Abstract
Abstract
Objectives
To assess self-reported knowledge, training and clinical practices related to female genital mutilation/cutting (FGM/C) among healthcare professionals in Austria and to identify profession-specific gaps relevant to prevention and care.
Design
Cross-sectional online survey.
Setting
Nationwide survey conducted in Austria between September 2023 and February 2024.
Participants
A convenience sample of 537 healthcare professionals, including midwives (29%, n=157), gynaecologists (21%, n=113), general practitioners (18%, n=95), paediatricians (13%, n=72), and other (19%, n=100). Participants were recruited via professional associations.
Main outcome measures
Self-reported knowledge of FGM/C (including WHO typology, Austrian legislation and International Classification of Diseases (ICD)-10 codes), exposure to FGM/C training during professional education, clinical experience with patients from FGM/C-practising countries and comfort discussing FGM/C in clinical practice. Associations between professional group and outcome measures were analysed using logistic regression.
Results
Knowledge gaps were particularly pronounced as 63% of respondents were unfamiliar with legislation and 85% lacked knowledge of relevant ICD-10 codes. Compared with general practitioners, gynaecologists reported higher knowledge of legislation (adjusted OR (aOR)=4.75; 95% CI 2.47 to 9.14), traditional and cultural aspects (aOR=2.65; 95% CI 1.39 to 5.05) and ICD-10 codes (aOR=4.52; 95% CI 1.87 to 10.97). Only 34% (n=182) reported receiving any FGM/C training during professional education. Demand for additional training was high, particularly regarding legal frameworks (88%, n=474) and WHO typology (74%, n=397). Paediatricians were significantly less likely to feel comfortable initiating discussions about FGM/C (aOR=0.17; 95% CI 0.08 to 0.36) compared with general practitioners, whereas gynaecologists reported the highest comfort levels (aOR=1.44; 95% CI 0.64 to 3.28).
Conclusions
Substantial, profession-specific gaps in knowledge and training on FGM/C exist among healthcare professionals in Austria. Despite increasing availability of specialised services, insufficient integration of FGM/C into professional education may hinder effective prevention, identification and care. Targeted and systematic training, particularly for paediatricians and general practitioners, alongside national clinical guidelines may strengthen healthcare responses to FGM/C in Austria.
Keywords: Gender-Based Violence; Education, Medical; Clinical Competence; Health Services
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The study included participants from multiple healthcare professions and practice settings across Austria, allowing comparisons of female genital mutilation/cutting knowledge and training between professional groups.
Over-representation of certain professional groups may bias overall results, though this is mitigated by subgroup analyses.
Focus excludes professionals with key victim protection roles, such as nurses, social workers, psychologists and legal staff, thereby limiting the assessment of cross-sector knowledge gaps.
Sampling bias is likely due to self-selection by convenience sampling.
Reliance on self-assessed knowledge, which prior studies indicate that healthcare professionals often overestimate, might mask the fact that actual knowledge levels and preparedness may be even lower than reported.
