Female genital mutilation (FGM) has made headlines over the past few years; however, although many people will have heard the term, it is not always clear how much is understood about FGM. The World Health Organization (WHO) defines FGM as:
‘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, 2018).
FGM is when someone deliberately and intentionally alters and causes injury to female genitalia. It has no health benefits and can lead to serious morbidity and mortality in girls and women. The lasting physical and psychological trauma caused by FGM can have lifelong effects and complications. The history and current practices of FGM are well documented elsewhere (Royal College of Nursing (RCN), 2016; WHO, 2018).
FGM is also referred to as female genital cutting and female circumcision; however, this terminology implies the practice is similar to male circumcision. The degree of cutting is far more extensive and will often significantly impair sexual and reproductive functions and the ability to pass urine. The justifications for performing FGM vary widely between individuals, families and communities, as well as across different countries, where FGM is not illegal and can be performed openly.
The motivations range from cultural rites of passage to religion, hygiene, femininity and aesthetics, as well as social pressures and expectations, and are often related to the control of women and their sexuality and sexual freedom. The Muslim Council of Britain (2014) has condemned FGM and issued guidance criticising the practice, affirming that it was not supported by any religious doctrine or linked to the teaching of Islam.
Classifications
FGM is classified into four major types:
- Type 1: clitoridectomy. This is the partial or total removal of the clitoris – a small, sensitive and erectile part of the external female genitals – and in very rare cases only the prepuce, which is the fold of skin or ‘clitoral hood’ that surrounds and protects the clitoris
- Type 2: excision. This is the partial or total removal of the clitoris and the labia minora – the inner folds of the vulva – with or without excision of the labia majora – the outer folds of the vulva
- Type 3: infibulation. This is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without clitoridectomy
- Type 4: includes all other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterising the genital area (WHO, 2018).
Effects of FGM
Girls and women who have experienced FGM may suffer from mental and physical problems, for example in urogynaecology, sexual health, severe bleeding, infection, infertility, and serious complications in childbirth, including death. It should be noted that genital piercing is classed as type 4 FGM, which can cause some confusion for those caring for women. While adult women may choose to have genital piercings, in some communities girls are forced to have them. WHO defines all female genital piercings as a form of FGM and in July 2019, the National Leads for Female Genital Mutilation in England wrote to the safeguarding leads, clarifying that:
‘Genital piercings performed on non-consenting women and/or girls are likely to raise safeguarding concerns and should be reported. Perpetrators could be prosecuted an array of criminal offences depending on the circumstances.’
(National Leads for Female Genital Mutilation et al, 2019: 3)
They also clarified the situation with re-infibulation:
‘Re-infibulation is a criminal offence caught by the provisions of the Female Genital Mutilation Act 2003.’
(National Leads for Female Genital Mutilation et al, 2019: 2)
Infibulation
Infibulation is the practice of narrowing the vaginal opening with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora. Re-infibulation is when the raw edges of this wound are sutured again, closing off the introitus, for example following childbirth. This recreates a small vaginal opening similar to the original appearance of infibulation. Some women expect re-infibulation after birth and there are reports of practitioners being asked to perform this, which is contrary to the Female Genital Mutilation Act 2003.
The global picture
In 2016, the United Nations International Children's Emergency Fund (UNICEF) estimated that at least 200 million girls and women in 30 countries have been subjected to FGM across Africa and the Middle East. These are regions where FGM is primarily concentrated, and these women are living with the consequences of having had FGM performed on them. For example, UNICEF (2019) reports that:
‘FGM is nearly universal among girls and women of reproductive age in Egypt.’
Some countries in Asia also practice FGM, for example Indonesia, where approximately half of girls under the age of 12 have undergone some form of FGM (UNICEF, 2019).
In 2014, a study by Macfarlane and Dorkenoo (2014) estimated that 137 000 women and girls affected by FGM were residents in England and Wales in 2011, and 60 000 girls under 14 years were born to mothers who had undergone FGM, and therefore they were potentially at risk. This provided some information on the extent of the issue, and in 2015 NHS Digital (2018) launched a programme of work which is intended to record, collect and return information about FGM in the patient population of England. This is intended to enable more accurate data on the women accessing the NHS services in either acute trusts, mental health trusts and general practices. This project aims to determine the extent of issues being seen in practice and add value to more accurate commissioning of services to support the needs of those affected by FGM. NHS Digital (2019) reported that:
‘There were 6415 individual women and girls who had an attendance where FGM was identified in the period April 2018 to March 2019. These accounted for 11 575 attendances reported at NHS trusts and GP practices where FGM was identified. The increase in total attendances during 2018–19 would appear to be a change in recording practice, as the number of distinct individuals has remained broadly stable. There were 4120 newly recorded women and girls in the period April 2018 to March 2019. Newly recorded means this is the first time they have appeared in this dataset.’
