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Female genital mutilation – the UK perspective

Mr Ashokkumar Oliparambil1 and Mr Vikram Sinai Talaulikar2

1 - Consultant Obstetrician and Gynaecologist, Whittington Hospital, London, UK

2 - Associate Specialist, Reproductive Medicine Unit, University College London Hospital, London, UK

Definition

Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for no medical reasons.

Classification

The WHO/UNICEF/UNFPA (World Health Organization/United Nations International Children's Emergency Fund/United Nations Population Fund) joint statement classifies FGM into four types (Figure 1):

Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)

Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)

Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)

Type 4: All other harmful procedures to the female genitalia for non-medical purposes for example pricking, piercing, incising, scraping and cauterization

Figure 1 Classification of female genital mutilation

Prevalence and practice

Type 1, 2 and 3 FGM have been documented in 28 countries in Africa and in a few countries in Asia and the Middle East. WHO estimates that between 100 and 140 million girls and women worldwide have been subjected to one of the first three types of FGM. The prevalence varies considerably, both between and within regions or countries with ethnicity as the most decisive factor.

The most recent prevalence data indicates that 91.5 million girls and women over 9 years old in Africa are currently living with the consequences of FGM and about 3 million girls at risk of undergoing FGM procedures every year. It is believed that more than half a million women with FGM live in the UK mostly in the cities of London and Birmingham. FGM is also found in the UK amongst members of migrant communities. It is estimated that approximately 60,000 girls aged 0–14 were born in England and Wales to mothers who had undergone FGM. UK communities which are most at risk of FGM include Kenyan, Somali, Sudanese, Sierra Leonean, Egyptian, Nigerian and Eritrean. Non-African communities that practice FGM include Yemeni, Afghani, Kurdish, Indonesian and Pakistani.

Reluctance to be identified as a victim of FGM is believed to be one of the reasons for the low incidence of reporting of this offence. It is anticipated that providing for the anonymity of victims of alleged offences of FGM will encourage more victims to come forward. Although FGM is mostly carried out on girls between the ages of 0 and 15 years, the age at which girls undergo FGM varies enormously according to the community. The procedure may be carried out when the girl is newborn, during childhood or adolescence, just before marriage or during the first pregnancy. The age at which FGM is performed varies with local traditions, customs and circumstances. It is mostly performed by untrained personnel using locally available instruments such as razor blades, knives, scissors, glass pieces, etc. usually without the use of analgesics and/or antiseptics. Children born in Western countries are often taken back to their ancestral countries for the operation and are brought back once the wounds have healed.

FGM appears to be a manifestation of gender inequality that is deeply entrenched in some social, economic and political structures. FGM represents society’s control over women. It is claimed that the procedure improves women’s purity and modesty, and many think that it is aesthetically pleasing to have the procedure. Where FGM is widely practiced, it is supported by both men and women usually without question, and anyone departing from the norm may face condemnation and harassment. FGM is considered to raise a girl properly and prepare her for adulthood and marriage, and to become responsible members of the society. There is often an expectation that men will marry only women who have undergone the practice and in some communities this practice is considered as a religious act.

Complications and dangers of female genital mutilation

Immediate health complications of FGM:

  1. Severe pain: owing to cutting of nerve ends and sensitive genital tissue (as the procedure is often performed without anesthesia or analgesia);
  2. Shock: owing to pain and/or hemorrhage;
  3. Difficulty in passing urine and feces owing to local swelling, edema and pain;
  4. Infections including human immunodeficiency virus (HIV): owing to repeated use of surgical instruments without sterilization;
  5. Death can be caused by hemorrhage or infections including tetanus;
  6. Injury to the urethra, vagina or bowel;
  7. Psychological consequences: the pain, shock and the use of physical force by those performing the procedure makes FGM a traumatic event;
  8. Unintended labial fusion: type 2 FGM may, owing to labial adhesion, result in a type 3 FGM;
  9. Repeated genital mutilation appears to be quite frequent in type 3 FGM usually owing to unsuccessful healing.

