1. FGM in Hull Dr Tonye Wokoma Consultant Sexual and Reproductive Health Conifer Service CHCP CIC

2. Overview: Definition The law Prevalence Classification Management – Safeguarding Management – Clinical What the women want? Post natal Contraception

3. Definition: “All procedures which involve partial or total removal of the female external genitalia, or any other injury to the female genital organs, for non-therapeutic reasons”

4. FGM Act 2003 (updated from 1985): “A person is guilty of an offence if s/he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris. It is an offence for a UK national or permanent UK resident to aid, abet, counsel or procure this procedure for another person”

5. Serious Crime Act 2015 Female Genital Mutilation Protection Order (FGMPO) 1 st order was obtained in July 2015 Duty to notify Police of FGM ( came into effect 31st October 2015) “regulated professions” – healthcare professionals, teachers, social care workers Notify the police on 101 non-emergency number if FGM discovered (in any girl under 18yrs) in course of work (disclosure and/or physical signs) Professionals should record all decisions and communicate sensitively with the girl/and or her family Anonymity of victims

6. Key facts: A type of ‘Violence against Women and Girls’. No health benefits Prevalent in 29 countries in Africa and Middle East. >125 million girls and women alive today have been cut. Usually performed sometime between infancy and age 18 and may be repeated. Fact sheet N°241, Updated February 2014 http://www.who.int/mediacentre/factsheets/fs241/en http://www.who.int/mediacentre/factsheets/fs241/en Macfarlane A, Dorkenoo E, (2014) FGM in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk Interim report on provisional estimates. City University, London.

7. World wide distribution: Traditional Practicing Communities Migrant Communities AfricaEurope Asia/M East - Iraq, Iran, India, Pakistan, Indonesia, Malaysia USA Canada Australia New Zealand

8. Countries where FGM is most common: SOURCE: INTERNATIONAL DEVELOPMENT COMMITTEE, JUNE 2013 CountriesPrevalence 35-39yrs Prevalence 15 – 19 yrs Djibouti 94.7%89.5% Egypt 96.4%80.7% Eritrea 92.6%78.3% Gambia 79.5%79.9% Guinea 98.6%89.3% Mali 84.9%84.7% Sierra Leone 96.4%75.5% Somalia 98.9%96.7

9. National Prevalence 2011census data FGM makes up 1.5% of all maternities each year. Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimates http://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released- text.pdf 2011 (UK)No of womenPrevalence 15-49 yrs103,0007.7/1000 >50 yrs24,0002.3/1000 0-14 yrs10,0002.2/1000 Total137,0004.8/1000

10. Local Prevalence 2011census data Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimates http://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released- text.pdf Local AuthorityNo of womenPrevalence Hull2021.6/1000 Yorkshire and the Humber 5,6582.1/1000 England134,6455/1000

11. Maternities to women with FGM 2005-2013 Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimates http://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released- text.pdf Local Authority Total maternities No of women% maternities to women with FGM Hull32,2441620.50 Yorkshire and the Humber 580,7524,4410.76 England5,91829197,5251.65

12. No of girls born to women with FGM 2005 -2013 Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimates http://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released- text.pdf Local Authority Estimated number of girls born to women with FGM Total number of girls born % of girls to women with FGM Hull7916,6960.48 Yorkshire and the Humber 2,277300,0560.76 England49,7973,066,3111.62

13. Reasons for FGM: Toubia, N. (1993). Female Genital Mutilation: A Call for Global Action. New York: Women, Ink; pp. 21

14. Type I: Clitoridectomy partial or total removal of the clitoris Type II: Excision partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora Type III: Infibulation narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora withor without excision of the clitoris Type IV All other harmful procedures to the female genitalia for non- medical purposes, for example: pricking, piercing, incising, scraping and cauterisation WHO definition of FGM:

15. Normal female genitalia:

16. FGM Type 1 - Clitoridectomy:

17. FGM Type 2 – removal of the clitoral hood and part of the labia:

18. FGM Type 3 - Infibulation:

20. Management - safeguarding:

21. Management – safeguarding If pregnant, the welfare of the unborn child should be considered and action taken accordingly Referral to the police should not be an automatic response to FGM Refer any child(under-18s) or vulnerable adult using standard existing safeguarding procedures: with symptoms or signs of FGM if it is suspected that they are at risk of FGM Consider family history or other relevant factors Notify police if <18yrs

22. Management – clinical : History taking Examination Appropriate referral Suitable interpreter vital All women should have the opportunity to be given support and guidance

23. Sensitive identification: Ask all women/children from high risk areas (some women have little/no recollection of the event!) Acknowledge awareness of a traditional practice in her country of birth where girls genitals are cut – Ask, What do you call this practice? Explain this practice can cause severe health complications Use value neutral terms “Were you circumcised/cut as a child” Or use the word she uses to describe FGM Be non- judgemental but direct

24. Short Term Health Consequences Long Term health Consequences Pregnancy/Childbirth painchronic anxiety, phobias, depression, PTSD Mother severe bleedingcysts Recurrent infections urinary retentionchronic painLSCS infectionabscessesSevere perineal/vaginal trauma broken bonesulcers, scarringsevere bleeding death 10%recurrent infectionsextended hospital stay sexual dysfunctionBaby subfertilitylow birth weight, poor condition at birth still birth, neonatal death

25. Specialist clinic - History sheet

27. Focus group discussions: (with Refugee Council) 23 women Majority Somalian, 2 Congolese Age range 18yrs – 40 +yrs Had been in the UK 7 months – 12 yrs 18 women had children, 8 born in the UK Majority had experienced FGM

28. Women reluctant to raise the subject themselves Were not asked about FGM If asked, they were not examined and no further info/advice offered “felt there was a general lack of knowledge” Focus group discussions cont:

