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IntroductionDear Attendees,
Thank you very much for attending the Educational Event today, and I really hope you have benefited from listening to the fantastic speakers. This booklet aims to provide you with key summary points, both from the lectures and guidelines published to date and included in your information pack, in order to aid recognition and management of cases of female genital mutilation. There are many ongoing projects in the UK that are aiming to raise awareness of FGM, and you can find further information of how to help on their websites, provided in the references section.
It is my hope that this booklet will be applicable to the learning of the following professionals:
Medical StudentsMidwifery StudentsObstetricians and GynaecologistsPaediatriciansUrologistsMidwives
I would be very grateful if you could read through the booklet and then fill in a short evaluation survey online at http://www.surveymonkey.com/s/M9YNNSG
Finally, I would like to say a special thanks to all those who have advised me throughout the organisation of the Educational Day on Female Genital Mutilation, and supported its running:
Lisa Zimmermann Integrate Bristol Project Manager www.integratebristol.org.ukSarah McCulloch Director, Agency for Community Change Management (ACCM) Dr Hillary Cooling General Practitioner, Minority Ethnic Women's and Girls' Clinic, BristolChavala Madlena Journalist, Guardian News & Media Limited
Without whom this event would not have been possible.
Many thanks,
Eleanor Zimmermann4th Year Medical Student Peninsula Medical [email protected]
1/11
Contents Page
What is FGM?...…...................................................................................3
Definition and diagrams of the different types of Female Genital Mutilation.
Who is at risk?..…....................................................................................4
The national and global distribution of FGM. The communities at risk.
Consequences of FGM............…............................................................5
Short and long term complications of FGM including gynaecological, obstetric and
psychological complications.
The Law and FGM…................................................................................6
The law in the UK and other EU countries. Outlining what has been done in the UK so far,
and comparison to other countries such as France and Denmark.
What is our responsibility?.......................................................................7
Our role as a doctor/midwife – what can we do now, and what can we do when
encountering a case of FGM. How to manage common situations. Useful contacts.
Defibulation – Reversal of FGM...............................................................8
The indications for defibulation, and how it is performed.
Case studies............................................................................................9
Example situations for discussion and thoughts.
Summary................................................................................................10
References and Further Reading...........................................................10
Acknowledgments...................................................................................11
Sponsor list, description of their services, and discounts for attendees.
2/11
What is FGM?“Female Genital Mutilation (FGM) comprises all procedures which involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons.” 1 The procedure may be carried out when the girl is newborn, during childhood, adolescence, at marriage or after labour, and is dependant on the ethnic group practising it. 2
There are four types of FGM, which are defined below:
Type Definition
I Clitoridectomy: Removal of the prepuce with or without excision of all or part of the clitoris.
II Excision: Excision of the clitoris and the labia minora, with or without excision of the labia majora
III Infibulation: Excision of part or all of the external genitalia (the clitoris, labia minora and labia majora) with stitching of the labia minora or majora to narrow of the vaginal opening
IV All other harmful procedures to the female genitalia for non-medical purposes. Includes pricking, piercing, incising of the clitoris and/or labia; cauterisation by burning of clitoris and surrounding tissue; scraping of the tissue surrounding the vaginal orifice (angurya cuts) or cutting into the vagina (gishiri cuts), introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purposes of tightening or narrowing it.
Table adapted from WHO 3, and FGM Green-Top Guidelines No.53 1
FGM types I and II constitute 80% of female genital mutilation performed world-wide.4
Type III is the most extreme form of FGM, involving removal of almost two thirds of the female genitalia. Type III is estimated to constitute 10% of mutilations performed world-wide.5
Fig1: Diagrammatic representation of the types of FGM. Taken from FGM Green-Top Guidelines No.53.1
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Who is at Risk?Young girls aged 4-10 in the UK from ethnic minorities4 – especially those from countries listed in the table below are at risk of FGM. It is estimated that in the UK over one hundred thousand woman have undergone FGM2 and up to seven thousand young girls are at risk per year. 6
In the UK, most of the at risk communities are in major cities such as London, Manchester, Sheffield, Liverpool, Birmingham, Bristol and Cardiff.4
These figures are based on estimates due to the sensitivity of FGM and inability to conduct systemic surveys. The true prevalence of FGM is not known, but the World Health Organisation and FORWARD fear the true figures to be much higher.2
Countries with a high prevalence of FGM are listed below:
Country Prevalence (%) Type of FGM performed
Somalia 98-100 Type III
Guinea 99 Type II
Egypt 97 Type II (72%)
Eritrea 95 Type I (64%), Type III (34%)
Sierra Leone 90 Type II
Sudan 89 Type III (82%)
Table adapted from RCOG FGM Green-Top guidelines No.531
Fig2: Prevalence of FGM in Africa. Taken from World Health Organisation5
“Over 6,000 communities across Africa abandon female genital mutilation/cuttingBy Kutloano Leshomo
LONDON/GENEVA, 6 February 2010 – Over 6,000 communities have chosen to abandon the practice of female genital mutilation/cutting according to a joint United Nations programme designed to eliminate this practice, and the number is growing.”