Long-term health complications of FGM:

  1. Long-term psychological issues such as increased likelihood of fear of sexual intercourse, post-traumatic stress disorder, depression, anxiety and relationship problems owing to an inability to have pleasure during sex;
  2. Chronic pain owing to trapped or unprotected nerve endings;
  3. Dermoid cysts, abscesses and genital ulcers can develop with superficial loss of tissue;
  4. Chronic pelvic infections can cause chronic back and pelvic pain;
  5. Recurrent urinary tract infections can lead to damage to the kidneys resulting in renal failure and sepsis;
  6. Retained menstrual blood may lead to pelvic inflammatory disease and endometriosis;
  7. Slow and painful menstruation and urination can result from near-complete sealing of the vagina and urethra. Dribbling of urine is common in infibulated women, probably owing to both difficulties in emptying the bladder and stagnation of urine under the hood of scar tissue;
  8. Vesicovaginal and vagino-rectal fistulae;
  9. Keloid: excessive scar tissue may form at the site of cutting;
  10. Quality of sexual life: sexual sensitivity may be decreased owing to pain during sex due to scar formation;
  11. Obstetric complications: increased risk of perineal tears, obstetric fistulae, obstructed labor, postpartum hemorrhage and associated neonatal morbidity;
  12. Late surgery: infibulations must be opened (defibulation) later in life to enable penetration during sexual intercourse and childbirth;
  13. Subfertility: mainly owing to cutting of the labia majora and risk of infection.

Law and female genital mutilation

FGM is outlawed or partially banned in most countries; however, the law is not strongly implemented universally. The United Nations (UN) general assembly has declared FGM a violation of women’s rights. FGM is child abuse and illegal in the UK. Anyone undertaking and abetting this procedure can be prosecuted and, if found guilty, jailed for up to 14 years. All healthcare professionals, social services workers and teachers have a responsibility to report cases or suspicion of FGM. An offence of failing to protect a girl from the risk of FGM can also be committed wholly or partly outside the UK by a person who is a UK national or UK resident. The extra-territorial offences of FGM are intended to cover taking a girl abroad to be subjected to FGM. Anyone who commits FGM faces up to 14 years in prison or a fine, or both. Anyone found guilty of failing to protect a girl from risk of FGM faces up to 7 years in prison or a fine, or both.

Female genital mutilation and issues related to clinical management

All National Health Services (NHS) staff in the UK must take appropriate safeguarding action every time they identify a child with, or at risk of, FGM following local safeguarding arrangements. The Department of Health has published guidance (March 2015) which provides support to NHS organizations when developing or reviewing safeguarding policies and procedures around FGM. It can be used by health professionals from all sectors. Patient information leaflets are available to give to patients identified with FGM. The leaflet defines the different types of FGM, explains the health consequences and the help and support available, and provides information on the FGM data being collected in the NHS. It is important for the healthcare professionals to inform social services or the police if there is any suspicion that FGM is likely to be or has been carried out. Regulated health and social care professionals and teachers are required now to report cases of FGM in girls under 18 years which they identify in the course of their professional work to the police. The duty does not apply if the woman is over 18 years. In that case the health professional should signpost the woman to services offering support and advice. The health professional may also need to carry out a safeguarding risk assessment considering children who may be at risk of or have had FGM. Psychological support is essential for children and women who are subjected to these procedures. The affected children and women should be offered a referral to the NHS specialist services set up to support them. When a woman with FGM is identified, the health professional must explain the UK law on FGM. The health professional must understand the difference between recording (documenting FGM in the medical records) and reporting (making a referral to police and/or social services) and their responsibilities with regards to these.

