Protecting victims of FGM

FEMALE genital mutilation (FGM) is more common in the UK than most people think. A recent report concluded that nearly 4,000 women have been treated for FGM in London hospitals over the last five years and yet not a single case has been prosecuted in the 28 years since the practice was made illegal (though two cases are now pending).

A new surge of interest in the issue can in part by attributed to a Guardian newspaper campaign promoted by 17-year-old schoolgirl Fahma Mohamed. This has prompted recent calls to toughen laws on the detection and prevention of FGM. Doctors and other healthcare professionals can expect greater pressure to help protect patients who may be potential victims.

Female genital mutilation is a form of child abuse and health professionals have a legal obligation to refer suspected cases to social services. However, a recent intercollegiate report (Tackling FGM in the UK) published by The Royal College of Midwives concluded that FGM is still not fully integrated into the child protection system at the local level and girls at risk of FGM are not receiving adequate protection from harm.

The report states: “FGM is often not viewed as a safeguarding issue, and is therefore not aligned with professionals’ current duties to identify, report and refer child maltreatment.”

In written evidence to a Home Office Select Committee, the Royal College of General Practitioners last month called for the development of specific care pathways for FGM that involve health, education and social services. In the meantime health professionals must be aware of their responsibility to individual patients who may be at risk.

An estimated 100 to 140 million women and girls globally have undergone FGM and a further three million girls are “cut” each year in 28 African countries and also parts of the Middle East and Asia. The highest prevalence rates (over 90 per cent) are found in Sudan, Djibouti, Egypt, Guinea and Sierra Leone. In Somalia 97 per cent of women aged 15-39 have undergone FGM. It follows that in the UK, prevalence and risk to young girls is highest among immigrants from these countries.

Precise figures are hard to come by due to the secrecy surrounding the practice but in 2001 an estimated 66,000 women resident in England and Wales had undergone FGM and over 23,000 under the age of 15. Numbers are thought to be much higher now.

FGM is usually performed on girls under the age of 18 and the WHO classifies it into four types, the most extreme of which (Type III) involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). The surgery can be crude and unskilled, carried out with unsterilised knifes or razors although a WHO survey has found that globally up to 18 per cent of FGM procedures on girls were conducted by medical staff.

Complications are common and in the short-term include severe pain (FGM is often performed without anaesthetics), bleeding, shock, urine retention, infections, injury to neighbouring organs and death. Among long-term complications are failure of the wound to heal, abscess formation, urinary tract infection, dermoid cysts, vulval adhesions, keloids, neuromas, painful sexual intercourse and sexual dysfunction. Victims can also suffer lasting psychological effects such as post-traumatic stress disorder and depression.

UK professionals in regular contact with children – such as doctors, teachers, midwives and nurses – are often unaware that girls are at risk of FGM and child protection guidelines are not followed. Reasons cited in the RCM intercollegiate report include:

• Professional lack of awareness of FGM (when to consider a child at risk).
• Concerns that they risk offending or stigmatising people from BMER communities.
• Concerns that referrals of at-risk girls will overwhelm services.
• Unclear referral thresholds, particularly within health, education and children’s social services.
• Lack of robust monitoring and surveillance systems and lack of accountability in relation to local performance.

Despite these difficulties health professionals still have a legal duty to protect girls from FGM. In accessing potential risk the following questions should be considered:

• Is FGM practised in the girl’s or family’s country of origin?
• Is the family well integrated into UK society?
• Has the girl’s mother undergone FGM?
• Have sisters or other children in the extended family undergone FGM?

Care should be taken to ensure that affected girls and women do not feel stigmatised but health professionals must be aware that UK law sets out clear thresholds for intervention when a child is at risk of “significant harm” with a legal duty to report and refer cases. Investigations and enquires about any criminal offence including FGM are the responsibility of the police and social care and should not be conducted by health professionals.

Doctors are also under a professional obligation to act in cases where there is a risk of suspected harm by FGM. In 0-18: guidance for all doctors, the GMC states: "Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child’s best interests or necessary to protect other children or young people."

The GMC guidance further states that a doctor must justify any decision not to share a concern over a child at risk and this should be recorded.

ACTION: Make yourself familiar with the risks associated with FGM and if you have any reason to suspect a child may be at serious risk of immediate harm follow local health authority guidelines on who to contact. Members can also phone MDDUS for advice.

Sources/Further reading:
• BMA (2019) Sent back to danger – the struggle to evade female genital mutilation
• HM Government (2011) Multi-agency statutory guidance on female genital mutilation
• RCM, RCN, RCOG, Equality Now, UNITE (2013) Tackling FGM in the UK: Intercollegiate recommendations for identifying, recording and reporting