The Third ‘E’ Of Eradicating Female Genital Mutilation: Enforcement (And The Role Of Public Health?)

I was delighted to be invited to talk at the Launch of the Greater Manchester FGM Strategy today (1 December ’16). Most unfortunately however, the fates intervened and I’ve found myself travelling to Washington DC for the global FGM Summit the self-same day. But, my talk already written, here it is. Particularly, I wanted to raise some issues around supporting those in regulated activity who must report FGM, FGM restoration and repair, leadership and accountability, human rights, a single national FGM reporting route … and Public Health.

 

Approaches to Tackling Female Genital Mutilation

There are four essential factors , the 4Es, which must be included in any serious effort to Eradicate female genital mutilation (FGM).

These are Engagement, Education, Enforcement and Economics.

Engagement focuses on involving all parties in a constructive way, developing dialogue, openness and a degree of trust to enable meaningful communication.

Education is multi-faceted; it’s information that people share informally, it’s what children (and their parents and wider family) learn at school, it’s books, social media and also, importantly, the deep messages which your community endorses without you even realising.

Enforcement is about making sure the rules – in this case prohibition of FGM – are implemented in a firm and fair way.

And Economics addresses the inequalities of status, income and influence which somehow make harmful traditional practices seem acceptable aspects of the lives of women and men in some communities.

My primary task is to examine the third of these factors, Enforcement, which covers both protection and, where necessary, prosecution.

[Then, later, we shall consider also some other aspects of tackling FGM in a modern civic setting such as Manchester UK.]

Whilst ideally prosecution would never be required because protection has been effective, to date prosecutions have not been achieved because of failings in the legal system, rather than because there is no need for them; which takes us to the thorny issue of (mandatory?) reporting – an issue complicated by the fact that reporting suspected risk of FGM in children is now mandatory for those in regulated activity, ie teachers, clinicians, youth and social workers etc; but the debate about whether mandating should be required when the victim is adult, or all forms of child abuse, continues.

The case for mandatory reporting of concerns about girls at risk of FGM by those in regulated activity is in logic compelling – if everyone shares their concerns, the risk to children diminishes greatly, and we can build a much better informed epidemiological picture of likely incidence. But still some professionals, especially perhaps some midwives / other obstetric and gynaecology professionals, and social or community workers, object.

Reluctance to report the risk of FGM

My enquiries suggest there are a number of reasons for this reluctance to report all suspected risk of FGM.  Here are some – by no means not all – of them:

Although there is a significant number of conditions, whether in adults or children, which doctors (RMPs / ‘registered medical practitioners’) must report: infectious diseases, obviously including sexually transmitted ones, food poisoning, gunshot and other wounds, some domestic violence – all these matters may be subject to mandated reporting, whether the doctor is in the UK, the USA or, in to most of us less familiar territory, say, Iran.

On the whole, however, these other types of serious incidents are not encountered by, for instance, most midwives, who are therefore less acquainted with the professional challenges of squaring legal requirements and personal connection. And aligned with this is the feeling expressed by significant numbers of those who work in areas such as that most intimate of fields, obstetrics, that they are the ‘only advocate’ for, the only service provider who cares about, some patients.  Apart from that care, the worry is that the patient is on her own, maybe in very vulnerable, dependent and unsupportive circumstances.

Because of these very human and decent concerns, midwives may, as one example, advise clients about housing and other issues beyond their formal remit, in the belief that ‘she won’t trust or go to anyone else’.  (The development of professional techniques for passing clients safely and respectfully between different service providers is at best in its infancy.)

Some of these vulnerable women, pregnant and perhaps isolated from the wider society, will have experienced, or even still be at risk of, FGM.  The question for midwives and others with a close relationship to these clients / patients is always: will their patient’s expected child, if a girl, be also at risk of mutilation? And if so – as must almost always be at least considered – am I ‘betraying’ this woman by reporting my concern?  Will she be without any advocate if I speak up? (Another complexity is that many nations have pronounced under-18 marriage to be illegal child abuse. But in the UK a 16 year-old bride is both a ‘child’ and a ‘woman’.)  It’s often a tough call emotionally for clinicians to report their patients, but putting aside unspoken fears may leave an infant soon to be born – or their siblings – at risk.