The health professional should be aware that it is not mandatory to report all pregnant women to social services or the police. An individual risk assessment should be made by a member of the clinical team (midwife or obstetrician) using an FGM safeguarding risk assessment tool (an example of such a tool can be found at https://www.gov.uk/government/publications/safeguarding-women-and-girls-at-risk-of-fgm). If the unborn child, or any related child, is considered at risk then a report should be made. Specialist multidisciplinary FGM services should be led by a consultant obstetrician and/or gynecologist and be accessible through self-referral. These services should offer information and advice about FGM, child safeguarding risk assessment, gynecological assessment, de-infibulation and access to other services. Healthcare professionals should be vigilant and aware of the clinical signs and symptoms of recent FGM, which include pain, hemorrhage, infection and urinary retention. Examination findings should be accurately recorded in the clinical records. Some type 4 FGM, where a small incision or cut is made adjacent to or on the clitoris, can leave few, if any, visible signs when healed. Consideration should be given to photographic documentation of the findings at acute presentation.

All women should be offered referral for psychological assessment and treatment; testing for HIV, hepatitis B and C; and sexual health screening. Where appropriate, women should be referred to gynecological subspecialties, e.g. psychosexual services, urogynecology and fertility.

Gynecologists should be aware that narrowing of the vagina owing to type 3 FGM can preclude vaginal examination for cervical smears and genital infection screens. De-infibulation may be required prior to gynecological procedures such as surgical management of miscarriage (SMM) or termination of pregnancy (TOP). Others will need de-infibulation during labor and delivery to facilitate childbirth. Women who are likely to benefit from de-infibulation should be counselled and offered the procedure before pregnancy, ideally before first sexual intercourse. Women offered de-infibulation should have the option of having the procedure performed under local anesthetic in the clinic setting in a suitable outpatient procedures room. All gynecologists, obstetricians and midwives should receive mandatory training on FGM and its management, including the technique of de-infibulation.

Female genital mutilation and care in pregnancy

Antenatal care

Women with FGM are more likely to have obstetric complications and consultant-led care is generally recommended. However, some women with previous uncomplicated vaginal deliveries may be suitable for midwifery-led care in labor. Referral for psychological assessment and treatment should be offered. The vulva should be inspected to determine the type of FGM and whether de-infibulation is indicated. If the introitus is sufficiently open to permit vaginal examination and if the urethral meatus is visible, then de-infibulation is unlikely to be necessary.

Screening for hepatitis C should be offered in addition to the other routine antenatal screening tests (hepatitis B, HIV and syphilis). De-infibulation may be performed antenatally, in the first stage of labor or at the time of delivery and can usually be performed under local anesthetic in a delivery suite room. It can also be performed perioperatively after cesarean section. The midwife or obstetrician should discuss, agree and record a plan of care. Women should be informed that re-infibulation will not be undertaken under any circumstances.

Intrapartum care

Women with FGM should generally be delivered in units with immediate access to emergency obstetric care and should have intravenous access established in labor and blood taken for full blood count and group and save. However, in certain circumstances women with FGM may be considered low risk and midwifery-led care in labor may be appropriate. If a woman requires intrapartum de-infibulation, the midwife and obstetrician caring for her should have completed training in de-infibulation or should be supervised appropriately. If de-infibulation planned for the time of delivery is not undertaken because of recourse to cesarean section, then the option of perioperative de-infibulation (i.e. just after cesarean section) should be considered and discussed with the woman. Labial tears in women with FGM should be managed in the same manner as in women without FGM. Repairs should be performed where clinically indicated, after discussion with the woman and using appropriate materials and techniques. The impact of FGM on labor and delivery should be sensitively discussed and a plan of care agreed. The technique of de-infibulation at delivery is similar in principle to de-infibulation performed at other times. However, in contrast to de-infibulation prepregnancy, antenatally or in the first stage of labor, when either a scalpel or scissors may be used, at delivery the incision should be made with scissors (rather than a scalpel) just before crowning of the fetal head. Lidocaine without adrenaline (epinephrine) should be used. Once the procedure has been performed, the need for episiotomy should be assessed; this is commonly required (irrespective of FGM type) owing to scarring and reduced skin elasticity of the introitus. In women for whom intrapartum de-infibulation was planned to permit safe vaginal delivery, emergency cesarean section may result in the woman having an ongoing need for de-infibulation during a subsequent pregnancy. If feasible from the perspective of maternal and fetal wellbeing, the option of perioperative de-infibulation, after safe cesarean delivery of the baby, should be discussed with the woman prior to transfer to theater. This scenario may be discussed with women antenatally.

