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Talking About FGM: The Welsh Obstetrics And Gynaecology Society Meeting

March 31, 2017

My invitation to speak at the Welsh Obstetrics and Gynaecology Society Meeting in Llandudno today was impetus enough to look again at issues around female genital mutilation (FGM) specifically from the perspectives of clinical medicine.  I prepared a one-sheet briefing for those attending. The notes below are an annotated version of the thoughts I shared – ending as ever with a plea for more direct engagement by Public Health and the School Medical Service in support of those clinicians (eg Obs/Gynaes) on the frontline of efforts to end this epidemic of ‘traditional’ criminal harm.

Female Genital Mutilation (FGM) – some thoughts

NB Female genital mutilation is never an easy subject to talk about.  Discussions sometimes trigger flashbacks or other distress in those with direct and/or personal experience of FGM, even if they are themselves clinicians.

All obstetricians and gynaecologists will have a general idea that things are ‘different’ when they observe direct clinical evidence of female genital mutilation (see a guide to the issues).  But not all are aware that sometimes the evidence is less overt (FGM may, for instance, have been done to a very young infant), nor will all of them consider the possibility that symptoms reported by a patient relate to FGM.  FGM delivery modes are many and require further investigation by medical anthropologists; assumptions or vague ideas about who may have experienced FGM will also mask the reality that women and girls are at risk in different places of different forms of this serious assault and breach of human rights.
FGM is patriarchy incarnate, underpinned by the economics of the communities in which it is practised. It therefore presents in different ways in different places.

Some who encounter FGM in the course of their clinical work say they have ‘one chance to get it right’, in the few moments after the possibility that FGM is presenting has arisen….

> Clinicians need to be prepared for their first encounter with FGM before it occurs.  There are numerous accounts of women with FGM who found their clinicians’ first responses alarming. Routine early training for clinicians on FGM is compelling.  (Consider the situation in which Dr Dharmasena of Whittington Hospital found himself. For more direct narrative see also evidence in my second book by Lucy Mashua, an FGM survivor, and midwife Comfort Ottah.)

> It is now standard that all women attending initial antenatal care be asked about FGM (and FGCS?); and conversations (the ‘FGM pathway’) about any future risk to baby girls are also essential. Guidance on this and other formal aspects of addressing FGM in the UK are available from the Home Office website.  A Home Office FGM e-learning package can also be accessed for free.

> Likewise, clinicians must be aware of mandatory requirements around both anonymous statistical reporting and to alerting relevant authorities if there is any direct evidence of harm or of suspected future risk to minors.  (See Home Office information, above. Why this requirement is viewed differently by some clinicians from, eg, reporting infectious diseases / hazards is an interesting and rarely considered issue.)

> FGM is at epidemic levels. Globally some two hundred million women and girls alive today are affected, and around five thousand new cases annually of known FGM in England are now being reported by the HSCIC.   At least 137,000 women and girls in England and Wales are thought to have undergone FGM (including 10,000 still under the age of 18).  This media report details some of these findings and gives considerable detail on the locations, ages etc of the girls and women concerned.
The situation is now becoming a little clearer, but the practicalities of the route to reporting suspected risk for girls (see here, but NB written before reporting was made mandatory) may still vary by location.  Whilst the NSPCC has an FGM helpline [0800 028 3550] there is still no single nationally defined route for referring concerns and protecting minors; and given this variation (above) some probably fall through the gaps.
Top-level advice on reporting for professionals in regulated activity (generally, teaching and health and social care) who have concerns around FGM on minors is here.

> Nonetheless, to date there have been no successful prosecutions for FGM in the UK.  The reasons for this lack of success relate to matters ranging from reluctance by survivors (victims of the crime) to report their own parents – “Surely my mum permitted my FGM only because she believes if necessary for an advantageous marriage?” – to the lack of diversity of enforcement agencies. Enforcement of the law remains problematic.

> FGM is one of a number of harmful traditional practices (HTPs) to which some women and girls may be exposed (breast ironing etc…); some traditionally practising now ‘ex-pat’ communities abandon HTPs, whilst others regard FGM as a way to distinguish themselves from people elsewhere.

Female genital cosmetic surgery is becoming more common; there are however serious questions to be asked both about legality (in the absence of serious clinical indications, it is probably FGM) and about the notion of patient ‘choice’. Who is regulating it in the private sector? Is the charge of ‘white hypocrisy’ valid? Who is attending to the psychological care of vulnerable / pressured / poorly informed girls and women?  The legal (and RCOG) advice seems to be, proceed with extreme caution – and, unless there is compelling clinical need, not at all on minors.
Some of the challenges and ethical issues in relation to FGCS are discussed by Mr K, a legal professional, in his contribution to my second book.

> The publisher of Uncut/Voices books on FGM, Dr Tobe Levin, and I, with colleagues, have very recently set up a charity to support women who want their FGM repaired: The Clitoris Restoration and Fistula Repair Fund.

> There is no case for ‘just a nick’ as some have suggested. All FGM is illegal and unethical and there is in any case no evidence that the ‘nick’ approach will reduce harm.  Perhaps these considerations apply also to male circumcision (which I and many other #EndFGM campaigners also fundamentally oppose).

> The personal child health record ‘red book’ offers an opportunity to establish that infants have not been harmed – but only if, as is the case eg in France, the child is examined thoroughly. Initially this aspect of care is the responsibility of midwives, health visitors and GPs, but watchfulness diminishes at school.
To what extent should the protection of girls from FGM (and the protection of all children from other abuse) be continued proactively via the school health service, school nurses etc?

> And finally, FGM cannot be eradicated by any one discipline alone.  I argue in my book that it requires a Public Health approach within an inter-disciplinary framework or paradigm, with visible high-level leadership. Ambitions to eradicate FGM ‘in a decade’ are unconvincing in the absence of genuinely meaningful levels of #EndFGM programme investment.  ‘Multi-agency’ approaches alone fail to address the big questions around the eradication of FGM:

who ultimately is in charge, and who is providing what resources?

2 Comments leave one →
  1. April 5, 2017 10:14

    Hilary, I’m always impressed by your clarity, expertise, and passionate engagement, not to mention the utility of your guidelines for action. Adapting to your professional audience needs, you advise well. First, be prepared! All too many memoirs by survivors contain what is nearly a trope of Western medical incompetence — due to ignorance — of painful, discouraging encounters with practitioners. When asked whether they have been in traffic accidents, or suffered burns, or are simply exhibited to assembled interns (often without their permission), patients share the indignity of those encounters. Certainly physicians don’t deliberately hurt feelings; but their own horror when encountering the damage of FGM for the first time often results in inadvertent additional pain. Hence, you rightly advise: be informed beforehand. To facilitate learning, the Clitoris Restoration and Fistula Repair Fund includes instruction in medical schools among its aims.

    • April 5, 2017 13:07

      Thank you Tobe, and yes indeed! You remind me here that I must also add a note re midwife Comfort Ottah’s testimony to this piece – her account in my second book about how she first encountered FGM at the critical point whilst delivering a baby tells us much; as indeed does Lucy Mashua’s hair-raising narrative in the same book about her first encounter with a gynaecologist in the USA.
      As you say, we are determined that our CRFRF remit includes centrally the need for across-the-board undergraduate clinical training on FGM.
      Thank you!

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