Gendered Harmful Practices (FGM, CEFM) Are A Public Health Crisis. Community Nurses Can Help Mitigate These Problems.
The Virtual Conference on Nursing Innovation & Reproductive Health (Rome, Italy: WINRH-2026) invited me to give a talk on 13 April on FGM (female genital mutilation) and CEFM (child, early and forced marriage). In dialogue with nurses, one approach might be to consider the various junctures at which FGM – and other harmful practices – are relevant to their normal work. My perspective here is Public Health, not the clinical treatment of FGM (I am a social scientist, not a clinician).
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District and neighbourhood nurses can be the health and well-being ‘eyes and ears’ of their communities.
The risks of experiencing FGM, CEFM and /or other harmful practices are often dependent on contexts and circumstances. We consider here how nurses attending vulnerable communities, particularly in Italy, Britain and the USA, may play an important role in preventing or ameliorating such harms.
FGM in Italy
Female genital mutilation (FGM) is globally widespread: the World Health Organisation reports that more than 230 million women and girls alive today have undergone this cruel practice. In Italy there are some 90 thousand ‘cut’ women, with around four thousand more girls at risk every year. Similar data apply elsewhere in Europe (in total 600,000 women living with FGM and about 190,000 girls at high risk), and this growing phenomenon is closely linked to the presence of young migrants from high-risk regions.
Globally an estimated 230 million girls and women alive today have undergone female genital mutilation, that number having risen by 15 per cent (30 million more cases) over the past few years, due to rapid population growth in regions where the practice is most common, such as sub-Saharan Africa and the Arab States.
In addition to the physical and psychological cruelties to children (and in some instances women) which are somehow still seen as ‘normal’, there are specific harmful practices which align with various aspects of the concepts around FGM. These are serious human rights violations that disproportionately affect girls (and some boys) and women.
Amongst these harmful practices are, most significantly, child, early and forced marriage (CEFM): gender inequality and discrimination, which undermines girls’ and adolescents’ health, education, and bodily autonomy, often perpetuating cycles of violence and poverty. It is thought that globally around 640 to 650 million women and girls alive today were married before their 18th birthday – a rate of 12 million girls annually, with 1 in 5 girls worldwide married before 18.
CEFM in Italy
There are no officially available statistics on CEFM in Italy, but 85% of forced marriage victims in that country are women and girls, and 38% of forced marriage victims are under 18. One important report is the Research study of child marriage in Italy. Other reports suggest that the rate of child marriage – nearly six times as many girls as boys – in Italy is, like FGM, exacerbated by poverty, minority ethnic status (especially in Italy, Roma?) and migration.
Globally CEFM is some two or three times as likely to occur as FGM but in either case hundreds of millions of women – even just in Italy probably hundreds of thousands – will suffer.
An important point to bear in mind here is that FGM is often, though not always, a precursor to child marriage: either should raise awareness that the other may occur. And both have significant potential to damage seriously the life-outlook for girls and women who experience them: years of education and economic potential may be lost, health harmed, babies (and mothers) put at risk, women’s autonomy diminished.
Other harmful practices
Other gendered harmful practices include ‘virginity’ testing: an ‘examination’ of the hymen and a serious violation of the human rights and dignity of women and girls, rooted in discriminatory gender norms to control female sexuality and enforce patriarchal standards of ‘purity’ (occurs in perhaps 1% of the relevant population, often legally minors). Related to this is the practice of hymenoplasty – the unethical and in many countries illegal ‘repair’ of the hymen in the (unscientific) belief that an intact hymen will thereby indicate ‘virginity’ and ‘purity’ before marriage.
Also significant are e.g. accusations of witchcraft, leading to physical violence, arbitrary and cruel punishments, forced displacement, stigmatization and other serious human rights violations. Other harmful practices amongst many including breast-binding / ironing, ‘honour’ stoning or killing, and leblouh or gavage (forced fattening).
Further, international studies reveal that 6 in 10 children under age 5 regularly suffer physical punishment and/or psychological violence from parents and caregivers, and 1 in 5 women and 1 in 7 men report having been sexually abused as a child. In armed conflict and refugee settings, girls – some of whom may have had FGM imposed in the forlorn hope it will prevent potential transgressions (sexual assaults) – are particularly vulnerable to sexual violence, exploitation and abuse by combatants, security forces, members of their communities, aid workers and others.
A global map of the prevelance of various harmful practices is available on the UK National FGM Centre website.
