Preventing FGM: Beware A Turf War Between Medicine And Law

The symposium Contestations around FGM: Activism and the Academy, held on 7 March 2015 and organised by Dr Tobe Levin, was a first, in formally bringing together activists and academics to discuss many aspects of continuing efforts to eradicate female genital mutilation.  My task was to contribute to a round table discussion on ‘the benefits, the hurdles and the effects on prevention of committed implementation of the law’. In my paper I examined the risk that an inadvertent turf war around FGM might now be emerging in the UK between the medics and the lawyers.

The symposium was held at Lady Margaret Hall, University of Oxford, as part of that Hall’s International Gender Studies programme for the Oxford international Women’s Festival, now in its 25th year.  A summary of my contribution follows….

Concerning prosecution, what are the benefits, the hurdles and the effects on prevention of committed implementation of the law?

The three established pillars of acquired influence in most societies are religion (‘the church’ or ‘faith’), the law and medicine.

Entry to any of these professions grants considerable power and autonomy to those who gain it – whether in ‘traditional’, heritage-facing settings or in modern technocratic ones.

The nature of the knowledge required for entry to the powerful, high-status position may vary, but the influence is, in its context, much the same.

And so the struggle, finally, to make FGM history finds itself at the epicentre of conflicting voices.

Let’s take these three elements in turn:

The religion and belief systems
Firstly, the ‘church’, or, more realistically in respect of FGM, belief systems:  FGM is aligned with many other harmful traditional practices, in subordinating women to the whims of men. Of course this synchronicity isn’t perfect; but it’s there.

In traditional belief systems the winners by a large measure are men; they dictate the terms, and– should there be any resistance – the repercussions.

Overwhelmingly, the men who maintain traditional belief systems are also the men who own the land and other resources and who, indeed, own the women marked by FGM as suitable to be their consorts.

Patriarchy resists change
Little wonder there is massive resistance to change from many clerics and other upholders of ancient beliefs.  There has even been (an abandoned) move to introduce legal training in Sharia law, in the UK. It is not surprising then that those modernisers who fight against FGM  find it so difficult.

To a degree however, perhaps we can belief systems – or the ‘church’ – here, if only because the schisms are becoming increasingly apparent…

Over time, schisms, however harshly repudiated, weaken traditional belief systems, and that can only help in the eradication of FGM.

Medicine
So what of medicine?

Modern clinical practice requires both hierarchy and, for those at the ‘top’, considerable autonomy.  Lead clinicians expect their judgement to be accepted and respected. Clinicians steadfastly maintain that they have their patients’ interests at heart, both medically and as individual people with particular needs.

Externally imposed constraints on clinical practice are therefore not welcome. At some level they are likely to be perceived as a threat to medical autonomy:

Medicine may require considerable teamwork, but it has well-defined hierarchies, and it also has long-established inter-disciplinary rivalries. Sadly, one has only to look at and of the recent reports of serious error in UK hospitals to see that disciplinary boundaries within health provision are a major contributor in failures.

Autonomy and rivalry
Each discipline has its own special pleading:  Midwives may perceive themselves as the only advocate of vulnerable or disenfranchised women…  health visitors and  general practitioners expect their judgements to be respected…

But at the same time midwives sometimes resent doctors,  junior doctors must bow to consultants, and  ancillary staff, however central to the team,  must know their place.  How else, we are asked, can it be, in matters potentially of split-second decisions and life or death? At the very least, hierarchical delineation acts as a control over professional rivalries.

However, the same urge to strict hierarchies and triggers for conflict within medicine may be even more pronounced in relations between medicine and the law.

The law
And so to our third profession, the law:

It’s probably helpful here to distinguish between legislators who create the law, lawyers who work at one remove, and the police, who act as first-line enforcers (and protectors).

Those in the legal profession as such tend to have little patience with the claim by clinicians that with few exceptions (there are some is understood and acknowledged) doctors must be the judge of who to bring to the attention of the law.  There may be a suspicion that the fall-backs to ‘patient confidentiality’ and ‘patients’ confidence in their clinicians’ are actually matters of professional convenience and succour.

Yes, the care of the individual patient is paramount in clinical practice; but clinical practitioners, for all their sterling work over the years in making us aware of FGM, are not, I’d suggest the best people alone to eradicate it.

The courts alone can adjudicate
The courts have an entirely independent role.

Clinicians – and teachers and others in regulated activity – must be required by law to report ALL suspicions of FGM (and other abuse) to a central authorised body. Lawyers and others can then take action where necessary to protect the child and / or to prosecute.

It is the courts who must decide on protection orders, guilt and if necessary, punishment. That is not a role for doctors (or, say, teachers or social workers).

The way forward: public health with legal reinforcement

These matters are however complex.  For clinicians, the focus on the individual can be at the cost of others; but public health, enhanced by legal powers, can take a much wider view.

On the other hand however, the front-line of law enforcement, the police, is as yet poorly equipped to provide the reinforcement which public health messages on FGM require; and the recent trial of a doctor, then acquitted of FGM, has united the medical profession against the lawyers.

An emerging turf war?
And so we may see a medical – legal turf war developing.

I believe a national, government-led ‘traffic lights’ system, such as I suggested during the Government consultation on Mandatory Reporting, for coping with all child abuse will help here, and is essential; and it would also ease the reservations expressed during that consultation by the clinicians.

But without clarity about a shared modus vivendi, to move on from this medical / legal inter-disciplinary conflict may be difficult.

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FURTHER INFORMATION AND ACTION

Readers are invited to support these two FGM e-petitions:

UK Government: Enforce the UK law which forbids FGM (Female Genital so-called ‘Cutting’)    ..

and FGM abolitionists internationally: Support the Feminist Statement on Female Genital Mutilation

There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email:fgmhelp@nspcc.org.uk

The #NoFGM Daily News carries reports of all items shared on Twitter that day about FGM – brings many organisations and developments into focus.

Also available to follow is daily news from NoFGM_USA.

For more on FGM please see here.

Twitter accounts: @NoFGM1  @NoFGMBookUK  @FGMStatement  @NoFGM_USA   [tag for all: #NoFGM]

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More info on FGM in the UK here. Email contact: NoFGM email