Title: Female Genital Mutilation and Cutting: A Survey of Child Abuse Pediatricians
Version: 2 Date: 15 Oct 2023
Reviewer's report:
Thank you for the opportunity to review this manuscript titled “Female Genital Mutilation and
Cutting: A Survey of Child Abuse Pediatricians” submitted to BMC Women’s Health.
The authors conducted an online survey of child abuse pediatricians (CAPs) where they recruited
members of the Ray E. Helfer Society through invitations on the Society’s listserve over a period
of a month in 2020.
The topic of FGM/C is salient and an understanding of the level of knowledge, comfort level
in care of and received training on FGM/C among US CAPs is an interesting question. The
manuscript is well written and easy to read.
The questionnaire appears to have been developed in consultation with international experts
in the field, and the methodology is straightforward. The authors describe the questionnaire as
having been adjusted in consultation with experts but did not describe whether the instrument
was piloted with non-experts or with a sample of CAPs. Doing so may have allowed for better
understanding of why the response rate was so low.
In fact, the main limitation of this study is the low response rate and small sample size which
limits the generalizations that would be allowed for an analysis that represents the universe of
US CAPs. The authors should provide more detail on the number of eligible members, that is US
based practicing CAPs at the time of the survey. International CAPs, including those practicing
in Canada, were not eligible. Also, please provide the contemporary number of practicing board-
certified CAPs in the US at the time of the study if that data is available. Additionally, invitations
did not appear to exclude non pediatricians who are Society members, which may include
forensic physicians, ophthalmologists, and radiologists. In Table 2, 11 (16.9%) respondents were
not trained CAPs, though their backgrounds regarding specialty training are not specified. Please
add this data to the supplement.
Details in the methodology about the nature of the survey and the planned analysis were either
omitted or appear in the results. How the correct responses to survey items were determined
should be specified. For example, the four brief case vignettes that were aimed to elicit responses
on reporting to statutory authorities should be described in the methods section. The Likert scale
used throughout the survey should be presented. Please report confidence intervals for the results
in addition to p-values.
The number of responses is reported as 65 in the abstract, though in some of the main domains,
the response number appears to diminish further to 54 and on the WHO subtypes question, the
denomination is n=46. Please introduce the results section with an explanation of the various
responses in the different domains. This should be brought into the discussion section as well as
the limitations. The authors are appropriately transparent about the limitations of the study due
to the low response rate. They speculate on this being due to the extensive length of the survey.
Other factors, such as expectations of responding correctly to questions should be considered.
More caution on the interpretation of the results as representing the CAP workforce should be
stated in the manuscript. For instance, the discussion starts with the study described as the first
national survey of CAPs on FGM/C, while it is a small sample of respondents.
The authors conclude with noting that qualitative studies with parents from high-prevalence
countries should be conducted. While this is undoubtedly desirable, this identified need does
not emanate from the  results  of the current study. Instead, qualitative or mixed methods studies
of US CAPS may further improve our understanding of the need for greater awareness among
CAPs of published guidance and the need for further training so that CAPs can readily take on the
potential leadership role in addressing and preventing FGM/C that is described by the authors.