Introduction
Female genital mutilation/cutting (FGM/C) is a form of gender-based violence internationally recognised as a human rights violation. The WHO defines FGM/C as ‘all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’ and distinguishes four main types, with additional subtypes: Type I, partial or total removal of the clitoral glans and/or the prepuce (clitoral hood); Type II, partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia majora; Type III, narrowing of the vaginal opening through the creation of a covering seal by cutting and repositioning the labia minora or labia majora, with or without removal of the clitoral prepuce and glans; and Type IV, all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping or cauterisation.1
Following Johnson-Agbakwu et al,2 we adopt the term ‘FGM/C’ as a compromise between ‘female genital mutilation’ and ‘female genital cutting’, recognising its dominant Western perspectives, as many languages have their own vernacular terms that capture the variations of the practice.2 The choice of terminology concerning FGM/C is highly political, shaped by global power dynamics, raising questions about who decides how cultural practices are named.2
FGM/C constitutes a violation of bodily autonomy and is associated with a range of short-term and long-term health consequences, including urogenital and obstetric complications, as well as sexual and mental health problems.1 The reasons for performing FGM/C—such as adherence to local traditions, religious beliefs, marking the transition to adulthood or safeguarding virginity—vary between countries and ethnic groups but are consistently rooted in gender inequality and the regulation of female sexuality.1
Worldwide, an estimated 230 million girls and women are affected by FGM/C.3 The practice is reported in at least 31 countries across Africa and Asia. Due to global migration, increasing numbers of girls and women affected by FGM/C now live in Europe, North America and Australia, although country-specific prevalence data remain limited: over half a million girls and women are estimated to be affected by FGM/C, and specialised outpatient clinics have been established in several countries to provide care.4 Research focusing on health professionals, however, has repeatedly demonstrated insufficient knowledge and preparedness. Multiple studies have examined the knowledge, attitudes and practices of healthcare professionals regarding FGM/C, including midwives, gynaecologists, nurses, paediatricians and, to a lesser extent, general practitioners, for Europe but also for the USA and high-income countries in general.5–12
According to indirect estimates published in 2024, 10 869 girls and women living in Austria are potentially affected by FGM/C. These estimates are based on population data as of 1 January 2023, combining information on females by country of birth and age with available prevalence data from countries where FGM/C is practised.13 Previous estimates suggested that 8000 women and girls were affected, indicating an increase in recent years. The analysis of sociodemographic data on the country of birth indicates that the majority of individuals potentially affected were born in Egypt (49%), followed by Somalia (26%) and Nigeria (6%).13
Austria’s statutory social health insurance scheme provides near-universal health coverage with open access to ambulatory care, general practitioners, specialist physicians and hospitals. Unlike systems with formal gatekeeping, patients may directly consult general practitioners, specialists or hospital outpatient services without referral.14 In 2021, a national FGM/C coordination centre was established, contributing to improved service availability; specialised outpatient clinics are now available in most Austrian federal states. In the capital city of Vienna, the women’s health centre FEM Süd, which is funded by the city government’s women’s service (MA 57), has functioned as a primary point of contact since 2007. The centre has specialised in the provision of health services for women affected by FGM/C, as well as the facilitation of prevention activities. The activities of FEM Süd have served as a good practice example for approaches to prevention and care, informing measures in other federal states. Other smaller non-governmental organisations such as the African Women Organisation serve as more informal counselling centres on FGM/C. There are also several outpatient clinics specialised in FGM/C in Viennese public hospitals.
Despite these developments, Austria lacks national clinical guidelines on FGM/C, and the level of knowledge among healthcare professionals remains unclear. Under Austrian law, FGM/C is punishable as bodily harm with severe and permanent consequences, and physicians have a duty to report cases. However, exceptions exist and obligations to report or notify in connection with FGM/C must always be assessed on a case-by-case basis and require a high degree of sensitivity.15
Previous surveys examining healthcare professionals’ knowledge in Austria have focused on midwives16 and on gynaecologists and paediatricians.17 A 2023 retrospective analysis of data on the documentation of FGM/C in the university hospital in Graz, a regional capital, shows a significant discrepancy between documented rates of FGM/C based on International Classification of Diseases (ICD)-10 (3.2%) and rates that could be expected according to the number of women with a birthplace in a country with FGM/C prevalence who delivered in the hospital (38.6%).18 Consistent with findings from other European countries, these studies suggest insufficient knowledge and a need for further training.
The aim of the present study was therefore to assess the level of knowledge and training related to FGM/C among healthcare professionals in Austria. The research question guiding the study was: What knowledge and training do different healthcare professional groups in Austria have regarding FGM/C?
Methods
Study design
This article draws on data from a mixed-methods study conducted between April 2023 and May 2024 and commissioned by the Austrian Federal Chancellery. The study contained data collection among affected communities as well as among healthcare professionals. One important part of the study was the indirect estimation of FGM/C prevalence data by extrapolating data from countries where FGM/C is documented. All the results were published in a final project report.13 As part of this study, we conducted a quantitative cross-sectional online survey between mid-September 2023 and mid-February 2024 using the SoSci Survey tool. The survey was conducted in German. A pretest of the online survey, involving five participants, was conducted in August 2023 to assess the clarity and appropriateness of the questionnaire and to make necessary adjustments.