http://www.unicef.org/infobycountry/eritrea_52819.html
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Consequences of FGMAcute Complications:1,2,4
Severe pain Localised infection, abscess formation
Haemorrhage Hepatitis and HIV infection
Retention of urine Tetanus
Broken limbs from being held down Septicaemia
On admission of an acute case:1
1. Check for signs of hypovolaemic shock and sepsis2. Offer analgesic relief3. Check for broken limbs 4. Consider Tetanus vaccination5. Consider antibiotic prophylaxis6. Consider urinary catheterisation7. Assess for risk of Hepatitis and HIV infection
Late Complications : 1,2,4,6
It may be helpful to divide the multiple complications under subheadings, although many are applicable to more than one heading, especially when considering the pathology or implications on the victim:
Sexual:• apareunia (impossibility of sexual intercourse)• supercifical dysparaeunia (pain during
intercourse)• sexual dysfuntion, anorgasmia• vaginal lacerations -sexual intercourse and
rapeObstructive:
• dysmenorrhoea – haematocolpos (accumulation of blood in the vagina)
• urinary outflow obstruction• prolonged or obstructed labour• post-partum haemorrhage
Infective:• recurrent urinary tract infections• pelvic infections
Inflammatory: Fig3: Keloid scarring due to FGM• chronic pain Taken from Rashid & Rashid6
• keloid scar formationPsychological:
• post traumatic stress disorder• difficulty conceiving (intercourse, pelvic infection, obstructed menstruation)
Other: Difficulty during and Avoidance of other Gynaecological Procedures, for instance:• cervical cytology• screening for sexual transmitted infections• gynaecological examinations• evacuation of uterus following termination of pregnancy
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The Law and FGMThe 1985 Act1,7
The 1985 act states that is is an offence for any person to:
a) excise, infibulate or otherwise mutilate the whole or any part of the labia majora or clitoris of another person; or
b) aid, abet, counsel or procure the performance by another person of any of those acts on that other person's own body.
The Female Genital Mutilation Act 20031,7
Any person found guilty of the 1985 Act will carry a penalty of up to 14 years imprisonment. No offence is committed if the cutting is undertaken during labour provided the purpose is to aid birth.
FGM of a UK National or permanent UK resident is prohibited by the Law in England, Scotland and Wales, whether carried out in the UK or abroad.
The law allows surgery to be performed on a woman's labia if the indication is for comfort, sexual confidence or self esteem. It is the clinicians responsibility to determine the true reason of the request and to seek medico-legal guidance should there be any doubt.
Investigations and Prosecutions to date:
In 2008/09 there were 46 investigations undertaken by the Metropolitan Police; in 2009/10 there were 58, however to date there have been no prosecutions in the UK under this act.6,8
The Metropolitan Police Authority (MPA) have issued a number of reasons to explain the lack of prosecution and justice, including not being able to date scar tissue and prove the mutilation has been performed after 2003, the victims being too young at the time of mutilation to remember the incident and the lack of referrals from healthcare professionals.8
Rashid & Rashid state that there are private doctors and nurses that carry out FGM in the UK, who are often based in the communities at risk. 6 There are also traditional circumcisers amongst the communities who carry out FGM and parents and communities protect the names of these health professionals and circumcisers. 6,9 The age at which young girls are being mutilated has decreased, probably due to the uprising in anti-FGM awareness in Western countries.1,4
Investigations in Other European Countries:
In France, Sweden and Denmark, circumcisers and families have been prosecuted, leading to imprisonment and penalty of compensation to the young victims.8
“In France a girl who has been identified as being at risk of FGM will be the subject of mandatory intervention from the authorities and children’s social care. As part of this intervention there will be a compulsory medical examination, and additional annual examinations as well as examinations when the girl returns to France having been outside of the country. If the girl is found to have had FGM whilst under the management of the authorities the parent or carer could be prosecuted.
