BAME Birthing With Colour: Female Genital Mutilation (FGM) Has Many Meanings and Contexts – And The Buck Stops… Where?

Saturday 7 November 2020 is the date for the online conference BAME Birthing with Colour, at which I have been asked to talk on FGM, an issue which encompasses many complex challenges for those seeking to end it. Many women and girls seek help only when the harm has already reached them and they need urgent attention for gynaecological or obstetric problems; and often, like the medics, other sectors of the FGM prevention community are too hard pressed and focused on the imperative for action to have much time to reflect on the wider contexts in which this cruel abuse of women and girls’ human rights occurs.

In preparing my presentation for BAME Birthing with Colour I have drawn on a wider social, psychological and economic analysis of FGM, in the hope that such an overview can enhance perspectives around the important work in which activists and professionals are engaged as they strive to make FGM history forever.  My talk is now ‘in the can’, ready to go on Saturday 7 November.  Below are some notes I made for my presentation. I hope they may be useful when we come to discuss the morning’s  programme of formal presentations.

Birthing With Colour: Female Genital Mutilation (FGM) Has Many Meanings and Contexts

Most of you joining us today will be involved in health care, so I will take account of that , but I also want to ask the question, who else is critical in our efforts to stop FGM?  And my response to that question is: many different people.

But first, a reminder of what FGM actually is: It’s female genital mutilation – not all FGM is ‘cutting’, so I avoid that term.

FGM is a procedure where the female genital organs are injured or changed and there is no medical reason for this.

You can check out the detail of this definition yourself any time by looking up the UK’s Multi-agency statutory guidance on female genital mutilation. 

FGM is an ever-present epidemic
FGM is an on-going global epidemic.  Probably more that 200 million women and girls now alive on our planet have undergone FGM, and another 3 million are expected to have it inflicted on them every year in the short / medium term.

Of those, a significant number will die, and a very much larger number will suffer life-long damage to their health, both physically and, in many cases, psychologically.

Turning to the UK, recent estimates suggest that probably around 130 thousand women who have migrated to England and Wales have had FGM, as have approximately ten thousand girls aged under 15.  No local authority in England and Wales is likely to be free entirely from FGM, and much the same applies to Scotland and Northern Ireland.

So we have a massive problem.  FGM is an important aspect of the health and wellbeing of women and girls in the UK- as well as in many other parts of the world.

FGM is however a very significant challenge not ‘only’ for obstetrics and gynaecology, but also for Public Health, in all its guises – clinicians, lawyers and the police, teachers and trainers, social carers, economists, psychologists, sociologists, statisticians, the media, community leaders and many others must all be involved in our work to STOP FGM.

Unlike some other epidemics, if people stopped doing FGM, within a few years it would simply also stop being a problem.  FGM is the result of human agency.  We can chose to stop it if we wish, and prevention is always better than ‘cure’;

So how can we all help to move this forward?

Pressure points to stop FGM
Some questions, in quite random order:

Do we understand enough about FGM to be able to explain,  to those at risk,  and to those who operate as ‘cutters’,  that FGM is very harmful to health?

Do we know the terms used in various communities to refer to FGM?  Can we, in that sense, speak the same ‘language’ as the people we need to reach? Are our teams adequately diverse, with enough people actually from the various at-risk communities, so that we can communicate clearly about FGM  – and so we will know the signs that FGM may occur?

Do we understand that FGM has very serious economic as well as health and ‘moral’ consequences?

Are we adequately aware that bride-price (the sale of young women to be wives) may depend on the ‘purity’ of girls – and that cutters’ may receive fees for ‘ensuring’ virginity via FGM?

How can we explain the connection between FGM and the loss of girls’ education, and the restrictions on their lives that will come about because of this?

Is the connection between ‘virginity’, FGM and early / child marriage and / or honour killings understood?

Are we aware that traditional families may greatly fear the judgement of their ancestors (even grandparents) if they don’t impose FGM on their daughters?

Have we considered that the trend in some countries towards the medicalization of FGM is a dangerous breach of ethics and often also of law?  Have we considered why this practice still occurs?

And are we aware that cosmetic genital surgeries may be illegal under FGM legislation, as well as perceived by some in communities where FGM still occurs as hypocritical?

How can we address the psychological pressure on generations of girls and women who continue with FGM because it is a question of trusting their (grand)mothers, or they cannot believe that their mothers would inflict such damage if it were not essential to do so?

How can we identify those girls and women who need protection from FGM? Or identify their need for psychological and other support as a result of their FGM?

All of you will have some answers to these and similar questions.  But where is the joined-up thinking?

UK / English agency guidance on FGM
Looking at the example of FGM policy in England and Wales, there are a number of agencies which seek to give structure and guidance on approaches to FGM.

These include, amongst others and at different levels

The Multi-agency Statutory Guidance discussed above, which is for Local Authorities, the NHS and Health Trusts, the Police, the Governors of schools and others in regulated professions

Guidance in the Working Together to Safeguard Children document, including Local Safeguarding partners such as the leaders of Local Authorities, the Police and Clinical Commissioning Groups

and, for instance, the FGM Safeguarding Pathway for obstetric care.

All these documents, relating to numerous national and local organisations, require significant resourcing and training schedules, but how many of them are fully co-ordinated?  How many are adequately funded?  Are we aware of the inevitable costs to society as well as individuals if these agencies are not supported properly to address the challenges of FGM?

How many meet fully the requirements placed upon them?

How many have consciously worked to incorporate whichever of the issues listed above are necessary for the work to be fully effective?

Or, conversely, who, amongst the on-the-ground workers, is actively aware of these agencies and requirements?

And who amongst those who work in communities and with clients and patients, has been able to make input into the high level decision-making bodies?

Are there enough local midwives and health visitors, GPs, school nurses, youth and psychiatric care services for them to be fully engaged in tackling FGM?

Who is collaborating on the basis of mutual respect with volunteer and not-for-profit organisations on the ground?  Who is seeking to learn more from these groups about how and why FGM still occurs? Who is helping to keep them financially afloat?

I could ask many more questions of this sort, but perhaps this is enough.

Moving forward
#Each of us, as professionals, activists and lobbyists seeking to end FGM, brings our own understanding and effort to the challenge. None of us has anything like all the answers.

Enforcement of the very necessary legislation against FGM is essential but not alone enough.  Likewise, the provision of clinical and other care is a vital, but not alone adequate.

For FGM to end, whether in Britain or elsewhere, we all need to understand and respect the contributions others can offer, as we try to understand what FGM means to those who still practise it. Necessarily competing agencies are unlikely to be able to do a superb job.

Then we can find other ways forward, bringing together many different aspects of the collective effort.

This sort of collective, collaborative approach is used to positive effect by many in Public Health – which is in my view overall the best vehicle for ending FGM and the challenges it produces.

Who is in charge?
But still there is one more question which must be asked: Who, ultimately, is in charge?

At present we have a situation in England where the buck is so easily passed, between different local agencies and authorities, different ‘responsible’ organisations and different arms of government, all of them on shoestring – and competing – budgets.

When we all know with whom the buck finally stops, and when we know how to communicate with and feed information into his / her remit, there is a much better chance that we will finally make FGM history.

The buck stops… where?

The BAME Birthing with Colour event is on Saturday 7 November.  You can join here.

Read more about FGM and Public Heath

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