FGM: Torture not Culture

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FGM Torture not Culture

• Faye Macrory MBE
• Consultant Midwife
• Central Manchester University Hospitals NHS
  Foundation Trust (CMFT)
• Alison Byrne
• Specialist Midwife (FGM)
• Heart of England NHS Foundation Trust

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the starting point

• FGM is the manifestation of gender
• inequality that is entrenched in social,
• economic and political structures.
• FGM is a form of violence against
• women and girls.
• (WHO 2008)

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The FGM Act (2003)

• It is an offence to excise, infibulate or
  otherwise
• mutilate the whole or any part of the labia
  majora,
• labia minora or clitoris of another person for
  non
• medical reasons, or to aid, abet council or
  procure
• any of these acts on that persons own body.
• It is also an offence to take a child out of the
  Uk for
• that purpose or to arrange it.
• The penalty is up to 14 years imprisonment.

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Where FGM is practised communities at risk

• Africa
• Benin, Burkina Faso, Cameroon, Central African
• Republic, Chad, Cote dIvoire, Dijibouti, Egypt,
• Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-
• Bissau, Liberia, Mali, Mauritania, Niger,
  Nigeria,
• Senegal, Sierra Leone, Somalia, Sudan, Togo,
• Uganda, United Republic of Tanzania.
• Also
• Iran, Iraq, Malaysia, Saudi Arabia

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Classification
of FGM

• FGM (also called cutting) comprises all
  procedures that involve partial or total removal
  of the external female genitalia, or other injury
  to the female genital organs for non medical
  reasons
• (WHO 2008)
• Terms used e.g.
• sunna, kakia, bundu, tara, tahur- meaning
  purification

without
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Type 1 Clitoridectomy partial or total removal
of the clitoris
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Type 2 Excision partial or total removal of
the clitoris and the labia minora with or without
excision of the labia majora
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Type 3 Infibulation narrowing of the vaginal
opening through the creation of a covering seal,
repositioning outer and inner labia with, or
without removal of the clitoris
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• Type 4
• All other harmful procedures to the female
• genitalia for non-medical purposes e.g.
• pricking
• piercing
• incising
• scraping
• cauterizing the genital area
• ?? and what about labioplasty/ cosmetic
  surgery??

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Why the practice continues

• custom and tradition
• mistaken belief that FGM is a religious
  requirement
• preservation of virginity/chastity
• social advantage, especially for marriage
• enhancing fertility
• hygiene and cleanliness
• increasing male sexual pleasure
• family honour
• sense of belonging to a group vs fear of social
  exclusion (WHO 2008)

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Short term complications of FGM

• haemorrhage
• shock
• acute urinary retention
• damage to other organs
• infection
• failure to heal
• death

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Long term complications of FGM

• difficulties passing urine
• urinary tract infection/HIV, Hep.B
• menstruation difficulties
• chronic pelvic infection
• infertility
• vulva abscess/cyst/calculus/neuroma
• keloid scarring/fistula
• increased risk during delivery e.g. perineal
  trauma, PPH and perinatal death
• Sexual, psychological and psychosexual
  difficulties

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• Psychological impact of FGM
• physical effects well documented but emotional
  effects remain limited in the research.
• psychological counselling may lead to feelings
  of betrayal by parents, incompleteness and anger,
  overwhelming trauma and the long lasting
  emotional damage and implications from FGM and of
  suffering in silence.
• psychosocial implications of NOT undergoing FGM
  are also considerable. Therapeutic interventions
  need to take into account deep rooted beliefs
  into the practice of FGM and the cultural and
  social pressures women from practising
  communities are likely to experience.
• (Mulongo, P. et al. 2014)

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NESTAC (New Step for African Community 2012) and
Support our Sisters (SOS)

• Aim to add to the body of knowledge re the
  emotional effects of FGM appropriate
  interventions
• 3 year collaborative research project under
  Salford University Well-Being Programme
• a community based programme mainly supporting
  refugees asylum seekers and attending to their
  socio-cultural needs
• the development of a specialized service (SOS)
  for cognitive emotional support
• 3 drop-in clinics ( Rochdale, Lower Broughton and
  St. Marys)
• accredited training for peer mentors

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Health

• Health professionals have many opportunities to
• identify women affected and girls at risk
• particularly in
• AE/ED
• maternity and gynaecology
• female surgery
• urology/continence team
• SARC, GUM, CASH
• GPs, HVs, School Nurses

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CMFT action plan

• 2 key aspects in managing FGM
• provision of sensitive appropriate services to
  all women identified with FGM
• Safeguarding infants and girls at risk of FGM
• 3 elements
• data collection
• education awareness
• safeguarding

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Completing the form online

• form combines 4 forms from original DH documents
  so minimises repetitive data capture
• to be used for all new FGM patients
• details submitted to database - automatically
  amends duplication registrations made under same
  case note number
• all future contacts recorded on PAS and CMIS
  automatically identified to satisfy requirement
  to report on ongoing active caseloads of contacts
  with known FGM
• patients

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What did we need to do before going live?

• addition of instruction sheet to data collection
  form, including SARC GUM
• agree when how information is shared with
  Safeguarding
• implement a sign-off and assurance process before
  monthly data is shared externally
• add link to Intranet for easy access to online
  form
• communicate with staff and raise awareness e.g.
  via WWN

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Safeguarding Guidance

• identifying risks
• pathways
• response from CS
• sensitivities and complexities of FGM

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Whats going on.?

• community based prevention what works?
• multi-agency collaboration
• nationally
• internationally

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• CASE STUDY 1
• A woman presents needing a vaginal/speculum
  examination and is found to have FGM. She is
  extremely distressed during the examination.
• What should you do?

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• CASE STUDY 2
• A pregnant woman discloses at booking that her
  1st child born in Somalia in 1997 has had FGM.
• What course of action would you take?

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• CASE STUDY 3
• Following disclosure of FGM a woman asks you
  where she can get FGM performed in this country
  for her daughters.
• What will your response be?

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• CASE STUDY 4
• Police officers request that a child is
  physically examined as there has been an
  allegation that the child is at risk of FGM.
• What would you do?

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Useful websites

• www.fgmnationalgroup.org
• www.rcm.org.uk
• www.who.int/
• www.amnesty.org.uk
• www.fgmnetwork.org
• www.equalitynow.org
• www.dofeve.org
• www.nspcc.org.uk

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• www.endthefear.co.uk/practitioners
• www.afruca.org
• www.forwarduk.org.uk
• www.nestac.org
• www.fgmelearning.co.uk
• http//greatermanchesterscb.proceduresonline.com/c
  hapters/p_fgm.html
• House of Commons, Home Affairs Committee FGM
  the case for a a national action plan 2014-2015
• http//www.hscic.gov.uk/catalogue/PUB15711

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FGM is child abuse

• Call the NSPCC helpline
• 0800 028 3550
• or
• email fgmhelpline_at_nspcc.org.uk

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never forget

• Its torture.
• not culture.

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In the memory and admiration of

• Efua Dorkenoo
• 1949 - 2014
• Cutting the Rose FGM Practice Prevention
  (1994)