29. What the women wanted Education and information on practice & types of FGM Information regarding potential future medical problems Whether current problems were related to FGM Information on issues regarding sexual intercourse & childbirth Information on de-infibulation and to explain the process

30. Focus group discussions cont: What the women wanted? “the need to be listened to and wanting someone to examine them, explain what they should look like and what, if anything, could be done to rectify their appearance”

31. Challenges : Co-ordinated care for women affected by FGM “Good knowledge … education … support … practical systems … monitoring” Lack of mental health care resources for FGM survivors Aftercare of women who have undergone de-infibulation Engagement with communities Funding

32. Summary: Be sensitive Ask direct questions Consider safeguarding issues Support the woman - Refer to Community Gynaecology clinic if necessary Mandatory reporting

33. Useful websites and links: FGM RCOG Green top Guidelines No 53 FGM National Clinical Group Daughters of Eve Forward UK NSPCC NHS Choices – Information about FGM Tackling FGM in the UK - a report and set of recommendations for identifying, recording and reporting FGM, produced by a coalition of Royal Colleges, trade unions and Equality Now

34. Who can you contact? The Police - call 999 or 101 Hull City Council Children Services Access and Assessment Team on 01482 448 879 during normal office hours. Emergency duty team on 01482 300 304 out of normal office hours Hull Safeguarding Children's Team - Tel: 01482 379 090 Email: hscb@hullcc.gov.uk If abroad you can call the Foreign & Commonwealth Office on +44 (0) 20 7008 1500.

35. Post natal Contraception Dr Tonye Wokoma Consultant Sexual and Reproductive Health Conifer Service CHCP CIC

36. Unintended Pregnancy Unintended Pregnancy in the United States Guttmacher Institute http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

37. Unplanned pregnancies Unplanned pregnancies in Hull and East Yorkshire are common among women undergoing IA 75.8% (95%) Unplanned pregnancies in Hull and East Yorkshire are uncommon among women attending ANC (5.5%) 1/3 rd of women not using contraception reported that they were unable to obtain the method they wanted 1/3 rd of women using contraception stated that they were not using the method they would have preferred Bexhell H, Guthrie K, Cleland K, Trussell J Contraception. 2015 Oct 28. pii: S0010-7824(15)30105-0. doi: 10.1016/j.contraception.2015.10.004. [Epub ahead of print] Unplanned Pregnancy and Contraceptive Use in Hull and East Yorkshire.

38. Post natal Contraception “Women born outside the UK were significantly more likely to die than those born in the UK (RR 1.77, 95% CI 1.39-2.24)” >1/3rd (34%) of women were born outside the UK Time in the UK - 4 years (range 1 month to 21years) >70% Asia (mainly India, Pakistan, Bangladesh and Sri Lanka) Africa (mainly Nigeria, Somalia and Ghana) Saving mothers live 2014

39. Key messages WHO recommends interbirth-interval – 2yrs It is important to reach women before they are at risk of an unintended pregnancy with information about return of fertility their options to space or limit future pregnancies the benefits to their own and their baby’s health of doing so LARC methods should be encouraged

40. Effectiveness Chart When - Antenatally Contraception should be discussed with all women while they are still pregnant How - Women should be provided with information Listen to the woman Dispel misconceptions Avoid undue pressure Allow the opportunity to discuss with family members if she wants She is more likely to continue with a method she is happy with The method of contraception chosen should be documented Condoms reduce the risk of STIs and HIV

41. How can we do better? Increased awareness of staff on cultural issues consider their beliefs and customs Use of appropriate interpreters Listen to what women want – Patient feedback Expanded coverage

42. Opportunities When - Antenatally Contraception should be discussed with all women while they are still pregnant How - Women should be provided with information Listen to the woman Dispel misconceptions – many worry about return of fertility, they might not be allowed to remove the LARC Avoid undue pressure Allow the opportunity to discuss with family members if she wants She is more likely to continue with a method she is happy with The method of contraception chosen should be documented Condoms reduce the risk of STIs and HIV

43. Outreach nurse Dedicated nurse for Contraception and Sexual Health Visits the postnatal ward Referrals – Midwives – Health visitors Doula’s – Self referrals from women (husbands ring due to language barrier) Fast track service for LARC methods Domiciliary visits (attend with health visitors sometimes)

44. Outreach nurse Somali lady seen at home 6 children. Last child 18/12 old 2/52 postnatal Discussion with husband’s agreement Nexplanon fitted Husband said no contraception available in their country at all. The couple wanted a space between children.

45. Thank you! Any Questions?

46. References: Toubia, N. (1993). Female Genital Mutilation: A Call for Global Action. New York: Women, Ink; pp. 21 Fact sheet N°241, Updated February 2014 http://www.who.int/mediacentre/factsheets/fs241/en http://www.who.int/mediacentre/factsheets/fs241/en Macfarlane A, Dorkenoo E, (2014) FGM in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk Interim report on provisional estimates. City University, London FGM Multi Agency practice Guidelines https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3801 25/MultiAgencyPracticeGuidelinesNov14.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3801 25/MultiAgencyPracticeGuidelinesNov14.pdf Female Genital Mutilation Prevention Programme: Requirements for NHS staff, Department of Health and NHS England Statement 8/12/2014

47. References: Female Genital Mutilation Risk & safeguarding: Guidance for professionals DOH March 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/418564/2903800_DH_FGM_Accessible_v0.1.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/418564/2903800_DH_FGM_Accessible_v0.1.pdf Serious Crime Act 2014 Factsheet FGM https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/416323/Fact_sheet_-_FGM_-_Act.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/416323/Fact_sheet_-_FGM_-_Act.pdf