The Hurt Of Female Genital Mutilation Doesn’t Go Away Over The Years
A conversation about FGM today with my friend and colleague Dr Phoebe Abe-Okwonga has raised some quite important questions about ‘Where do we go from here?’. Phoebe has been working in her pro bono London clinic with FGM victims / ‘survivors’ for many years, so she has a massively valuable perspective on what’s happening. Unfortunately, the answer is: We’re not doing enough. People and things to be recorded change over the years, and perhaps the UK approach to FGM hasn’t always kept up?
It is of course an excellent medical achievement that most women with female genital mutilation (FGM) who reside in the UK will live well into their retirement years. There is now a full protocol of clinical care for pregnant women and mothers who have had FGM, well established over several years.
But what happens after that? For some women the injuries and harms of FGM do not recede with age; but the presentation of their conditions may change.
Unwell years later
It seems that older women, experiencing the menopause and beyond, are coming to the surgery with back pain, dryness, kidney problems and much else, physical and psychological, as a result of the damage done to them years before via FGM.
To quote Reisel and Creighton (2014)
With increased longevity, the number of older adult women living with FGM will increase. They will require high quality, sensitive and evidence based care and this will be an unprecedented challenge for General Practitioners, Gynaecologists, Geriatricians and indeed all involved health professionals.
Diagnosis, treatment and training
The connection with the original harm is not however always made by the doctor they consult long after the event, which means that the patient may be referred to the ‘wrong’ consultant (eg the appropriate gynaecologist or urologist) and treatments may as a result not be ideal.
One move towards better diagnosis and treatment is obviously better training for clinicians – GPs, practice nurses, consultants – who see women patients in their later years. They need to be aware that women of a certain age with a wide range of conditions are perhaps experiencing ill-health because of FGM, however long ago it may have occurred.
Data and records
And then there is the question of data and records. Whilst there is a requirement to provide information (for anonymised analysis) on patients presenting with FGM, this is more likely to be observed during an obstetric or gynaecological consultation. The likelihood of observing the harm is less as women get older, and the obligation to check and report is it seems more vague for women coming in with problems decades later.
As a result it is less probable that data about FGM will be reliable for older women presenting for the first time with FGM-related conditions. There may also be nothing on the person’s clinical records which would point her doctor to an FGM problem.
Health care provision
Dr Abe-Okwonga observes that not only is it less likely that an older women will have FGM noted and brought to bear on the diagnosing illness about which she is consulting a doctor, but there is also another problem. There are too few actual FGM clinics for women now to attend to seek help about their FGM – which could in turn also reduce the number of clinicians with focused experience of the tradition.
The care of those with FGM is an important aspect of health provision for thousands of women (estimated at around 137,000) in the UK. There is however a real danger that this condition and its life-long impacts are being sidelined by other issues, doubtless COVID amongst them, which have arisen in the past few years.
Yet again it may be that the personal and community costs of FGM are being overlooked.
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Read more about FGM and Health.
Your Comments on this topic are welcome.
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Books by Hilary Burrage on female genital mutilation
https://orcid.org/0000-0002-6684-2740
Eradicating Female Genital Mutilation: A UK Perspective (Hilary Burrage, Ashgate / Routledge 2015).
Full contents and reviews HERE.
FEMALE MUTILATION: The truth behind the horrifying global practice of female genital mutilation (Hilary Burrage, New Holland Publishers 2016).
Full contents and reviews HERE.
FURTHER INFORMATION AND ACTION
There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email: fgmhelp@nspcc.org.uk
Details of NHS Specialist Services for FGM here.
More info and posts on FGM here.
Activists, service providers and researchers may like to join the LinkedIn group Female Genital Mutilation (FGM): Information, reports and research, which has several hundred members from around the world.
Email contact: via Hilary
[NB 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.]