Public health
These issues are more than medical emergencies or gynaecological and obstetric challenges, but even in that field of expertise SIGO – the Italian obstetric body – reports there are gaps in their FGM knowledge among healthcare professionals, who are nevertheless recognized by the WHO as the main actors in the eradication of this practice.
Good, carefully considered medical and obstetric care and gynaecological clinical practice is not however the focus of this present discussion. Rather, it is the wider contexts of FGM, CEFM and other abuse which nurses and other non-ObsGynae clinicians are most likely to encounter in their everyday work. Interventions in these contexts are probably going to employ public health perspectives rather than detailed clinical procedures.
We have seen that certain demographics within the population are more vulnerable than others to harmful practices. Nurses (and other clinical colleagues) need to be aware of these specifics – but it is always vital that individuals are not stereotyped on the basis of their ethnicity: not every woman in any given ‘ethnic’ group is ‘cut’; and stereotyping also, understandably, creates backlash from those within a group who detect it, which does not help in combatting the practice. Awareness of potential harm in any given community is important. Assuming harm will necessarily occur must always be avoided.
It is important nonetheless to be aware that, like many other public health conditions, certain aspects (e.g. there is risk to a child) mandate FGM as notifiable in most (but not all Eastern) European countries. The exceptions to mandating however vary between countries: Italy, for instance, permits some exceptions such as if a doctor would expose a patient, if reported, to the risk of prosecution:
…there are exemptions from the report obligation (art. 365 of the criminal code): when the presentation would expose the assisted person to criminal proceedings (priority of the Right to Health); if the doctor has failed to submit a report due to having been forced to do so by the need to save himself or a close relative from a serious and inevitable harm to freedom or honor (Article 384 of the criminal code).
National procedures for mandated reporting are usually set out both in formal documentation, as in the U.K. and as broader guidance in Italy.
Abating the harms
Ideally FGM and other harms should be stopped before they happens. As any public health practitioner would agree, ‘prevention’ is always better than ‘cure’; and it is often very much less expensive. But these harms are frequently hidden, subject to ‘shame’ on the part of victims / survivors, and strictly taboo within practising communities. A level of consistent professional awareness is required to avert or try to remediate them.
Essentially girls at risk of FGM may talk of long ‘holidays’ in the countries of family ‘origin’; they may refer to anticipated ‘celebratory’ parties, or to visits from elders, especially grandmothers or maybe aunts, they may say they will soon ‘be a woman’. These and other indicative or more formal factors will sometimes raise concerns.
The UK National FGM Centre has a freely available FGM checklist for social workers when considering likely risk, as well as more information on witchcraft and similar practices.
Nurses, teachers and others will be aware that girls and women who have experienced FGM may have difficulties when walking or sitting, show signs of e.g. depression or anxiety (an issue in school?), or be particularly reluctant to consult medical advisors.
This discussion of reducing the harms of FGM, CEFM and other abuse is however necessarily indicative rather than definitive; but some points of departure are evident:
- Prevent ‘medicalization’
It is illegal almost everywhere now to perform FGM (in any guise) or, in many countries, say, to examine a girl or woman supposedly to determine her virginity. No clinician should ever become involved or give the impression that such malpractice is acceptable. Yet around one in four medicalized FGM ‘procedures’ is conducted by a health professional – a practice which the World Health Organization condemns in the strongest terms. Concerning FGM the WHO also tells us that
The health sector has an important role to play, not only in ensuring the highest quality health care for girls and women living with female genital mutilation (FGM), but also in preventing FGM from being performed. FGM is a socio-behavioral norm that, despite increasing the risk of negative effects on the health and well-being of girls and women, is often difficult for health care providers to discuss. However, health care providers, particularly nurses and midwives, are in a unique position to influence and change the attitudes of their patients regarding FGM, which is a key step towards preventing new cases of the practice in their communities.
This WHO training manual complements previous publications by building person-centred communication skills specifically for FGM prevention.
The protocols for the prevention of virginity testing etc are also context-dependent, and the legal situation may vary by country, but the UK Government has produced a helpful guide to many of the issues.
In all these situations the prime consideration for clinicians such as nurses is of course ‘do no harm’: make sure that your own actions do not increase the vulnerability of the (potential) victim, and where necessary also involve other public authorities such as medical bodies and / or the law to prevent the crime of medicalized FGM.
- Clinics and general practice
Clinics and general practice surgeries are places where nurses and patients naturally meet. The particular protocols which will guide how discussions and explorations around difficult topics such as FGM and other abuse may well be set by the host institution – but if in some places there are no generally acknowledged guidelines, perhaps they need to be produced or agreed?