Similar scenarios may also apply to teachers, youth workers and others who have a direct and personal relationship with their clients; and always there is additionally the fear that, as well as issues of confidentiality, and of labeling the client, the professional practitioner, by reporting, may also be branded irresponsible or suspect, especially if the concern is later adjudged unfounded.

Possible ways forward

The problem here is two-fold.

Firstly, reporting pathways and protocols may be confused.  It can be difficult for a concerned care provider (especially one relatively unused to reporting) to know to whom it is safest and most effective professionally to turn.  Few will be happy simply to show up at a police station. The reporting phone-lines for risk of FGM are not always accessible. Not all safety officers in schools and other service-providing agencies are well trained.   Plus, it is often difficult also to be certain how serious any perceived threat actually is.

The answer to this is obvious.  There must be one single reporting route, shared by all the services which require it.  And that route must be on at least a regional, if not – ideally – a national, level.  (Otherwise, children in unstable situations may be lost.) Then, except if it is imminent, the risk can be logged on a ‘traffic lights’ system, assessed by specialists whose role nurtures their building knowledge and expertise through close involvement.  If two reports of a risk show up, even it is initially deemed low, appropriate action must be taken.

It is extraordinary that such a system still is not in place.  Even if reporting were assiduous (which it currently is not) vulnerable children must surely fall through the gaps, when so many professionals of all sorts, some inexperienced or untrained in abuse detection and prevention, let alone in the specifics of FGM as it presents in different communities, are left unsupported to deal with protection concerns.  Further down the line, such considerations also apply to the specifics of knowledge and competence in court protection hearings etc.

The management and prevention of all child abuse requires specialist insights, but this is even more necessary – and less, currently, in supply – than that of FGM.  The only way that this expertise will be developed on an adequate scale is to enable a core of dedicated and coordinated regional and national hubs where specialist, system-integrated knowledge and skills can be consolidated.  We don’t have that as the norm, so far.

The second major obstacle to progress is much less about the logistics of reporting, and much more about the psychology of care provision.  Unless reporting is mandated, and unless there are repercussions if or when failure to report by those with statutory obligations comes to light, there will be a natural caution on the part of some professionals; and this, in addition to any reticence about ‘betraying’ the client.

Those required to report such serious suspicions need support, particularly if they are unused to this responsibility.  The range of care-givers who have a mandatory remit concerning FGM is wide, and it is by no means clear that everyone is conscious of important distinctions between professional requirements to report, and the subsequent and separate legal process to determine whether and how to take reported concerns forward.

There is no necessity for a turf war between clinicians (and other care-givers) and lawyers, but without overt acknowledgement of their different briefs there is a possibility that professional antagonisms become embedded.

Slowly, agreement is coalescing around the obvious and vital need for FGM survivors to receive adequate psychological, as well as physical, care.  But as yet there is almost nothing to support care-givers who work with, or in the possible shadow of, FGM and other child abuse.  Probably all that’s needed is a decent health and welfare scheme for both paid workers and volunteers in this difficult field, one that acknowledges the personal and professional stress for all those dealing with (potential) FGM and other abuse.

Burn-out and the loss of personnel who have conscientiously developed bespoke skills will be an almost inevitable outcome, unless this issue is addressed.

Multi-agency or interdisciplinary?  Who’s in charge?

A larger, strategic tension also exists in the structure of provision of services around FGM.

As the government’s Multi-Agency Statutory Guidance on FGM demonstrates very well, there are numerous different state and voluntary organisations involved in this field, and probably even more will eventually engage.  (However were GPs not included from the start? Perhaps there are lessons to be learned on all sides from that.)

Inevitably, each of these organisations, from the smallest and least formal to the largest and most weighty, has its own hierarchies, budgets and remits.  Little surprise then that, even with great goodwill all round, disagreements and antagonisms may arise. Perhaps some people in a voluntary body have thin skin; perhaps a well-established organisation expects compliance from others, regardless of who has the most expertise; perhaps sometimes relatively well-paid professionals seek without much sensitivity to ‘supervise’ community volunteers on the ground….