The questionnaire was distributed via mailing lists of national and regional professional associations and organisations, such as the Austrian Medical Association and the Austrian Midwives Association, as well as directly by email to physicians and midwives. Recipients were encouraged to forward the survey link to eligible colleagues, resulting in a convenience snowball sampling strategy. Due to the snowball sampling approach and open distribution of the survey link, the total number of individuals reached is unknown and a response rate could not be calculated.
The study population comprised all registered general practitioners, gynaecologists, paediatricians and midwives, as these professional groups are presumably most likely to provide care to individuals affected by FGM/C. In addition, other healthcare professionals with potential contact with individuals affected by FGM/C were eligible to participate and could be selected under the category ‘other’. Eligible participants were required to be healthcare professionals, fluent in German, have potential contact with patients affected by FGM/C in their professional practice, and provide informed consent before completing the questionnaire. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
The questionnaire was adapted to the Austrian context and the targeted healthcare professional groups based on previous European studies, developed by Ziyada et al11 (see online supplemental file 1). The final questionnaire of non-standardised questions collected information on:
Sociodemographic and professional characteristics: Gender (male, female, other/prefer not to say), age (<30, 30–39, 40–49, 50–59, >60), professional group (general practitioner, gynaecologist, paediatrician, midwife, other), years of work experience (<5, 5–15, 16–25, 26–35, >36 years) and work setting (hospital, publicly contracted practice, private practice and other; multiple answers possible).
Self-reported knowledge on FGM/C: (1) legislation (yes, no), (2) traditional and cultural aspects and (3) ICD-10 medical codes (yes, somewhat, no). For analysis, ‘yes’ and ‘somewhat’ responses were combined. Participants also indicated their desire for further knowledge on (1) legislation (yes, somewhat, no) and (2) WHO typology (yes, somewhat, no, already familiar).
Training on FGM/C: (1) during professional education, (2) during further professional education (yes, a little, no) and (3) whether they had received training on FGM/C associated health consequences and treatment (yes, a little, no, self-study).
Clinical practice: Participants were asked (1) to rate the role FGM/C plays in their daily professional practice on a 5-point Likert-scale ranging from very low to very high; (2) whether they had ever treated patients from countries where FGM/C is practised (yes, no, maybe); (3) report the number of consultations with women/girls affected by FGM/C they had conducted in the previous 5 years; (4) if they would feel comfortable discussing FGM/C with a potentially affected patient or their parents (yes, somewhat, no). For analysis, ‘yes’ and ‘somewhat’ responses were combined. Respondents answering no were asked about the reason for their discomfort being patients/parents or personal reasons (yes, somewhat, no). Participants who reported (maybe) caring for patients originating from countries where FGM/C is practised (n=328; excluding paediatricians) were asked whether they routinely ask whether patients have been affected by FGM/C if they come with specific FGM/C associated health problems (yes, no).
Filter questions were used to skip non-applicable items and tailor follow-up questions based on previous answers (eg, only those who reported treating FGM/C-affected patients were asked about specific health problems). For reporting the results of the survey, we followed the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) checklist.19
Statistical analysis
Data were analysed using IBM SPSS Statistics V.29. Descriptive results are presented as frequencies and percentages. Differences between professional groups were assessed using χ² tests; Fisher’s exact test was applied where cell counts were below five. Binary logistic regression analyses were conducted to examine associations between professional group and self-reported knowledge as well as clinical practice. For analysis, responses were dichotomised, combining ‘yes’ and ‘somewhat’ to represent a positive response, because ‘somewhat’ was considered to indicate partial endorsement of the outcome rather than a negative response, consistent with a previous study using a similar analytical approach.11 Additionally, a sensitivity analysis was performed in which only ‘yes’ responses were classified as a positive outcome (see online supplemental file 2). In addition to crude analyses, adjusted binary logistic regression models were performed to estimate adjusted ORs (aORs). Age, gender and years of work experience were entered as covariates to control for their potential confounding effects after verifying that the model assumptions were met. Results are presented as both crude and aORs with 95% CIs and p values. A p value of <0.05 was considered statistically significant. All tests were two-tailed.
