct answer proportions, at the item level.

The mean knowledge score was 25.7 (SD: 4.0) out of 31 points. Physicians scored significantly higher than midwives and nurses. No differences were observed between French- and German-speaking hospitals (table 5).

Paediatrics workers

Paediatrics workers showed similar knowledge gaps to reproductive health workers, also scoring low in three additional areas: understanding defibulation, including its indications and consequences; awareness that FGM/C-related sexual issues are treatable; and knowledge of the Swiss legal context. While most participants correctly recognised that FGM/C is illegal in Switzerland, a small but meaningful proportion were unsure or believed it to be legal, with even higher uncertainty regarding vacation cutting. See table 5 for more details.

The mean knowledge score was 19.5 (SD: 4.0) out of 27 points, with no differences between German- and French-speaking hospitals. A comparison between physicians and nurses was not possible due to the absence of nurse data (none had completed the knowledge test entirely).

Common to both reproductive health workers and paediatrics workers

Overall, reproductive health and paediatrics workers shared similar attitudes and beliefs towards FGM/C and those who perform it (table 6).

An overwhelming majority of respondents strongly disagreed that parents have the right to cut their daughters, while agreement that it is wrong to surgically alter the genitals of any child (boy, girl or intersex) was lower.

More than half of participants disagreed or strongly disagreed that performing FGM/C honours an important cultural tradition, and a similar proportion strongly disagreed that social benefits outweighed health risks for some women.

Additionally, most reproductive health and paediatrics workers agreed or strongly agreed that women with FGM/C are “victims”. Most participants disagreed or strongly disagreed that women with FGM/C are less educated. Most disagreed or strongly disagreed that communities practicing FGM/C are not oppressive towards women.

Almost three quarters agreed or strongly agreed that adult women should have the right to undergo genital cosmetic surgery, but only a third believed in the right of adult women to undergo FGM/C.

Paediatrics workers were more likely to report distress when treating a patient with FGM/C and found it harder to hide this distress from patients, compared to reproductive health workers.

Reproductive health workers

Some attitude items were specific to the scope of practice of reproductive health workers. Almost half of reproductive health workers agreed or strongly agreed that women with FGM/C were more difficult to manage during childbirth. When asked about reinfibulation – defined in the survey as the “re-closure of the female mutilation/cutting type 3 scar (for example, after childbirth)” – almost half believed that women wanted their scars re-closed after childbirth and a fifth agreed or strongly agreed that they should be able to perform reinfibulation at the patient’s request.

Reproductive health workers

Only about one fifth of reproductive health workers consistently ask all women about FGM/C, with even fewer limiting inquiries to those perceived as at risk. About half consistently recommend a genital examination when suspicion arises. When counselling women with FGM/C, workers address gynaecological health concerns more consistently than sexual and mental health issues.

Approximately one third of reproductive health professionals reported ever performing defibulation, most commonly during the second stage of labour. Routine episiotomy and postpartum repair were less frequent, and most providers offered follow-up care.

Interpreter use was generally high, but consistent interpreter use was significantly higher in French-speaking regions (95.0%) than in German-speaking regions (68.1%, p <0.001).

Paediatrics workers

Only about half of paediatrics workers routinely examine female genitals during well-child visits, and fewer consistently document FGM/C status or record the WHO type. A notable proportion were uncertain about mandatory reporting to authorities.

Interpreter use was high and there was no significant difference in consistent interpreter use between Swiss German (84.2%) and Swiss French paediatrics workers (87.7%, p = 0.70).

Reproductive health workers

A majority of reproductive health workers reported being somewhat or very confident in detecting FGM/C in adult women through visual inspection, yet only a third felt confident in identifying it in paediatric patients. A large majority was confident they could address the health concerns of patients with FGM/C. Over a third of respondents felt somewhat or very confident in performing defibulation, despite fewer than one third having prior experience with the procedure. Confidence levels were quite low for coding abilities.

Paediatrics workers

In general, paediatrics workers showed lower confidence levels than their reproductive health counterparts. Paediatrics workers were more confident in their ability to identify FGM/C visually in children compared to adult patients. However, only a third believed they could adequately address the health issues of patients with FGM/C. Confidence in coding capacities was similarly low.

Prior exposure

Our sample of respondents was generally very exposed to women and girls with FGM/C in their clinical practice: 97.6% of reproductive health and 32.9% of paediatrics workers had already been in contact with a patient, numbers higher than a recent study in similar populations in France [15]. Despite this, only a quarter of paediatrics workers received any FGM/C training, and just 6% attended a full-class lecture, similar or slightly lower than previous paediatrician studies [17-19]. About half of reproductive health workers were trained, comparable or slightly higher than prior reports [20]. Comparisons should be cautious, as our survey included reproductive health and paediatrics professionals across disciplines (physicians, midwives, nurses), unlike multiple prior studies focusing mainly on physicians. Unlike earlier research [15, 17, 21], we did not find higher training rates among midwives, though the small number of midwife respondents limits interpretation.