A fundamental aspect of scenarios in such settings is that the vulnerable person is often reluctant to divulge her concern, or will attend purportedly for another type of health problem. But however the situation presents, it is vital that professionals hear patients’ information (or hints or withdrawn behaviour) calmly and without judgement. Clinicians need to prepare an open and accepting mindset before the occasion ever arises. A 2023 research report from Spain makes this point well:
Although most professionals are aware of the current legislation on FGM in Spain, only a few of them are aware of the existence of the FGM prevention protocol in Castilla-La Mancha. This lack of knowledge together with the perception that FGM belongs to the private sphere of women, contributes to the loss of opportunities to identify and prevent FGM.
The London Safeguarding Children Procedures and Practice Guidance provides a helpful guide to some matters which may indicate concern is appropriate, almost regardless of location. These factors, observed by an alert nurse or other clinician, may take discussion to a conversation about difficult matters with patients who are reluctant to disclose directly what potential worries they have.
- Education
Studies in the UK and USA have shown that one important role for nurses is within the school / education system. Whilst during political shifts the number of school nurses has fallen dramatically (from around 2,915 in 2009 to 1,945 in 2022) in, e.g., the UK, the benefits of a school nursing service are rarely disputed: school nurses can provide a wide range of services to support and enhance children’s health (see e.g. the UK Government’s School Nurse Toolkit). Whilst school nursing is well established in for instance Norway, Estonia, Finland and Iceland (as well as the UK and USA) it features less in Germany and insignificantly in e.g. Greece, as well as Italy.
A critical aspect of the work of school nurses may be RSHE (relationship, sex and health education). This part of the curriculum leaves many teachers uncomfortable; they are concerned that talking about ‘sex’ may be questioned, and they may have little formal knowledge or training about matters such as protecting children from sexual or other abuse. Nonetheless, the UK teachers’ union NEU (National Education Union) is clear on such matters as FGM:
The NEU has always welcomed the Government’s commitment to addressing FGM and believes that all types of gender-based violence can, and should be, tackled through partnership with health professionals, social care and the police.
The NEU knows that the safeguarding of children is of paramount importance to members.
Whilst it is true that school nursing services (and indeed trust overall in public health provision?) may have diminished since COVID in the USA, the case for provision is well-made:
Schools have a long history of serving as effective settings for the delivery of health services as more than 80% of schools are served by school nurses and other health care practitioners (US Department of Education, 2020). School nurses provide basic health care to children; conduct screenings; administer medications; address acute conditions and assist in the management of chronic diseases (CDC, 2017; Council on School Health, 2016). Notably, school nurses are well positioned to identify children adversely affected by the social determinants of health (SDOH) because they are accessible to children who lack a regular source of health care and they tend to have established relationships with many children and their families (Schroeder et al., 2018).
It is self-evident that amongst the issues in the USA threatening less privileged children are FGM (over half a million women and girls), CEFM (also hundreds of thousands) and child abuse (again, over half a million children). School nurses, despite COVID still employed by a range of US schools, are well placed, like their diminished numbers of UK colleagues, to support these vulnerable children.
To date however the role of ‘school nurse’ remains undeveloped in Italy, despite a call for action:
In Italy, there is no school nursing service and the identity of the ‘school nurse’ is not recognised within Italian nursing systems. At present the management of health needs within the student body is entrusted to different professionals…. a school nurse would play a fundamental role in the management of student health issues (e.g., epilepsy, diabetes, asthma, neurodevelopmental disorders, mental health problems) by strengthening medical recommendations and providing the necessary health care during school hours. In this way, it is also possible to listen to the students’ voices on their state of health and on the school therapeutic environment.
Whilst then all countries have areas of excellent practice, and areas of almost none, it is possible that school nursing could helpfully have a stronger profile both in the UK and US, and in e.g. Italy. All three nations have a challenging (and to an extent shared) profile in regard to FGM, CEFM and child abuse, and in each of them the scope for care provision in these regards is broad.
- Community
There are numerous roles taken by nurses ‘in the community’. These include health visitors (specialist community public health nurses) who work with families and under-fives, district nurses / family and community nurses (FCNs – see also e.g. this Italian study). There are also mental health nurses, environmental health nurses and many others who work in the community.
To give a few examples of how nurses in such roles may be able to avert FGM etc, they are often more familiar with communities ‘at the edge’ of mainstream society; they may be alert to the challenges facing those seeking asylum far from home; they have the opportunity to see babies and children in local clinics or in schools; they meet and care for women (and men) in less formal settings; they probably have a good understanding of the economic and social issues facing some of their patients and other health-related clients.