Results
Sociodemographic and professional characteristics of study participants
A total of 716 individuals initiated the questionnaire. Of these, 178 did not complete it and five responses were excluded due to implausible data. The final sample comprised 537 participants from various professional groups: 29% midwives (n=157), 21% gynaecologists (n=113), 18% general practitioners (n=95), 13% paediatricians (n=72) and 19% from other healthcare professions (n=100). The professional group category ‘other’ comprised a heterogeneous group of medical trainees (n=7), physicians from various specialties and public health roles. The most frequently represented disciplines were internal medicine (n=14), anaesthesiology (n=14), neurology (n=7), surgery (n=5), psychiatry (n=5), dermatology (n=4) and urology (n=4), with other specialties represented by smaller numbers. The majority of participants were women (80%, n=429), and approximately half were aged between 30 and 49 years (51%, n=270). The largest proportion had 5–15 years of work experience (29%, n=154), followed by 26–35 years (24%, n=125) and 16–25 years (22%, n=118). More than half of respondents worked in hospital settings (63%, n=340). Detailed sociodemographic characteristics by professional group are provided in table 1.
Table 1. Sociodemographic and professional characteristics by professional group.
| Total | General practitioners | Gynaecologists | Paediatricians | Midwives | Other | ||
|---|---|---|---|---|---|---|---|
| n=537 | n=95 (18%) | n=113 (21%) | n=72 (13%) | n=157 (29%) | n=100 (19%) | ||
| Gender | Female | 79.9% | 66.3% | 80.5% | 65.3% | 98.7% | 73% |
| Male | 19.4% | 31.6% | 19.5% | 33.3% | 0.6% | 27% | |
| Other | 0.4% | – | – | 1.4% | 0.6% | – | |
| Age (years) | <30 | 12.8% | 4.2% | 9.7% | 4.2% | 28.7% | 6.0% |
| 30–39 | 24.6% | 23.2% | 27.4% | 27.8% | 24.8% | 20.0% | |
| 40–49 | 25.7% | 26.3% | 27.4% | 26.4% | 25.5% | 23.0% | |
| 50–59 | 22.5% | 21.1% | 26.5% | 22.2% | 15.9% | 30.0% | |
| >60 | 13.8% | 23.2% | 8.8% | 19.4% | 5.1% | 20.0% | |
| Work experience (years) | <5 | 16.6% | 8.4% | 11.5% | 8.3% | 33.0% | 10.0% |
| 5–15 | 28.7% | 34.7% | 34.5% | 29.2% | 27.0% | 19.0% | |
| 16–25 | 22.0% | 18.9% | 24.8% | 26.4% | 20.0% | 22.0% | |
| 26–35 | 23.3% | 24.2% | 23.0% | 25.0% | 15.0% | 34.0% | |
| >36 | 8.0% | 11.6% | 5.3% | 11.1% | 5.0% | 10.0% | |
| Work setting (multiple answers) | Hospital | 63.3% | 21.1% | 72.6% | 70.8% | 77.7% | 65.0% |
| Publicly contracted practice* | 17.1% | 52.6% | 12.4% | 18.1% | 4.5% | 8.0% | |
| Private practice* | 15.6% | 13.7% | 32.7% | 11.1% | 1.3% | 24.0% | |
| Other | 17.5% | 21.1% | 3.5% | 5.6% | 34.4% | 12.0% | |
In Austria, publicly contracted practices (‘Kassenpraxis’) provide services funded by statutory health insurance, whereas private practices (‘Wahlarztpraxis’) operate on a fee-for-service basis, often with partial reimbursement.
Self-reported knowledge on FGM/C
Most participants reported not being familiar with Austrian FGM/C-related legislation (63%, n=338) and with ICD-10 medical codes relevant to FGM/C (85%, n=458). In contrast, 69% (n=371) indicated that they had at least some knowledge of the traditional and cultural significance of FGM/C. As shown in table 2, statistically significant differences in self-reported knowledge were observed between professional groups. Gynaecologists reported significantly higher levels of knowledge regarding Austrian legislation (aOR=4.75; 95% CI 2.47 to 9.14), traditional and cultural aspects (aOR=2.65; 95% CI 1.39 to 5.05) and ICD-10 medical codes (aOR=4.52; 95% CI 1.87 to 10.97) compared with general practitioners. Paediatricians and midwives were also significantly more likely to report knowledge of legislation.