The motivations for FGM range from cultural rites of passage to religion, hygiene, femininity and aesthetics, as well as social pressures
‘Girls and women who have experienced FGM may suffer from mental and physical problems, for example in urogynaecology, sexual health, severe bleeding, infection, infertility, and serious complications in childbirth, including death. It should be noted that genital piercing is classed as type 4 FGM, which can cause some confusion for those caring for women.’
It should be noted that this gives some indication of the extent of women who are affected by FGM, but it does not collect data from other healthcare settings, such as sexual health clinics, or from outside England, and therefore it does not provide a complete demographic of those who may be affected by or have experienced FGM.
FGM in the UK
FGM is illegal across the UK and clearly recognised as a form of child abuse. It is vital that healthcare practitioners and teachers who come into contact with women, children and families from communities that practise FGM have an acceptable knowledge and understanding of the issues. This enables them to respond appropriately and act in the best interest of women and girls living with FGM, as well as practicing within the UK legal framework. An appropriate, sensitive and robust response is critical. It needs to respect the context of the person's cultural and personal boundaries, while remaining clear that this is a case of abuse. Health professionals will likely be shocked that girls and women are mutilated in this way, but they need to apply sensitive and culturally competent approaches when discussing this with possible or suspected cases.
Role of practice nurses
Apart from excellent communication skills, clinical competence and safeguarding, health professionals need two further skills when supporting and managing this patient group:
- Professional curiosity
- Thorough understanding of the person's local community, employing cultural competence to their practice.
Professional curiosity
Nursing practice has expanded to a more academic, evidence-based, decision-making culture, reflecting professional values and beliefs about effective care. Part of that role is the requirement for all health professionals to continue to develop their professional curiosity. This is in order to assess and support the needs of girls and women by taking an interest in the individual, understanding their holistic needs and expectations, as well as their understanding of what the health service can offer. A culture of curiosity is therefore a key requirement of modern nursing (Kedge and Appleby, 2010).
Nurses and midwives continue to expand their knowledge through lifelong learning, extending their abilities to be more inquiring in clinical practice. Their curiosity will enable them to get to know individuals better, and understand what is important to them. This naturally leads to knowledge about the person's particular lifestyle or home circumstances and, sometimes, sensitive information is imparted, especially in relation to safeguarding issues, such as domestic abuse and FGM.
There are barriers to developing this close relationship, including a fear of alienating the woman, not asking the question in a sensitive and understanding manner or causing offence by asking probing questions. This should not deter the professional from an inquiring pathway, but create greater awareness of how to ask difficult questions. A good knowledge and understanding of the issues and the local community will support best practice.
If in doubt about how to approach the subject, there are a number of useful resources produced by Department of Health and Social Care, Health Education England and NHS England. There are also three animated videos called #EndFGM (Box 1) available that provide useful insights as to how FGM is affecting people in the UK today. These can also be used effectively for all age groups to enhance understanding of the issues.
Box 1.Additional resources
- Daughters of Eve: http://www.dofeve.org/
- Forward UK: https://www.forwarduk.org.uk
- National Society for the Prevention of Cruelty to Children (NSPCC) 0800 028 3550 or fgmhelp@nspcc.org.uk https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/female-genital-mutilation-fgm/
- The Girl Generation: https://www.thegirlgeneration.org/
- Royal College of Nursing: Female genital mutilation https://www.rcn.org.uk/clinical-topics/female-genital-mutilation
- NHS England has 6 videos available: https://www.youtube.com/playlist?list=PL6IQwMACXkj06kcGt64sqh57jRLPcNv1s
- #EndFGM The Words Don't Come: www.youtube.com/watch?v=M5E936tbv4g&t=1s
- #EndFGM Our daughters: www.youtube.com/watch?v=n1HA4QNv1dk
- #EndFGM Its our time now: www.youtube.com/watch?v=FZ_6CCfWjPo
- Safeguarding Board for Northern Ireland: https://www.safeguardingni.org/female-genital-mutilation-fgm
- Oxford Health NHS Foundation Trust. Let's talk FGM: https://www.letstalkfgm.nhs.uk/
- Health Education England: FGM e-learning module https://www.e-lfh.org.uk/programmes/female-genital-mutilation/
- Health Education England: Cultural competence e-learning module https://www.e-lfh.org.uk/programmes/cultural-competence/
Box 2.Further reading
- Bagness C. Tackling FGM is everybody's business. Practice Nursing. 2015;26(2):74–8. 10.12968/pnur.2015.26.2.74
- Burchill J, Pevalin DJ. Demonstrating cultural competence within health-visiting practice: working with refugee and asylum-seeking families. Diversity and Equality in Health and Care. 2014;11(2):151–9
- Scottish Government: Violence against women and girls (VAWG) https://www.gov.scot/policies/violence-against-women-and-girls/female-genital-mutilation-fgm/
- National Safeguarding Team (NHS Wales): http://www.wales.nhs.uk/sitesplus/documents/888/FGM%20Annual%20report%202017-18%20Final.pdf
- NHS England. Commissioning services to meet the needs of women and girls with Female Genital Mutilation: https://www.england.nhs.uk/publication/commissioning-services-to-meet-the-needs-of-women-and-girls-with-female-genital-mutilation-fgm/
- Watt K, Abbott P, Reath J. Developing cultural competence in general practitioners: an integrative review of the literature. BMC Fam Pract. 2016;17(1):158. 10.1186s12875-016-0560-6
Cultural competence
The second key requirement is understanding their local community—if they live locally, what is the attitude to FGM? This can vary from a positive frame of mind to change traditions and move away from such abusive behaviour, right through to girls being abused locally (although evidence to support claims of FGM being carried out in the UK have so far remained elusive) or being taken abroad to have FGM carried out on them, despite legal frameworks in place to prosecute those who might try and remove girls abroad.
