The Challenge of Addressing the Health Care Needs of Immigrant Women Who Suffered Female Genital Mutilation/Cutting, in Spain
By Professor María del Mar Pastor Bravo
The contentious issue of Female Genital Mutilation/Cutting (FGM/C) poses unique challenges to health promotion and health care around the globe. FGM/C is defined by the World Health Organization (WHO) as “all procedures that involve injury to the female genital organs for non-medical reasons”*. This set of traditional practices is one of the most extreme expressions of gender-based violence and a violation of women’s rights,affecting some 200 million women and girls in over forty countries on five continents. It is estimated that 500,000 women living in the European Union (EU) have been subjected to FGM/C, and that 180,000 girls and women are at risk of undergoing FGM/C every year.In Spain, approximately 17,000 women and girls have either been mutilated or are at risk of being so.Despite the large numbers of women affected, it has been documented that availability and quality of care in Spain and Europe remain a challenge. WHO has set priorities to eradicate FGM/C, encouraging researchers to document the dramatic consequences of this practice.It is expected that such knowledge will help health care providers in Western countries better understand the experience of women who suffer the consequences of FGM/Cand provide transcultural, respectful care.
The article “Living with mutilation: A qualitative study on the consequences of female genital mutilation in women's health and the healthcare system in Spain” (Midwifery, 66, 119–126) reports the results of a study based on interviews with genitally-cut migrants who had given birth in the Spanish National Healthcare System. The study objective was to better understand the perspective of these women on health care. Participants reported physical, psychological, obstetric and sexual complications that could be linked back to FGM/C. Among immediate physical consequences they described hemorrhage and intense pain, with related difficulty urinating. Long-term complications were also mentioned that could be ascribed to this practice, including recurrent urinary infections and hepatitis B. Psychological consequences identified through the interviews included fear, emotional pain, rage, frustration, anguish, sadness, depression, and post-traumatic stress disorder. Women suffered changes in their sexuality, such as fear of engaging in sexual intercourse, dyspareunia (decrease in sexual pleasure), and difficulties in reaching orgasm. They also experienced complications during pregnancy with a greater need for episiotomies, instrumental deliveries, and caesarean deliveries. Furthermore, participants reported that health care professionals did not openly address the issue of FGM/C, never discussing with them the implications of their condition at any phase of care.
The lack of acknowledgement and information-sharing regarding FGM/C does not represent adequate care for this population. As a universal, publicly funded system, the Spanish National Healthcare System, as other health care systems in the EU, should be responsive to changes in the population it serves. Given how rapidly the demographic profile of the European population is evolving, monitoring changes in population needs and establishing appropriate responses, including training of health care professionals, is essential for immigrants but important for all users.
*WHO (2018) Fact Sheet: Female Genital Mutilation. https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
María del Mar Pastor Bravo, PhD
Faculty of Nursing, University of Murcia
By Professor Anahi Viladrich
In recent years, the United States (U.S.) has witnessed heated debates on immigrants’ rights to government-sponsored health coverage, particularly after the passage of the 2010 Patient Protection and Affordable Care Act (i.e., ACA or Health Reform; Public Law 111-152, 2010). ACA was aimed at providing accessible and affordable health care coverage to formerly uninsured populations. However, it ended up barring undocumented immigrants—about 12 million people—from any publicly subsidized health insurance. Given the American public’s heated rhetoric with respect to immigration, scholars have become increasingly interested in understanding the frames most often used by the media that argue for either the inclusion or exclusion of unauthorized immigrants in the U.S.
Frame analysis, a well-known conceptual tool among political theorists has become popular in the broader social sciences in recent years given its power to deconstruct and explain media images. In this article, we define frames as conceptual packages of information summarizing a topic and imbuing it with a particular moral weight and ideological direction. For example, terms such as “illegal immigration” or “amnesty” are not neutral as they imply that unauthorized immigrants are law-breakers and perpetrators of criminal acts. Given the ubiquitous presence of the media and its role in shaping attitudes towards immigration, it is key for researchers to understand the common frames (i.e., scripts, metaphors and representations) that are publicly constructed either against or in support of immigrants’ entitlement to health services.