Table 2. Association between self-reported knowledge and professional group, n=537.
| Legislation (Yes) |
Traditional and cultural aspects (Yes/somewhat) |
ICD-10 medical codes (Yes/somewhat) |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| % | OR (95% CI) | aOR (95% CI) | % | OR (95% CI) | aOR (95% CI) | % | OR (95% CI) | aOR (95% CI) | |
| General practitioners | 18.9 | Ref. | 62.1 | Ref. | 9.5 | Ref. | |||
| Gynaecologists | 51.3 | 4.51 (2.40 to 8.49)** | 4.75 (2.47 to 9.14)** | 80.6 | 2.52 (1.35 to 4.71)* | 2.65 (1.39 to 5.05)* | 27.4 | 3.61 (1.62 to 8.05)* | 4.52 (1.87 to 10.97)* |
| Paediatricians | 40.3 | 2.89 (1.44 to 5.79)* | 2.73 (1.34 to 5.58)* | 66.7 | 1.22 (0.64 to 2.32) | 1.16 (0.61 to 2.24) | 9.7 | 1.03 (0.36 to 2.91) | 1.25 (0.42 to 3.77) |
| Midwives | 48.4 | 4.01 (2.20 to 7.32)** | 4.34 (2.26 to 8.35)** | 69.4 | 1.39 (0.81 to 2.37) | 1.44 (0.8 to 2.58) | 15.9 | 1.81 (0.81 to 4.06) | 2.3 (0.91 to 5.82) |
| Other | 18.0 | 0.94 (0.46 to 1.94) | 0.91 (0.43 to 1.91) | 64.0 | 1.09 (0.61 to 1.94) | 1.01 (0.56 to 1.84) | 7.0 | 0.72 (0.26 to 2.02) | 0.92 (0.31 to 2.74) |
Results are based on binary logistic regression and are presented as adjusted and crude ORs with 95% CIs. Adjusted models included age, gender and years of work experience as covariates. Statistically significant results are shown in bold (**p<0.001; *p<0.05).
aOR, adjusted OR; ICD, International Classification of Diseases.
A majority of participants expressed a desire to improve their knowledge: 88% (n=474) on Austrian FGM/C-related legislation and 74% (n=397) on WHO FGM/C typology (table 3).
Table 3. Desire to improve knowledge by professional group.
| Legislation | Typology | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Yes | Somewhat | No | P value | Yes | Somewhat | No | Already familiar | P value | |
| General practitioners | 64.2% | 31.6% | 4.2% | 0.420 | 58.9% | 29.5% | 1.1% | 9.5% | <0.001 |
| Gynaecologists | 59.3% | 26.5% | 14.2% | 46.0% | 10.6% | 2.7% | 40.7% | ||
| Paediatricians | 62.5% | 25% | 12.5% | 52.8% | 25.0% | 4.2% | 18.1% | ||
| Midwives | 63.1% | 24.2% | 12.7% | 54.1% | 19.7% | 1.9% | 24.2% | ||
| Other | 56.0% | 30.0% | 14.0% | 46.0% | 31.0% | 11.0% | 12.0% | ||
Legislation: n=537, typology, n=536.
Differences between professionals are calculated with χ² test. If <5 people are in one category, Fisher’s exact test is applied.
Training on FGM/C
Only 34% (n=182) of respondents reported that they had received at least some training on FGM/C during their initial professional education. Training varied substantially by profession: more than 60% of midwives reported some form of training, compared with 35% of gynaecologists, 17% of general practitioners and 14% of paediatricians (p<0.001) (table 4). Notably, 35% of gynaecologists reported having received no training on FGM/C even during postgraduate or specialist education, with a significant difference between groups. Overall, 18% (n=99) of respondents indicated that they had independently pursued further training on health consequences and treatment related to FGM/C.