Eliminating female genital mutilation

Eliminating FGM will need multifaceted action from several different sectors within the society. Both local and global institutions from areas of education, finance, justice and women’s affairs as well as the health sector will need to engage with community groups and non-governmental organizations to bring an end to FGM through a broad-based long-term commitment.

FGM is a dangerous practice, and a critical human rights issue. Decades of prevention work undertaken by local communities, governments, and national and international organizations has contributed to a reduction in the prevalence of FGM in some areas. UN agencies have confirmed their commitment to support governments, communities and the women and girls concerned to achieve the abandonment of FGM within a generation.

Training professionals who are likely to encounter children or women who may be at risk of FGM is crucial in fight against FGM. ‘FGM e-learning training modules: Raising awareness of female genital mutilation’ are five e-learning modules which are free of charge to all healthcare staff in UK via the ‘e-learning for health’ platform and cover a range of issues in relation to FGM at all stages of a girl or woman’s life. These e-learning modules have been developed by Health Education England and are available at: www.e-lfh.org.uk/programmes/female-genital-mutilation. A wallet-sized leaflet (Statement opposing FGM) has also been produced in the UK as a preventive tool for families travelling to FGM practicing countries. It can be shown to family members who may be pressuring a girl to undergo FGM. It is signed by a number of government ministers and clearly states that FGM is illegal, details the health problems it causes and lists sources of support. It is available in English and ten other languages at www.nhs.uk/fgm and www.orderline.dh.gov.uk.

Further reading

  1. National Society for the Prevention of Cruelty to Children (NSPCC). Female genital mutilation (fgm): The facts. FGM Helpline 0800 028 3550. Home Office FGM Unit. fgmhelp@nspcc.org.uk and FGMEnquiries@homeoffice.gsi.gov.uk.
  2. Macfarlane A, Dorkenoo E. Prevalence of Female Genital Mutilation in England and Wales: National and local estimates. London: City University London and Equality Now, 2015.
  3. OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO. Eliminating Female Genital Mutilation: An interagency statement. World Health Organization, 2008.
  4. RCOG Green-top Guideline No. 53. Female Genital Mutilation and its Management. Royal College of Obstetricians and Gynaecologists, UK, July 2015.
  5. Baillot H, Murray N, Connelly E, Howard N; Scottish Refugee Council; London School of Hygiene and Tropical Medicine. Tackling Female Genital Mutilation in Scotland. A Scottish model of intervention. Glasgow: Scottish Refugee Council; 2014.
  6. Department of Finance and Personnel, Northern Ireland. Multi-agency Practice Guidelines: Female Genital Mutilation. Bangor, Northern Ireland: DFP; 2014 http://www.dfpni.gov.uk/multi-agency-practice-guidelines-on-female-genital-mutilation.pdf. Accessed 2015 May 29.
  7. United Nations Children’s Fund. Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change. New York: UNICEF; 2013.
  8. Department of Health. Female Genital Mutilation Risk and Safeguarding. Guidance for professionals. London: DH; 2015.
  9. Royal College of Midwives, Royal College of Nursing, Royal College of Obstetricians and Gynaecologists, Equality Now, Unite. Tackling FGM in the UK: Intercollegiate recommendations for identifying, recording and reporting. London: RCM; 2013.