In our analysis of immigration in the U.S. context, a country where health care is a commodity, we found that inclusion has traditionally been supported by special circumstances. Typically, the rights of non-citizens to government-sponsored health care have been backed as a way of avoiding unintended consequences (e.g., as in the case of pregnant women bearing American children, whose lives may be at risk, or immigrants who are carriers of infectious diseases and are deemed a danger for the general U.S. population). Furthermore, public opinion has usually favored particular immigrant groups such as the innocent victim, the effortful agent, the elderly, the young, the frail, and the disabled. More recently, the U.S. media has supported highly educated immigrants, particularly those who arrived to the U.S. as children (i.e. Dreamers). These individuals are not only presumed to be industrious and talented but also “innocent,” a frame based on the assumption that they were not brought to the U.S. of their own volition.
The frames summarized above can be conflated under the figure of the “deserving” immigrant, an overarching frame that is at odds with the notion of immigrants’ entitlement to health care as a fundamental human right. While the U.S. represents a radical case, where universal health coverage represents a market-based commodity that is available either to those deemed exceptional or those with the financial means to access it, the principle of access to affordable (or free) and safe health care is being challenged in many countries. In this context, understanding how immigrants’ representations are socially constructed and disseminated through media frames is essential towards overcoming stigmatization, discrimination and exclusion of vulnerable groups across diverse nation-states and political sceneries.
Anahi Viladrich, PhD
Sociology & Anthropology, Queens College
Sociology, The Graduate Center
Community Health and Social Sciences, CUNY School of Public Health
The City University of New York (CUNY)
By Professors Andrea Cortinois and Denise Gastaldo, Editors
With this post, the Global Migration and Health Initiative (GloMHI) launches a series of original contributions, a collection we call ‘Echoes.’ On a monthly basis, we will host original contributions by migrants, advocates, community workers, students, educators, policy makers, and applied researchers, from all over the world, who want to share ideas that contribute to an in-depth understanding of migration and its articulations with health, from multiple perspectives and disciplines.
GloMHI, as a group of scholars and advocates, is interested in understanding the complexity of the migration phenomenon, its global determinants, and migration as a determinant of health. Our vision is at the same time simple and trying: health for all, regardless of birthplace. The reference to the 1978 Alma Ata Declaration is transparent. We chose this vision to attract attention to one of the fundamental contradictions illuminated by migration: the one between the responsibility nation states have to protect and promote health as a fundamental human right and the way they construct their identity, on the basis of the inclusion/exclusion, belonging/being foreigner oppositions, and on the protection of borders. If governments have a responsibility for the health of their people, as the Declaration states, who will protect millions of non-citizens/denizens worldwide?
We try to step back and reflect on this phenomenon from a comprehensive perspective. We believe migration is one of the defining phenomena of our time, directly and closely related to some of the central existential challenges we are currently facing as a species, including climate change, environmental degradation, and resource depletion. Understanding migration, today, requires moving beyond a narrow focus on immigrant health, to recognize this phenomenon as a global one, with global causes and consequences.
Meaningfully contributing to the debate on migration, today, means challenging many of the clichés that limit our vision. Migration is not a crisis for the wealthy countries of Europe, North America, or Australasia. Migration is a crisis for the hundreds of millions of people on the move, as much as for their families, communities, and entire societies in countries of origin. Migration as a determinant of health cannot be understood purely in terms of health risks and protective factors directly related to the various phases of the migration trajectories: pre-departure; transit; short- and long-term destination situations; and return. It is essential, instead, to look at migration through an intersectionality lens, delving deeply into the complex identities of migrants, understanding their individual and collective lived experiences, reflecting on the contextual factors that shape those experiences, and exploring both the obvious and less obvious social costs of migration. Debating migration and the challenges it creates is an exercise in futility unless the historical and political economy factors at the root of this phenomenon, such as colonial rationalities, are openly and thoroughly addressed.
We hope to contribute to this debate by giving space to the voices and showcasing the work of many who strive to understand a phenomenon that is changing our societies in profound ways and that, we believe, will only increase in size and significance, over the next decades.
Andrea A. Cortinois, PhD
Assistant Professor, Dalla Lana School of Public Health
University of Toronto
Toronto ON M5T 3M7
Denise Gastaldo, PhD
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Toronto ON M5T 1P8