Knowledge

Reflecting low formal training, notable knowledge gaps were observed, especially in clinical understanding of FGM/C types (WHO classification) and awareness of national or institutional guidelines, consistent with other studies [15, 21, 22]. Awareness of the illegality of FGM/C in Switzerland was high, but knowledge of regulations regarding vacation cutting was limited, similar to findings among UK participants who were aware that FGM/C is illegal domestically but less familiar with the Female Genital Mutilation Act’s provisions covering vacation cutting [20, 22, 23]. Notably, neither our 16-year clinical experience nor current literature documents confirmed cases of FGM/C occurring within Switzerland or during travel since the introduction of the national law prohibiting the practice in 2012 [24]. However, even in the absence of reported cases, misconceptions about the legal framework surrounding FGM/C represent critical missed opportunities for prevention, adequate parental counselling and early intervention, potentially allowing the practice to persist undetected.

In addition to these knowledge items, we explored other underexamined areas such as knowledge about defibulation and clitoral reconstruction. Paediatrics workers had very low knowledge about surgical treatments available for women and girls with FGM/C. To date, this aspect of paediatrics workers’ knowledge has scarcely been studied. We believe it is necessary for paediatrics workers to be aware of existing available treatments and surgical techniques and indications to be able to inform their patients and refer them adequately [11].

Reproductive health workers had good self-reported theoretical knowledge of the effects of defibulation. Still, over a third believed that infibulation alone was a sufficient indication for a C-section. This suggests that many women may undergo unnecessary caesarean deliveries without discussion of the option for defibulation during pregnancy or labour, as recommended by national and international guidelines [3, 10, 25].

Among reproductive health workers who had ever performed defibulation, the majority reported doing so during the second stage of labour. This finding suggests that older protocols may still be in use and little discussion about possibilities of different timing of defibulation with patients at the beginning of their pregnancy. Current guidelines now recommend performing defibulation at any time considered most appropriate following discussion with the patient; therefore, other response options (except “on the day of consultation”) were correct [25, 26]. However, if the patient opts for an intrapartum defibulation and not a second trimester procedure, defibulation is recommended during the first stage of labour to better monitor labour, have access to urinary catheterisation, operate on less swollen tissues and with adequate time [3, 25]. Our data is difficult to compare with previous studies, as clinical guidelines have changed over the past few years. For example, a knowledge, attitude and practices study conducted in London in 2013 expected professionals to perform defibulation either before pregnancy or during the second trimester only, considering defibulation during labour not ideal [21]. In addition, anaesthetists were not included in this study, although they may play an important role in shaping access to spinal anaesthesia for defibulation during the second trimester. Their perspectives, knowledge and clinical practices could act as either facilitators or barriers to the provision of this procedure.

Around 16% of reproductive health workers reported routinely performing episiotomies in infibulated women, consistent with a recent meta-analysis showing significantly higher odds of episiotomy among women with FGM/C type 3 compared to controls [27]. This unnecessary intervention reflects suboptimal care, highlighting the need for increased provider knowledge of appropriate management of FGM/C. Swiss and WHO guidelines recommend episiotomy only when clinically indicated, even in type 3 FGM/C with defibulation [25].

Both paediatrics and reproductive health workers showed limited knowledge of clitoral reconstruction, despite growing evidence of its efficacy, particularly for chronic clitoral pain [28]. This may reflect a broader lack of understanding of clitoral anatomy: 75% of reproductive health and 90% of paediatrics workers believed FGM/C could involve removal of the entire clitoris. Longstanding gender biases in Western medicine have historically hindered anatomical understanding and perpetuated misconceptions rooted in racist and misogynistic beliefs [29, 30]. Although the body, crura and bulbs of the clitoris are not removed during FGM/C [11], misconceptions regarding the complete excision of the clitoris during FGM/C may lead clinicians to overlook reconstructive options and underestimate preserved sexual function, limiting holistic discussions of sexual health, sex therapy or physiological rehabilitation.

Attitudes

Many negative attitudes and double standards regarding FGM/C persist, often reflecting discriminatory views towards women and their communities. Women and girls with FGM/C may experience intersecting forms of bias across race, gender, migration, religion and linguistic status [31].

Previous knowledge, attitude and practices studies have examined healthcare workers’ attitudes, focusing on reasons for performing FGM/C, endorsement and medicalisation of the practice, and perspectives on reinfibulation [22]. In our study, we also investigated current controversies, including genital cutting of boys and intersex children and cosmetic genital surgery. Despite ongoing debates on double standards and the similarities and differences between FGM/C and cosmetic genital procedures [32-34], a big portion of our sample seemed to adopt the mainstream view that an adult woman’s consent is often seen as unquestionable when framed as “cosmetic surgery”, but is met with suspicion when framed as “FGM/C”.

