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

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)

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 person’s 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.

Where FGM is practised: communities at risk Africa: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire, 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

sunna, kakia, bundu, tara, tahur:- meaning purification 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

Type 1: Clitoridectomy: partial or total removal of the clitoris

Type 2: Excision: partial or total removal of the clitoris and the labia minora with or without excision of the labia majora

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

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??

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)

Short term complications of FGM haemorrhage shock acute urinary retention damage to other organs infection failure to heal death

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

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)

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. Mary’s) accredited training for peer mentors

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

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

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

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

Safeguarding Guidance identifying risks pathways response from CS sensitivities and complexities of FGM

What’s going on…….? community based prevention – what works? multi-agency collaboration nationally internationally

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?

What course of action would you take? 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?

What will your response be? 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?

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?

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

www.endthefear.co.uk/practitioners www.afruca.org www.forwarduk.org.uk www.nestac.org www.fgmelearning.co.uk http://greatermanchesterscb.proceduresonline.com/chapters/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

Call the NSPCC helpline FGM is child abuse Call the NSPCC helpline 0800 028 3550 or email: fgmhelpline@nspcc.org.uk

never forget It’s torture………. not culture…….

In the memory and admiration of: Efua Dorkenoo 1949 - 2014 Cutting the Rose: FGM Practice & Prevention (1994)