Every one of these contexts allows also for thoughtful observation of potential problems, and sometimes also opportunities for direct support. As one important example: women who have experienced FGM or CEFM may choose themselves to campaign to end these practices. In so doing these activists sometimes feel at risk or left to battle alone, and unresourced. Help and advice from well-informed community nurses about where to turn for support (and safety) would be a valuable source of support for such campaigners, if that were considered part of such nurses’ wider remit.
So whilst each district or neighbourhood nursing role has specific focus, nonetheless all may offer opportunities to prevent or reduce the on-going harms of FGM and practices and behaviours.
This potential has as yet however to be much acknowledged. A WHO-led report of 2017, Enhancing the Role of Community Health Nursing for Universal Health Coverage specifically notes that there is a ‘lack of consensus on the scope of practice for CHNs.’
Unfortunately this lack of consensus includes almost no mention of gendered harms.
- Awareness into action
As we have seen, however, the scope for attention to avoiding (or supporting the victims of) FGM, CEFM and similar abuses is considerable.
Not ‘only’ is it obvious that nurses are well-placed to have meaningful conversations with patients and other members of their communities, but there is also scope for direct messaging, and for less direct strategies which make clear the dangers of these harms. Connections which build dialogue in schools, community centres and other locations can serve well here.
Further, there is plenty of evidence that FGM, CEFM etc often co-exist with the exclusion of girls and women from modern mainstream society and from its benefits, socio-economic and in terms of personal autonomy. Whether it’s the opportunity for more education and better employment prospects, or simply knowing that the decision to marry is for the (adult) person concerned and no-one else, or perhaps knowing how to share concerns about a vulnerable or abused child, nurses are often particularly well-placed to raise awareness, and maybe to help.
Public health, again
Everything we have considered here relates to the roles nurses in the community may embrace, and to the well-being of the many thousands or women, girls and little children who live in those communities.
It all connects too with the actual economies of communities and societies – healthy women and girls are able to contribute more positively to benefit both themselves and their families and groups. And so also they require less spending on health needs, leaving more of it for other requirements.
But FGM and other gendered harms are currently not even mentioned in most public health documentation.
Our discussion here has been at best perfunctory, pointing simply in the direction which more developed conversations might take; but hopefully it is a start.
In the earlier 2010s there was genuine impetus in the focus on FGM and CEFM, and sometimes also on child abuse, but that has to an extent now been surpassed by other concerns. Attention to COVID has understandably now taken much of the international and public health agenda, but that, whilst also vital, is not alone an acceptable position in which still to find ourselves.
Lest anyone forget, the incidence of FGM globally is expected to continue to rise. A summary of the UNICEF 2024 Report on the Global Situation of FGM is clear:
The UNICEF 2024 report reveals alarming trends in the global prevalence of female genital mutilation (FGM). As of 2024, over 230 million girls and women have undergone FGM, reflecting a 15% increase since 2016. This increase of 30 million additional cases highlights the persistence of this harmful practice despite global efforts to eliminate it. The report underscores that the current pace of decline in FGM is insufficient to meet the UN Sustainable Development Goal (UN SDG) of eliminating FGM by 2030. To achieve this target, the rate of decline needs to increase by 27 times, indicating a substantial gap between current efforts and the necessary action required.
Whether a community health nurse is working in Europe or anywhere else, s/he has scope in the course of regular duties to support efforts to #EndFGM and other harmful practices. Now the task is to identify those mechanisms and routes most likely to deliver this important aim, and to ensure, at the very least, that nurses are aware of the potential they have to help end these cruel and dangerous practices.
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Read more about FGM:
What Is Female Genital Mutilation (FGM)? The Enduring Data And Debates
What We Know About Female Genital Mutilation – A Summary
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Books by Hilary Burrage on female genital mutilation
https://orcid.org/0000-0002-6684-2740
Hilary has published widely and has contributed two chapters to Routledge International Handbooks:
Female Genital Mutilation and Genital Surgeries: Chapter 33,
in Routledge International Handbook of Women’s Sexual and Reproductive Health (2019),
eds Jane M. Ussher, Joan C. Chrisler, Janette Perz
and
FGM Studies: Economics, Public Health, and Societal Well-Being: Chapter 12,
in The Routledge International Handbook on Harmful Cultural Practices (2023),
eds Maria Jaschok, U. H. Ruhina Jesmin, Tobe Levin von Gleichen, Comfort Momoh
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PLEASE NOTE:
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. ‘FGM’ is therefore the term I use here – 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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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 if in any specifics as discussed above.
Anyone wishing to offer additional comment on more general considerations around male 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 