Survey respondents also condemned FGM/C more strongly than the cutting of boys or intersex genitalia, highlighting a gender-based double standard in how genital cutting is judged as moral or not [35]. Finally, the failure of the majority of our sample to think of FGM/C also through a social lens, rather than solely through physical health risks, could limit culturally sensitive discussions and understandings during screening, care and prevention of FGM/C [36].

Most healthcare providers in our sample viewed women with FGM/C as “victims”. Viewing and/or treating women with FGM/C as “victims” can reinforce their social stigmatisation in diaspora settings, such as Switzerland [29]. It could also reflect a perception that women with FGM/C lack agency, as evidenced by the high number of healthcare professionals (especially paediatrics workers in our sample) who did not support women’s right to refuse defibulation during childbirth.

Similar to UK findings, where 18% of health professionals reported willingness to perform reinfibulation if legal [21], a small proportion of Swiss respondents were uncertain about reinfibulation. Most reproductive health and paediatrics workers opposed it, but nearly one third of reproductive health workers were neutral on whether it is less harmful than the original FGM/C. This ambiguity reflects both concern for women’s wellbeing and the need for training on complex ethical and sociocultural considerations.

Practices and confidence

Health workers’ confidence can reflect their ability to provide care, but it must be validated against actual practice. We observed inconsistencies between self-reported confidence and reported practices that may affect patient outcomes. Although many reproductive health specialists felt confident addressing FGM/C-related concerns, consultations primarily focused on gynaecological issues, with mental and sexual health often overlooked. This aligns with previous studies showing that reproductive health workers frequently lack sexual health training and rarely initiate such discussions, even though patients may expect them to [30].

Although most health workers had limited clinical experience with FGM/C, the majority believed they could identify affected patients through visual examination. This perception may stem from the assumption that FGM/C always produces obvious physical alterations. It may also reflect the Dunning-Kruger effect, a cognitive bias in which individuals with limited knowledge or experience overestimate their competence [37], leading clinicians to believe they can reliably identify FGM/C despite limited clinical exposure.

Similarly, over 40% of paediatrics workers felt confident identifying FGM/C in children, yet only half routinely examined genitals during well-child visits. Without regular examinations, clinicians may lack the experience to distinguish FGM/C from normal anatomical variations or conditions like lichen sclerosus or labial adhesions [38]. Given known gaps in paediatric gynaecology knowledge [11, 39, 40], clinicians unfamiliar with vulvar anatomy may over- or under-interpret FGM/C, expecting only severe forms or overlooking subtle cases, similar to challenges in child sexual abuse cases [41].

Overconfidence in visual identification may also lead to reporting in certain communities only, fostering stigma and undermining patient care.

Nearly 40% of paediatrics workers indicated they would report FGM/C in minors regardless of timing or context, raising concerns about unnecessary reporting. Under Swiss law (Article 124), FGM/C is criminalised if performed in Switzerland by a resident or abroad on a Swiss resident [42]. However, procedures carried out before migration, in the absence of ongoing risk, do not usually require reporting as doing so may fuel stigma and undermine trust in healthcare [43, 44]. The situation becomes more complex when FGM/C occurred pre-migration in a country where it was already illegal. In such cases, Swiss law allows for the possibility of prosecution under universal jurisdiction, a stance that differs from that of most European countries, as highlighted in the Boudry case [45]. This illustrates the legal ambiguities Swiss clinicians face and the resulting potential for inconsistent reporting. The broad application of the law, though protective, may not align with ethical or practical concerns, and universal prosecution may be inappropriate when there is no ongoing risk. This mirrors concerns in Sweden, where aggressive legal measures led to invasive compulsory genital examinations, suggesting that a high-suspicion climate may lead to overreporting and marginalisation rather than effective protection [46, 47].

Over a third of reproductive health workers felt confident performing defibulation, but fewer than 30% had experience. This discrepancy suggests that self-reported confidence does not necessarily reflect actual clinical exposure, a gap partly driven by the limited identification of cases and the absence of proactive defibulation in routine practice. Currently, the procedure is often performed only upon explicit patient request, meaning it is offered to a minority of patients who truly need it. Our 16 years of clinical experience reveal critical failures in care. For example, we have managed infibulated women suffering from severe genitourinary conditions and dyspareunia who underwent multiple C-sections without ever being offered defibulation.

Furthermore, the perception that most women will request reinfibulation after childbirth may influence providers’ expectations, potentially contributing to the underutilisation of defibulation services.

Finally, more than half did not consistently document FGM/C, reflecting low coding knowledge and aligning with prior Swiss hospital data [48]. Poor medical documentation limits the ability of the public health community to understand the scope and burden of FGM/C in Switzerland.