In the UK there are no routine or mandatory medical examinations of children in child abuse cases. Each investigation is assessed on the relevant facts and there is always careful consideration as to whether a medical examination is required. In addition to human rights considerations of necessity and proportionality there is research to indicate that a child protection medical examination could be considered as ‘abusive’ in certain circumstances.” 8
Metropolitan Police Authority – Project Azure 8
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What is our responsibility?
All professionals have a responsibility toward safeguarding children.
If concerned a girl is at risk you have a duty to seek urgent guidance and inform the Child Protection Team, or Safeguarding Board. 1,10
If a child is admitted after mutilation advice should be sought urgently from the local social services, local police child protection unit or National Society for Prevention of Cruelty to Children. This should include addressing concern for other children in the family who may not have undergone the procedure.1,10
If a woman who has undergone FGM presents antenatally, the RCOG advises that maternity units should adopt a questionnaire for patients at risk (who originate from areas where FGM is practiced) to establish the risks in labour. All maternity healthcare workers must be aware of the complications associated with female genital mutilation and labour, and advice patients on antenatal and delivery accordingly. To assess the requirement of defibulation an obstetrician or trained midwife or nurse should examine the patient.1,6
For all cases, a psychological assessment should be included for any women who has undergone FGM and they should be offered referral to a psychologist.1
Practitioners should seek medico-legal advise from their defense union if unsure of their position.1
Remember most women do not choose mutilation and the procedure is carried out in childhood. The practice is seen by some cultures as normal, is traditional, and in some communities is viewed as a 'coming of age' ritual. The woman will not only have suffered through experiencing female genital mutilation, but also through migration and separation, and in some cases war. It is important to remain non-judgmental, and offer support. 4,6
Useful Contacts:
Devon Children and Young People's ServicesTel: 01392 382059http://www.devon.gov.uk/cyps
Southwest Safeguarding and Child Protection GroupTel: 01392 384444http://www.online-procedures.co.uk/swcpp/
National Society for the Prevention of Cruelty to Children 24 Hour Help lineTel: 0800 800 5000http://www.nspcc.org.uk/
Bristol Safeguarding Children BoardFGM Training for Professionals & Bristol FGM NetworkJackie Mathers, Designated Nurse for Safeguarding Children, NHS Bristol.Tel: 0117 900 2670 [email protected]
FORWARDFor advice regarding a child at risk or support for a child who has undergone FGMTel: 0208 960 4000http://www.forwarduk.org.uk/at-risk
7/11
Defibulation - Reversal of FGM Guidance should always be sought from a specialist centre that has developed expertise in defibulation.6
Defibulation should be offered to any patient with FGM, with full explanation of the health risks associated with FGM. Any patient who is experiencing complications due to her mutilation should be advised regarding the reversal.1,6
Obstetric Management of Patients with FGM
The most common situation where defibulation is performed is during obstetric management of a patient. 6 As a general rule, if two fingers can be inserted into the vagina without discomfort or the urinary maetus can be observed, then labour should not pose any problems for the patient.6
Women must be advised on the necessity to maintain a healthy diet as some women have been reported to reduce their daily calorie intake in the hope that the baby will be small and thus reduce risks during labour. 6
Indications for Antenatal Defibulation:1,6
• Type III FGM• Repeated urinary and vaginal infections • Threatened or incomplete miscarriage• To check for proteinuria in FGM Type III*
*Urine always mixes with vaginal secretions in patients with Type III mutilation and therefore protein may be detectable in samples – giving a false positive result in a screen for pre-eclampsia.6
Consequences for withholding consent for defibulation include an increased risk of emergency C-sections due to inability to monitor fetus through fetal blood sampling.6 Fig 4: Obstructed labour resulting in
fetal demise. Taken from Rashid & Rashid6
Early defibulation has the advantage of easing vaginal examination and prevents unnecessary blood loss during delivery. 1,6
Defibulation should be offered at one the following stages of pregnancy: 6
Pre 20 week gestation Allowing the scar to heal before delivery
Between 34 and 38 weeks gestation
In the event of premature labour this will ensure fetal viability
During labour The least desirable option. This must be performed by a doctor or midwife trained in defibulating type III FGM. It should be performed during the first stage of labour with an epidural, or if the patient presents during the second stage, then a midline incision can be performed during crowning of the fetal head
In all cases, prophylactic antibiotics should be considered. 1
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Case Studies
You are the Paediatric on call SHO and are bleeped to accident and emergency. A 15 year old girl is waiting for you. She has brought in her 6 year-old sister who, she explains, has had FGM three days previously. Their parents do not know their whereabouts. The 6 year-old girl is quiet, does not maintain eye contact and will not sit down.
