1 Informed Consent

Informed consent is essential to ensure a trauma-informed, survivor-centered, ethical process that respects the (developing) autonomy of a patient.

If a patient does not (yet) have the developmental capacity to provide their own informed consent (i.e., is not sufficiently autonomous in the relevant sense), but is able to understand the basic ideas about what is being proposed, they should be involved in the decision-making process as much as possible and their “assent” should be obtained, along with the proxy consent of their parents or caretaker(s) (also known as parental permission). It is especially important to engage the patient and/or parents/caretaker(s) in an informed consent process when taking clinical or forensic photographs of sensitive body parts such as the genitalia. Even when informed consent is given by a parent or legal guardian, the clinician should obtain assent from the patient herself throughout the encounter.

Informed consent and assent apply to interviewing, carrying out a medical examination, taking photographs of the physical findings, and the dissemination of information and photos obtained at the visit to third parties (police, legal system, photo atlas, medical books, articles, or case reports).

  • You must gather informed assent/consent and confirm the patient is still in agreement, before handling the camera in front of the patient and taking photographs.

  • You must ensure that the patient fully understands the benefits and risks of photo-taking or any other action before they sign the consent form.

  • A patient (or a legal guardian in the case of a minor) has the right to refuse any action, at any time, even if he or she has previously consented to the actions. Make sure that the patient understands that refusing to be photographed will not affect their access to medical care or the legal process.

  • If you plan on taking photographs while the patient is under anesthesia, informed consent must be obtained before the patient is sedated.

  • You must explain that genital photographs will be used for medical education purposes and may be seen by many health professionals. As such, they are not going to be strictly confidential, though you will make sure no identifying information will be included.

2 Trauma-Informed Care

It is critical to take a trauma-informed approach to the history, physical examination, and photography of individuals with FGM/C. Trauma-informed care is an approach that assumes the person in front of you may have experienced trauma. Its principles emphasize establishing trust, ensuring safety, and yielding control to the patient, while striving to minimize discomfort, potential re-traumatization, and shame. This is particularly important in the context of performing a genital examination and photographing the genitalia of a child, which may elicit strong emotional reactions. A critical part of creating a safe environment for the patient is to clearly describe the purpose of the evaluation and photography, provide a concrete description of each step of the encounter, and reassure the child that she may pause or even stop the evaluation/photography at any time.

Photography is not the essential component of the exam and no pressure should be exerted on the patient or the family [47,48,49,50,51,52].

3 Photography: Technical Tips

  • Lighting can be critical to the appearance of some injuries/lesions. Bring in natural light if possible; if not, make sure the light source is not directly aimed at the lesion/area you want to photograph. The presence of bright lights or reflective surfaces can produce a washout of the detail (overexposure) and the injury or lesion will become less visible.

  • Darker skin reflects more light which can lead to overexposure. Often automatic settings on cameras do not account for this. Manual adjustment for flash and exposure may be needed.

  • Angled lighting reveals a higher level of detail than frontal lighting. A light source aimed at 45° angle to the lesion is considered the closest to natural lighting.

  • Consider using a ruler, or some other object of standard size (like a coin) to show the size of the anatomy or scars and to provide a scale of reference.

  • Take three photographs: a close-up, a medium-distance photo, and another showing the relationship to the rest of the perineum/genitalia/vulva.

  • If you are using a phone or tablet to take pictures, always use horizontal shooting.

  • Stabilize the device by holding it with both hands. You may need to have a nursing assistant help with the separation of the labia to allow for a full view of the area you wish to photograph. In some cases, it is ok to ask the patient if she is willing to assist.

  • Regularly clean the screen and lens BEFORE taking photographs.

  • Once the photographs have been taken and transmitted to an appropriate/secure source, DELETE them from your phone, tablet, or camera.