Such scenarios do not make for easy progress.  Only if everyone is willing to share openly is success likely; and it is doubtful that the Multi-Agency Guidance alone will deliver this objective.  Constraints on various provider budgets – if they even have a budget; community volunteers may not – are tight, professional authority guarded with care, the ‘value’ to the organisation of likely service provider benefits further down the line may vary.  In such circumstances it takes more than a generalised concern to deliver positive outcomes.

For this reason someone, an individual with a significant and public profile, needs to take charge and to accept that their desk is where the buck stops.  That person must – after due advice – decide who will receive which resources for which tasks, and how the whole is to be integrated.  (Sadly, at present some smaller, essential, uniquely informed but less formally engaged on-the-ground NGOs are of the view that ‘it’s not worth the trouble’ even to ask for money, so certain are they of rejection, and so hostile are they to the statutory providers.  Who is then best placed on either ‘side’ to improve matters is a moot point.)

But that buck continues to be passed between Departments at national government level.  A single government minister taking visible, overt, overall responsibility, setting out timetables for objectives to be reached and acknowledging accountability for them, would be ideal.  Until then, it may be easier to resolve some of these issues at regional or city level.

In the absence of any previously established holistic strategy there is a strong case for considering Public Health.  This approach embraces medicine, law, education and a socio-economically informed mode of service delivery which bolsters prospects for progress.

In short, Public Health encompasses all of the ‘4Es’ we considered: Engagement, Education, Enforcement and Economics.  That is one coherent model which could offer a way forward.

In the absence of an overarching national model for tackling FGM – for the Guidance, National Action Plans and reporting requirements do not constitute a holistic model, let alone a paradigm – towns, cities and perhaps even regions will seek their own solutions to co-ordination of provision.  It would be best if these were knowing and deliberate, considered, debated and publicly articulated by our civic leaders, not simply the result of an ad hoc implementation of various statutory rules and organisational whims.

Wider issues

The question often asked is, ‘how long?’ before FGM is eradicated.

This is an odd approach.  More important is to ask, ‘how much support and what sort of resources are needed?’ to make FGM history – for, grim though this truth is, we can hope FGM will in the end be eradicated, but it is less probable that all child abuse will come to an end.  Mitigation of all child abuse? A very firm yes.  Abolition? We can but hope.

For that ‘reason’ alone the abolition of FGM and other traditional harmful practices (HTPs) is vitally important.  It is thought FGM may be (amongst) the most common form/s of child abuse in Britain.  Eradicating FGM and attending seriously to the multiple disadvantages and hurts which it inflicts on survivors offers the prospect of healthier, happier communities which can escape the dead weight of harmful traditions.  It will be a long journey, but every step is worthwhile. Ending FGM releases resources to reduce child abuse overall.

But we know too that some 200 million women and girls world-wide have experienced FGM; and every year another three million are subjected to mutilation.

And we also know that one way to reduce the prospect of more FGM is to support healing and nurture the self-confidence of survivors.  When a woman can sense she is once more – in the words of many survivors – ‘whole’, she is free to share that knowledge and to promote the message far and wide that FGM must stop.  That is why colleagues and I have recently created the UK-based Clitoris Restoration and Fistula Repair Fund (CRFRF).  We want to support survivors, and, when we have the funds, other organisations in the UK and France (leaders in clitoral reconstruction and socio-psychological support) which share our objectives. Our aim is to help women back to good physical and mental health, so they can manage their lives confidently and autonomously, and demonstrate to everyone that FGM is absolutely not a ‘requirement’ for adulthood in any community anywhere.

For this wisdom alone it is extraordinary that in Britain the authorities choose to refuse asylum and care to FGM survivors and those at risk, who so desperately need protection.  Instead of deporting often vulnerable and already intimidated women and their children, we should be demonstrating by their lived example in the UK that a better life is possible.

In similar vein, the UK Government’s Prevent and Channel programmes to counter extremism have unfortunately been perceived by some as inappropriate interventions into people’s private lives.  Teachers reporting concerns about FGM is not the same as teachers reporting concerns about children being led into extremism, albeit each of these may sometimes be necessary. Both are very serious matters, and both can blight lives, but they are not identical issues – yet another reason why the recording of concerns about the safety of any child must be very much separate from any subsequent enquiry into the validity, or otherwise, of those concerns.  It cannot be overstressed that service providers and the courts have very different roles and responsibilities.

