Concordance between self-assessment using watercolor illustrations and clinical examination: implementing a visual...

Accurate identification and reporting of female genital mutilation/cutting (FGM/C) are essential for clinical care, documentation, and epidemiological research, yet self-reporting of FGM/C type remains unreliable and may benefit from visual support tools. This study aimed to evaluate the concordance between women's self-assessed FGM/C type using a watercolor-based visual tool and the World Health Organization classification determined by clinical examination.

We conducted a prospective observational study including women with a history of FGM/C. Participants self-assessed their vulval appearance by selecting one of eight watercolor illustrations inspired by representative images from a clinical atlas. Self-assessments were compared with diagnoses established during standardized vulval examinations by a trained specialist. The primary outcome was agreement between self-assessment and clinical classification, while secondary outcomes included recognition rates, predictors of accurate self-reporting, and acceptability of the tool. Insights gathered during clinical use informed the development of a digital version intended to facilitate implementation in clinical and community settings.

Eighty women were included. The most common types were Type IIb (n = 30, 37.5%) and Type III (n = 25, 31.2%). Agreement between self-assessment and clinical examination was low for both subtypes (κ = 0.205, 95% CI: 0.101-0.308) and types (κ = 0.204, 95% CI: 0.063-0.344). Recognition was achieved in 27/80 (34%) for a subtype and 35/80 (44%) for a type of FGM/C. Self-report accuracy was highest among women with Type III (n = 13, 52%). Among the 16 participants (20%) who selected the watercolor of a vulva without FGM/C, 37.5% (n = 6) had previously undergone defibulation. Type III was the only independent predictor of correct self-reporting (aRR = 2.16, P = .009).

Visual self-assessment tools may enhance communication and patient engagement but cannot replace clinical examination for accurate FGM/C classification and documentation. Strengths include the prospective design, standardized clinical examination, and a novel patient-centered visual tool, while limitations include single-center recruitment and tool development without direct input from affected women. Agreement between self-assessment and clinical examination was limited, indicating that visual tools may support awareness and communication but cannot replace clinical evaluation.