Table 4. Training on FGM/C by professional group, n=537.
| During professional education | During further professional education | Training on health consequences and treatment | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Yes | A little | No | P value | Yes | A little | No | P value | Yes | A little | No | Self-study | P value | |
| General practitioners | 1.1% | 15.8% | 83.2% | <0.001 | 6.3% | 17.9% | 75.8% | <0.001 | 2.1% | 15.8% | 69.5% | 12.6% | <0.001 |
| Gynaecologists | 5.3% | 29.2% | 65.5% | 23.0% | 42.5% | 34.5% | 12.4% | 30.1% | 24.8% | 32.7% | |||
| Paediatricians | 1.4% | 12.5% | 86.1% | 15.3% | 25.0% | 59.7% | 11.1% | 18.1% | 55.6% | 15.3% | |||
| Midwives | 25.5% | 39.5% | 35.0% | 29.0% | 24.8% | 46.0% | 12.7% | 37.6% | 35.7% | 14.0% | |||
| Other | 3.0% | 12.0% | 84.0% | 8.0% | 9.0% | 83.0% | 3.0% | 7.0% | 35.7% | 17.0% | |||
Differences between professionals are calculated with χ² test. If <5 people are in one category, Fisher’s exact test is applied.
FGM/C, female genital mutilation/cutting.
Clinical practice in contact with FGM/C-affected individuals
FGM/C was reported to play a relatively minor role in daily professional practice, with 78% of participants rating its relevance as very low or low. Nevertheless, 60% reported having treated patients from countries where FGM/C is practised and 54% indicated that they had provided care to at least one patient affected by FGM/C within the previous 5 years.
77% of participants reported feeling at least partly comfortable in talking about FGM/C; however, notable differences emerged between professional groups. While 89% of gynaecologists reported feeling comfortable discussing FGM/C, 50% of paediatricians stated that they would feel uncomfortable. Among these paediatricians, 86% attributed their discomfort to concerns related to the patient’s parents, and 44% cited personal reasons. Results of the logistic regression showed that paediatricians were significantly less likely than general practitioners to feel comfortable in discussing FGM/C with a potentially affected patient or their parents (aOR=0.17; 95% CI 0.08 to 0.36) (table 5).
Table 5. Association between level of comfort and professional group, n=537.
| Level of comfort (Yes/somewhat) | |||
|---|---|---|---|
| % | OR (95% CI) | aOR (95% CI) | |
| General practitioners | 84 | Ref. | |
| Gynaecologists | 89 | 1.44 (0.65 to 3.21) | 1.44 (0.64 to 3.28) |
| Paediatricians | 50 | 0.19 (0.09 to 0.39)** | 0.17 (0.08 to 0.36)** |
| Midwives | 82 | 0.83 (0.42 to 1.64) | 0.94 (0.45 to 1.97) |
| Other | 71 | 0.46 (0.23 to 0.93) | 0.45 (0.21 to 0.92) |
Results are based on binary logistic regression and are presented as adjusted and crude ORs with 95% CIs. Adjusted models included age, gender and years of work experience as covariates. Statistically significant results are shown in bold (**p<0.001; *p<0.05).
Gynaecologists demonstrated the highest odds of asking about FGM/C across all relevant contexts: urogenital problems (aOR=3.94; 95% CI 1.82 to 8.54), pregnancy (aOR=4.87; 95% CI 2.17 to 10.9) and sexual health problems (aOR=4.61; 95% CI 2.08 to 10.22), compared with general practitioners (table 6). Midwives also exhibited increased odds of inquiry for urogenital problems (aOR=2.32; 95% CI 1.03 to 5.19), though not for other health problems.
