Cultural perspectives of Female Genital Mutilation Theresa Bourne

What?

Types of FGM (WHO 2008) Partial or total removal of the clitoris and/or the prepuce (clitoridectomy) Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision) 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)

Types of FGM (WHO 2008) All other harmful procedures on female genitalia for non- medical purposes, for example pricking, piercing, incising, scraping and cauterization

Associated with high short and long term morbidly; in addition has an impact on female mortality as well as fetal injury and death F G M Female, male. Fertility. Childbirth, postnatal

Where?

Percentage of girls and women aged 15-49 who have undergone FGM/C Notes: In Liberia, girls and women who have heard of the Sande society were asked whether they were members; this provides indirect information on FGM/C since it is performed during initiation into the society. Data for Indonesia refer to girls aged 0 to 11 years since prevalence data on FGM/C among girls and women aged 15 to 49 years is not available. Source: UNICEF global databases, 2016, based on DHS, MICS and other nationally representative surveys, 2004-2015

United Kingdom Between April 2016 and March 2017 there were 9,179 attendances reported at NHS trusts and GP practices where FGM was identified or a procedure for FGM was undertaken. 87 per cent of these attendances were in midwifery or obstetrics services, where this was reported. Data for the treatment area was recorded for six in every ten attendances. The average age at attendance was 31 years. 95 per cent of the women and girls first recorded in the data in 2016/17 had undergone FGM before they were 18 years old. This information was recorded for three in ten women and girls. Female Genital Mutilation (FGM) Annual Report 2016/2017 [PAS] – Data from Enhanced Dataset (SCCI) http://digital.nhs.uk/catalogue/PUB30015 The Female Genital Mutilation (FGM) Enhanced Dataset (SCCI 2026) supports the Department of Health's FGM Prevention Programme by presenting a national picture of the prevalence of FGM in England

Case Studies

WHY?

Do parents set out to cause harm to their children? Is it always parents responsible for FGM?

Positive emotions Pride Believing oneself to be virtuous Happy to be like other women in her culture Feeling beautiful and desirable to men Pleasant memories of the ritual associated with the procedure and “coming of age” (not all cultures have a ritual, or practice it at adolescence.) Cleanliness Economic security

Rationale Social rejection by peers and community – women without associated with prostitution. Hygiene / Cleanliness Spiritual purity / cleanliness Beauty Religious dogma/ religious identity Tradition Thought to increase male desire – reduce possibility of divorce or desertion Cure for infertility Believed will continue to grow - ugly If clitoris touches neonate – baby will die Procedure not linked to long term health and social problems. Luck and progression. Believed to protect virginity and control sex drive/ promiscuity - maintaining girl and family honour Patriarchal economics within society - women’s access to material needs through man (therefore need to be marriageable – important not only for girl but her family as increases eligibility for marriage and dowry paid) Financial Family responsibility Long term good of child Rite of passage to womanhood. May not be considered adult without (Kenyan MP) Status

Professional Issues Hidden problem – private, uncomfortable with disclosure, unaware of difference, fear of difference/ judgement, wary of western interference Lack of professional knowledge and understanding Cultural sensitivity May not be an individual decision Language Child protection

Issues Modernisation Age Community Them and us

What’s you role?

European Union Priorities 2013 Top priority - prevention Raising awareness of detrimental effects both psychological and physical Provision of support for victims

Prevention Identification Examination Support Offering choices Mandatory Recording Mandatory Reporting UTIs example

Identification Awareness of possibility Ethnic background Previous history – e.g. recurrent UTIs Asking the question – Are you closed below? Were you cut as a child? I have cared for many women from X, a lot of them were circumcised….

Data Collection Figures now collected and published by Health and Social Care Information Centre via GP and NHS Trusts

Mandatory Recording Enhanced Data sets. Electronic recording contributing to national data on the prevalence of FGM within the UK. Should be recorded whether 18 or under and includes piercing as type IV.

Mandatory Reporting DOH 2016 The FGM mandatory reporting duty is a legal duty provided for in the FGM Act 2003 (as amended by the Serious Crime Act 2015). The legislation requires regulated health and social care professionals and teachers in England and Wales to make a report to the police where, in the course of their professional duties, they either:

are informed by a girl under 18 that an act of FGM has been carried out on her; or observe physical signs which appear to show that an act of FGM has been carried out on a girl under 18 and they have no reason to believe that the act was necessary for the girl’s physical or mental health or for purposes connected with labour or birth. DOH 2016

Where there is a risk to life or likelihood of serious immediate harm, professionals should report the case immediately to police, including dialling 999 if appropriate. DOH 2016

How do you create long term change?

Health care providers can play a key role in preventing female genital mutilation and in supporting and informing patients and communities about the benefits of eliminating it. WHO 2008

This can be done by providing women with information about their own sexual and reproductive health, making it easier for them to understand natural body functions and the harmful consequences of female genital mutilation. Health care providers can also play an important role in community outreach, such as through school programmes and public health education programmes. WHO 2008

Making a difference Education Community Intervention/ action Women supporting women Bride prices Offering alternatives Information Free, anonymous reporting with actioned response Fear