Cultural competence (Dean, 2017; National Institute for Health and Care Excellence (NICE), 2019) is key to effective care. It requires individual nurses/midwives to understand how they can best meet the needs of the increasingly diverse population, and how to effectively advocate for individuals based on their needs and expectations. Trust in healthcare provision is essential to support best practice, and girls and women need to feel comfortable, respected and culturally safe when they access care.
Understanding individual differences in demographics, location, culture, beliefs, practices, and expectations for health and social care requires challenging in a positive and helpful manner. This challenge can appear to be in conflict with some individuals trying to impose FGM on their children/relatives; however, in the case of FGM, it is clear that it is not to be tolerated, not least because of the suffering it causes, and because it is illegal.
The Home Office has a range of useful resources, including factsheets in a number of key languages, to help with explaining the duty for health and social care professionals and teachers to report FGM to the police (Home Office, 2014; Department of Health, 2016). It is also necessary to consider that health professionals may be ambivalent or hostile to the idea of eradicating FGM—health professionals come from communities, with their own values and beliefs—and the hope is that everyone sees FGM as abuse. However, this may not be the case, therefore there is also a duty to educate colleagues who may have less of an understanding about the short- and long-term physical, psychological and psychosexual impacts FGM has on girls and women.
In 2015, the Serious Crime Act (2015) was explicit in its assertion that failing to protect someone from FGM is an offence. It also outlined FGM Protection Orders, lifelong anonymity for survivors, and extended elements of the 1984 FGM Act, such as the extra-territorial coverage. It also brought about the mandatory reporting of FGM by health professionals, social workers and teachers who must now report to the police cases of FGM or suspected FGM involving girls under 18 years of age. Mandatory reporting requires:
‘regulated health and social care professionals and teachers in England and Wales to 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.’
For example, if a practice nurse sees a girl aged under 18 years who has experienced FGM, they should commence safeguarding procedures, including reporting to the police. Every health professional should be familiar with the local safeguarding processes and know who to contact in the event, regardless of where they work across the UK. The Home Office (2015; 2016) has clear guidance, including a pathway to help understand how this process should be undertaken in England. However, Wales, Scotland and Northern Ireland have separate processes.
In recent years, greater media coverage and organisations, such as the National Society for the Prevention of Cruelty to Children, Daughters of Eve, Forward UK and The Girl Generation working alongside Royal Colleges, have raised the profile of FGM in both the UK and in countries where FGM is a risk to life and health.
Despite all of these efforts, FGM continues to be surrounded by myth and misunderstanding, and it remains one of the most significant health challenges faced by some girls and women today.
Conclusion
Practice nurse roles have become very diverse. They see girls and women for a wide range of health issues, including contraception, immunisations, health promotion, travel health inquires and urogynaecology issues, as well as cervical screenings. They can also be the initial person a woman confides in if she is having issues with urination and/or menstruation, as well as wider psychosexual issues that can impact on fertility.
Understanding the local community is critical to safeguarding those women and girls who are or will be adversely affected by abuse. Having the correct skills, knowledge and understanding, as well as the open attitude best suited to all health professionals to remain professionally curious, will help women and girls to lead fulfilled and happy lives.
KEY POINTS
- Female genital mutilation (FGM) is child abuse and a safeguarding issue
- FGM needs to be understood by anyone caring for girls and women
- The procedure has no health benefits and damages lives and families
- Health professionals have a mandatory duty to report FGM
- FGM is illegal across the UK, including removing girls abroad to have the procedure carried out in another country