Table 6. Association of asking about FGM/C and professional group.
| % | Urogenital problems (Yes) |
Pregnancy (Yes) |
Mental health problems (Yes) |
Sexual health problems (Yes) |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | aOR (95% CI) | % | OR (95% CI) | aOR (95% CI) | % | OR (95% CI) | aOR (95% CI) | % | OR (95% CI) | aOR (95% CI) | ||
| General practitioners | 36.2 | Ref. | 31.1 | Ref. | 24.4 | Ref. | 37.8 | Ref. | ||||
| Gynaecologists | 68.5 | 3.85 (1.83 to 8.09)** | 3.94 (1.82 to 8.54)** | 68.1 | 4.73 (2.19 to 10.22)** | 4.87 (2.17 to 10.9)** | 44.3 | 2.46 (1.09 to 5.54)* | 2.7 (1.15 to 6.34)* | 72.4 | 4.32 (2.01 to 9.29)** | 4.61 (2.08 to 10.22)** |
| Midwives | 54.0 | 2.07 (1.00 to 4.30)* | 2.32 (1.03 to 5.19)* | – | – | – | 38.4 | 1.93 (0.86 to 4.31) | 2.36 (0.96 to 5.8) | 47.0 | 1.46 (0.7 to 3.06) | 1.59 (0.7 to 3.61) |
| Other | 50.0 | 1.77 (0.72 to 4.33) | 1.68 (0.66 to 4.29) | 45.2 | 1.82 (0.71 to 4.71) | 1.64 (0.6 to 4.48) | 37.0 | 1.82 (0.65 to 5.12) | 1.58 (0.52 to 4.77) | 46.4 | 1.43 (0.55 to 3.72) | 1.34 (0.49 to 3.67) |
Urogenital problems: n=257, pregnancy: n=167, mental health problems: n=237, sexual health problems: n=243.
Results are based on binary logistic regression and are presented as ORs with 95% CIs. Adjusted models included age, gender and years of work experience as covariates. Statistically significant results are shown in bold (**p<0.001; *p<0.05).
aOR, adjusted OR; FGM/C, female genital mutilation/cutting.
Discussion
This article examined self-reported knowledge, training and clinical practices related to FGM/C among 537 healthcare professionals in Austria. Although the heterogeneous professional backgrounds of participants and their varying likelihood of encountering girls and women affected by FGM/C limit comparisons between professional groups, the findings provide important insights into existing knowledge gaps and training needs within the Austrian healthcare system.
Overall, participants reported limited knowledge of Austrian legislation, medical coding and the WHO FGM/C typology, together with limited exposure to FGM/C during professional education. Only one third of participants reported having received any training on FGM/C during their education, a lower proportion than reported in studies from other countries.11 20 21 Most respondents were unfamiliar with Austrian legislation (63%, n=338) and medical codes (85%, n=458) related to FGM/C and approximately three quarters expressed a need for further knowledge on the legal framework and the WHO typology. These findings are consistent with previous studies reporting limited knowledge of WHO typology, legal provisions and medical coding among healthcare professionals.7 11 12 22
While physicians in Austria have a legal duty to report FGM/C in specific circumstances, this obligation must be assessed on a case-by-case basis, as numerous exceptions exist to safeguard the trust relationship between patient and provider.15 The national FGM/C coordination centre offers case-specific advice to professionals via a dedicated hotline, particularly in situations where prevention and child protection are at stake. Prevention in particular represents a sensitive area of practice that requires careful consideration of individual circumstances. In several other countries, clinical guidelines and structured tools are available to support healthcare professionals in discussing FGM/C and conducting risk assessments.
Compared with findings of Ziyada et al,11 Austrian healthcare professionals reported a higher level of comfort discussing FGM/C than general practitioners in Norway. However, paediatricians reported comparatively high levels of discomfort when addressing FGM/C with parents. Given their regular contact with families through mandatory child health consultations, this finding suggests that paediatricians may benefit from additional education and support related to discussing FGM/C in clinical practice. Further research could explore whether tailored educational approaches would help improve confidence in discussing FGM/C.
