1. 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

2. 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)

3. 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.

4. 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

5. 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

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

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

8. 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

9. 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??

10. 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)

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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

19. 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

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

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

22. 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?

23. 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?

24. 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?

25. 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?

26. Useful websites www.fgmnationalgroup.org www.rcm.org.uk www.who.int/

27.
House of Commons, Home Affairs Committee: FGM: the case for a a national action plan

28. Call the NSPCC helpline
FGM is child abuse
Call the NSPCC helpline or

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

30. In the memory and admiration of:
Efua Dorkenoo
Cutting the Rose: FGM Practice & Prevention (1994)