Teachers (or midwives or doctors or youth leaders) are not law enforcement officers.  Yes, evidence of potential tragedy, whether via FGM or indoctrination, must indeed be noted, but, whilst building children’s resilience against any and all harmful influences is always important, the teachers’ task is to encourage young people and equip them for adulthood, not to police them.

Finally, as we all know, FGM does not occur only in the UK.  In Britain we have the legal and service provision infrastructure, if the authorities so decide, to stop FGM.  Other nations are less well equipped in these respects, and for them the struggle to eradicate FGM is a far greater challenge. There is a fundamental hypocrisy in the claims of the UK government that they wish to end FGM in the UK and globally, whilst at the same time they seek – despite nodding tokenistically to universal human rights – wherever possible to export the problem elsewhere.  We need to think about this more.

Manchester

And so to Greater Manchester, and the launch of the FGM Strategy today.

Many of the issues I have considered here are identified also in this strategy.  The programme is encompassing and considered and many of the tensions which come with the territory are acknowledged.  The announcement of a dedicated, co-ordinated resource to support children and families, and also to support professionals, embedding a consistent response, is especially to be celebrated.  For all these reasons its authors must be congratulated.

And the next tasks, I might suggest, are these:

1. Begin to develop a cost-benefit (economic) analysis of the work in hand. The prevention of FGM can never be ‘about money’ – human suffering is not an economic matter – but it is probably nonetheless possible to demonstrate that work to prevent and ameliorate the effects of FGM is very much cost-effective.  Mothers who are strong and healthy, and girls who can enjoy learning and in adulthood thrive autonomously, are both a credit and a benefit to their communities and to wider society.  Let’s show by examining the policies to eradicate FGM that this is so.  Let’s find out properly which aspects of our work have the most positive impact long-term.   If we want real investment in the future of currently FGM-affected communities it will take real money, not simply odd handouts and exhortation.  And let’s carefully note the currently unacknowledged massive value of community-based, volunteer, contributions whilst conducting our analyses.

2. Ensure that the excellent developments just announced are shared with other cities and regions. There is a momentum now towards success. A tipping point may soon be reached if that momentum continues and is consolidated. That belief in prospects for progress is what must bring everyone together, to make FGM history forever.

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[A note on terminology: The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation,  The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.]

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Books by Hilary Burrage on female genital mutilation

For more detail and discussion of female genital mutilation please see my textbook, which considers in some detail the situation globally, but also explores the issues relating specifically to Western nations:  Eradicating Female Genital Mutilation: A UK Perspective (Ashgate/Routledge, 2015). My second book, Female Mutilation: The truth behind the horrifying global practice of female genital mutilation (New Holland Publishers, 2016), contains narrative ‘stories’ (case studies) from about seventy people across five continents who have experienced FGM, either as survivors and/or as campaigners and activists against this harmful traditional practice.

FURTHER INFORMATION AND ACTION

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

The (free) #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 at no cost or obligation is the #NoFGM_USA Daily News.

Twitter accounts:          @NoFGM_UK  @NoFGMBookUK @FemaleMutlnBook  @FGMStatement  @NoFGM_USA @NoFGM_Kenya  @NoFGM_France  @GuardianEndFGM [tag for all: #NoFGM] and @StopMGM.

Facebook page: #NoFGM – a crime against humanity

More info on FGM here. Email contact: via Hilary

PLEASE NOTE:

This article concerns approaches to the eradication specifically of FGM.  I am also categorically opposed to MGM, but that is not the focus of this particular piece.

Anyone wishing to offer additional comment on more general considerations around infant and juvenile genital mutilation is asked please to do so on the relevant dedicated thread, originally developed in June 2012:

The Other FGM Debate: Is Male Circumcision (MGM) Also Child Abuse?

Pending further notice (of a planned new blog, sometime later in 2016?), discussion of the general issues re M/FGM will not be published unless they are posted on this dedicated page. Thanks.