As self-referral to specialised outpatient clinics is possible in Austria, differing from referral pathways in countries such as Norway,11 healthcare professionals across disciplines may play an important role in prevention, care and treatment for girls and women affected by FGM/C. Participants reported that they mostly do not routinely ask about FGM/C when caring for patients presenting with health problems potentially associated with FGM/C. While limited knowledge and discomfort may partly explain this finding, they do not fully account for the low frequency with which FGM/C is discussed. Although FGM/C is not necessarily the cause of all such health problems, it should be considered as part of a comprehensive clinical assessment.23 These findings suggest that training initiatives could extend beyond biomedical knowledge to include cultural competence and culturally sensitive and respectful communication and cultural competence, consistent with previous research.7 8 Practical tools and infrastructural supports, such as clinical guidelines and electronic health record prompts, may further assist healthcare professionals in identifying, documenting and managing FGM/C-related care.24–27
The limited integration of FGM/C into professional education suggests that more systematic inclusion of this topic in curricula and continuing education may be warranted. Given the fragmented nature of healthcare training in Austria and the variety of existing curricula, a compulsory national guideline could help ensure a minimum standard of knowledge and provide practical guidance for healthcare professionals. As Austria transitions to mandatory outpatient diagnosis reporting and implementation of ICD-11,28 targeted guidance on identification and documentation of FGM/C may become increasingly relevant. Most recently, a European multicentre survey of obstetrics and gynaecology trainees similarly identified substantial gaps in formal training and preparedness despite high awareness of FGM/C, highlighting the continuing need for structured education across the healthcare workforce.29 Overall, our findings are consistent with studies from other European countries reporting substantial knowledge gaps among healthcare professionals.7 9 11 12 We therefore recommend expanding existing educational initiatives tailored to different professional groups and evaluating their effectiveness, in line with previous recommendations.5
This study has several limitations. The use of a convenience snowball sampling strategy meant that the total number of healthcare professionals who received the survey invitation was unknown; therefore, a response rate could not be calculated and self-selection bias cannot be excluded. Healthcare professionals with a particular interest in FGM/C may have been more likely to participate, potentially limiting the representativeness and generalisability of the findings despite the relatively large sample size (n=537). As the study primarily targeted physicians and midwives, the findings cannot be generalised to all professional groups involved in the prevention, identification and management of FGM/C. In addition, several potentially relevant variables, including prior intercultural training, frequency of caring for patients affected by FGM/C and practice location, were not collected and may have contributed to residual confounding. The heterogeneous ‘other’ professional group also limits the interpretability of findings for this subgroup. Finally, knowledge was assessed using self-report rather than objective testing; therefore, the findings reflect perceived rather than actual knowledge and may be influenced by self-assessment and social desirability bias.
Conclusion
This study identified self-reported knowledge gaps among healthcare professionals in Austria regarding FGM/C and suggests that there may be opportunities to strengthen targeted education and training. Educational content could encompass legislation, medical coding (ICD-11), the WHO typology, culturally sensitive communication and cultural competencies. Paediatricians may particularly benefit from such training, given their potential role in prevention and their reported discomfort in discussing FGM/C with parents. Although FGM/C plays a relatively minor role in the day-to-day practice of many healthcare professionals, basic knowledge of FGM/C and established referral pathways may support the recognition and management of FGM/C for affected girls and women. Future studies should evaluate whether such educational interventions improve healthcare professionals’ knowledge, confidence and clinical practice. Overall, our findings highlight the importance of FGM/C-related knowledge across healthcare disciplines and may help inform the development of educational strategies and future research in Austria.
Supplementary material
Acknowledgements
We would like to express our gratitude to all participants and collaborators of the overall study on FGM/C in Austria. In particular, we would like to thank all the respondents who participated in the online survey for this publication. Special thanks go to the individuals who pretested the survey questionnaire. We also thank the Austrian national and regional professional associations, professional organisations and individuals who helped in distributing the survey.
Footnotes
Funding: This study was funded by the Austrian Federal Chancellery (grant number n/a).
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2026-119483).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Ethical approval was granted by the Ethics Committee of the Medical University of Vienna (ECS 1586/2018). Before starting the questionnaire, participants received detailed information about their rights and provided informed consent. Participation was voluntary, and the questionnaire could be discontinued at any time. Data collection was anonymous, and responses could not, in principle, be traced back to individual participants. Participants were informed of their rights to access, rectify, erase, restrict or object to the processing of their data, as well as their right to data portability. It was also noted that anonymity could no longer be fully guaranteed if participants chose to make voluntary contact.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
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