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, except in any specifics as discussed above. Anyone wishing to offer additional comment on more general considerations around infant and juvenile genital mutilation is asked please to do so via these relevant dedicated threads. Discussion of the general issues re M/FGM will not be published unless they are posted on these dedicated pages. Thanks.
Hilary Burrage 
Hilary Burrage, The zero tolerant and global, the fight which is and remains essential, their convictions to necessitate it and the maintenance of their traditions, is hopeless of abandonment, we see the adaptations, from certain regions to they have always been moderate without savagery, that they modernize their practice towards adulthood from the glans alone, even from birth, they are too supported in their traditions by the extremes.
Ouarzazate: they do the clit with a cryogenic pen device, death and cauterized
In Morocco recently I spent some time in the city of Ouarzazate.
I chatted with Noor, the receptionist of the hotel, and discovered she had been circumcised by the local midwife when she was 12. Her mother had taken her to the clinic without any explanation other than she was about to become a woman. The midwife told Noor she was going to trim a part of her genitals and she must keep perfectly still. There had been a cold sensation and a few seconds later she felt a slight tingling pain and it was over. She felt sore for a few days. A tiny black lump fell off a few days later. Noor now knew that it was her pearl.
Noor is now 19. I told her about my own circumcision and Noor suggested we visit the midwife to see how it was done. The people living in the area are from sub-Saharan Berber tribes. No man would marry an uncircumcised woman and it is usual to circumcise girls between ages 10 and 12.
Fatma’s clinic was in a modern office block in the old town and was well furnished. Fatma spoke only Berber so Noor translated. Her main work is ante-natal care. Circumcision is a small but important part of her work. We sat and sipped hot mint tea. A woman and a young girl entered the reception. Lisa tugged at my arm. We were about to watch an actual circumcision. The mother sat in reception with her daughter while Lisa, Noor, Fatma and myself entered the inner room. Fatma placed a clean sheet on the bed and called out “Zaneeb”. The daughter walked in calmly. Noor translated as Zaneeb removed her dress and underwear and lay back on the table. Fatma picked up a small stainless-steel cylinder with a gold-plated attachment at one end. She pressed a trigger and we heard a hissing sound. The tip of the spout began to ice over and I knew that it had to be a cryogenic pen device. There was a sweetish odour in the air. I remembered that smell when I had a milk tooth extracted as a child. It was nitrous oxide. Zaneeb innocently parted her thighs and brought her knees to her chest. Fatma spread open the girl’s outer labia and pulled back firmly on the hood until the glans was exposed. She eased a white plastic ring with a handle over the glans to protect the surrounding skin from frost damage. Fatma placed the tip of the cryogenic pen device over the centre of Zaneeb’s glans and squeezed the trigger for a few seconds. Again the hissing sound and I watched fascinated as her tiny pearl turned white.
The intense cold (-90°C) instantly burned her glans to death and cauterized it before the nerves became aware of what is going on. It was now dead and would drop off in a few days, along with the plastic ring. A few minutes passed. Zaneeb slowly stood up and replaced her dress. She was now a woman! She looked so happy and smiled at us as she left the room. I asked via Noor if Fatma circumcised older women. She did, but it was rarely necessary. Fatma then said something to Noor. To my surprise, Noor lifted her skirt and lay back on the table. Fatma spread her labia and retracted her hood. Her circumcision scar was barely visible. It was flat, round and slightly darker than the surrounding skin. With the hood forward I would never have known that Noor had been circumcised.
We thanked Fatma and returned to our hotel. Lisa told me she wished she had grown up here and I had taken her to the midwife to be circumcised when she was 12. She definitely would have chosen the cryogenic method for our circumcisions had she known about it. No fuss, almost no pain and it was perfectly legal. I fully agreed with Lisa.
Thank you so much for telling us about this important update on ways that FGM is done.
PS You mention Noor, Fatma and Zaneeb, but who is Lisa? (the other person who came with you to the clinic)? Did she already have FGM as well?