What would your first response be?What is your medico-legal situation?Who should you contact and what would you say?
What investigations would you perform? What conditions is this child at risk of developing due to her FGM?
You are a midwife working nights on the labour ward. A new patient has been admitted and she is not known to the department. She is visibly distressed and refuses to be examined. She later tells you that she 'has been done' and that she is worried about the baby coming out.
Who should you contact?What can you say to the patient to prepare her for the delivery?When would the optimal time be for her to be defibulated?What issues are raised in regards to her post-natal care?
A Somali patient comes to see you, her O&G consultant in the post-natal clinic. During labour you had performed defibulation to enable healthy delivery of her baby. She now expresses a wish to be re-infibulated, as she says she does not feel like a woman anymore. She asks you to perform the infibulation to reinstate her Type III FGM.
What is your legal obligation?What advice would you give her?What other issues are raised by this case?
You are collecting your child from school one afternoon, and you daughter says that her foreign friend is going on holiday for the first time this summer, to visit her family in Africa with her little sister. You know the friend she speaks of, and are concerned there may be an alternate motive to the trip.
As a parent – do you have a right to raise concerns?If so, who would you contact?If, when the girl and her sister return from their holiday you hear one is
always ill and doesn't come to school very often anymore – what would you do?
9/11
SummaryFemale Genital Mutilation is the partial or total removal of the external female genitalia for non-medical purposes. In the UK, school girls from ethnic minorities such as of African origin, especially Somalia, are at risk of FGM. If you suspect a child to be at risk of FGM, or to have undergone FGM, it is your legal obligation to seek advice from either your local Child Safeguarding Team or the Social services.
Women who have undergone FGM are at significant risk of numerous consequences, and obstetric management of these patients is complicated. Expert advice should be sought and if defibulation is required this should be performed by a trained midwife or consultant.
It is extremely important that healthcare professionals are able to identify and manage FGM, and report it when necessary. It is our duty to be trained and remain up to date at all times, in order to maximise patient care and ensure best practice.
References and Further Reading1- RCOG. Female Genital Mutilation and Its Management. Green-top Guideline. No. 53. 2009
2- FORWARD. Female Genital Mutilation Factsheet. 2005
3- World Health Organization. Fact Sheet No 241. Female Genital Mutilation. WHO: Geneva; 2004
4- FORWARD. Female Genital Mutilation: Information Pack. 2002
5- World Health Organisation. Sexual and Reproductive Health. Female Genital Mutilation and other harmful practices. Prevalence of FGM. http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/index.html(accessed 7th Feb 2011)
6- Rashid M, Rashid M. Obstetric management of women with female genital mutilation. The Obstetrician & Gynaecologist. 2007;9:95-101
7- Southwest Safeguarding and Child Protection Group. Female Genital Mutilation. Guidance.http://www.online-procedures.co.uk/swcpp/contents/guidance-child-protection/female-genital-mutilation/ (accessed 7th Feb 2011)
8- Carroll J. Metropolitan Police Authority. Female Genital Mutilation – MPS project Azure. Report 8. 2010http://www.mpa.gov.uk/committees/cep/2010/101104/08/ (accessed 7th Feb 2011)
9- World Health Organisation. Global Strategy to Stop Healthcare Providers from performing female genital mutilation. 2010. WHO/RHR/10.9
10- London Safeguarding children board. London Female Genital Mutilation Resource Pack. 2009
Amnesty Internationalhttp://www.endfgm.eu/en/female-genital-mutilation/what-is-fgm/what-is-fgm/
FGM National Clinical Grouphttp://www.fgmnationalgroup.org/Contact Ms Susan Smith on [email protected] to request a FGM Resource DVD.
Integrate Bristol http://integratebristol.org.uk/
10/11
AcknowledgmentsMany thanks to all the sponsors, each of whom have been extremely generous in their support of this event:
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