Female genital mutilation in BritainBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6994.1590 (Published 17 June 1995) Cite this as: BMJ 1995;310:1590
- a Victoria Mill House, Framlingham, Woodbridge, Suffolk IP13 9EG
- b Children's Services Unit, South Birmingham Health Authority, Birmingham
- Correspondence to: Dr Black.
- Accepted 7 February 1995
Much has been written about female genital mutilation in Africa, but little attention has been paid to its existence in Britain. Though it has been illegal in this country since 1985, it is practised secretly or children are sent abroad to have the operation. From the social worker's point of view it is technically a form of child abuse which poses special problems. Black and Debelle review the historical background of female genital mutilation and describe its medical complications. Gallard discusses the problem in France, and Walder considers why such mutilation still continues in Britain.
This article is concerned with female genital mutilation in Britain. The term is preferable to female circumcision, which is inaccurate and implies a minor operation equivalent to male circumcision. In many cultures the operation entails an extensive mutilation, with profound social, sexual, and medical consequences.
It is uncertain when female genital mutilation was first practised, but it certainly preceded the founding of both Christianity and Islam. There is no basis for the belief that the procedure was advocated or approved by Mohammed nor is it in any way part of the Islamic faith. Though the operation is largely confined to Muslims, it is also performed in certain Christian communities in Africa. Female genital mutilation is practised in various forms in over 20 African countries and also in Oman, the Yemen, and the United Arab Emirates and by some Muslims in Malaysia and Indonesia1; it is not practised in Iran, Iraq, Jordan, Libya, or Saudi Arabia.
What is female genital mutilation?
There are three types of operation. In the least mutilating form, known misleadingly as the “Sunna” procedure (meaning “following the Prophet's tradition”), the prepuce of the clitoris is removed; this is the only procedure which can be correctly called circumcision. In the most extensive form, called “infibulation” or in Sudan “the Pharaonic procedure,” the clitoris, the labia minora, and the medial part of the labia majora are excised and the sides of the vagina are then stitched together, leaving a small opening for urine and menstrual blood, patency being preserved by a sliver of wood. The term infibulation refers to the use of a clasp (infibula) to keep the cut edges of the vagina together. In the intermediate form of operation (“excision”) the clitoris is wholly or partly removed, together with part of the labia minora whose cut edges are sutured together to leave a small opening. In women who have had a procedure involving stitching together of the sides of the vagina, resuture is usually requested after delivery; this is not illegal (see below).
Complications are largely confined to the two more extensive operations. Early complications such as primary or secondary haemorrhage, sepsis, septicaemia, and tetanus are unlikely if the operation is performed by a skilled practitioner under good conditions. Long term complications include dyspareunia due to introital or vaginal stenosis, poor urinary stream, urinary tract infection, haematocolpos, vesicovaginal or rectovaginal fistula (after a prolonged delivery), keloid formation, and implanation dermoids. Soleiman Fayyad gives a horrifying account of the death of a woman in Egypt after the operation was done by force.2 Couples may complain of infertility, though the real problem is the inability of the husband to achieve penetration (D Paintin, personal communication). In Africa, prolonged or obstructed labour may occur if there is inadequate obstetric care. Dirie and Lindmark in Somalia found that even in otherwise normal deliveries anterior and mediolateral episiotomies were required.3
There are no figures for the incidence of emotional or psychological effects, but it is probable that this would be small in communities where social pressures are strongly in favour of the operation. Conversely, in such circumstances, the unoperated girl may be the object of disapproval and derision.
In Britain, with proper obstetric care there is rarely any difficulty in the second stage of labour, though an incision of the web of tissue across the vagina is often necessary (D Paintin, personal communication). In hospitals unused to looking after women with genital mutilation there may be hostility and incomprehension, particularly if the woman requests resuturing.
To appreciate why this operation is performed some understanding is required of the cultural background associated with female genital mutilation. In the least destructive operation, when only the prepuce of the clitoris is removed, the object is to reduce the woman's sexual desire and hence to ensure her virginity until she is married. The more extensive operations, involving stitching of the vagina, have the same aim of ensuring chastity until marriage. The reduction in the size of the vaginal orifice is supposed to increase the husband's enjoyment of the sexual act; there is no good evidence for this and initially penetration may be difficult and painful for both partners. From the family's point of view the operation ensures a satisfactory bride price; an eligible man would not consider marrying a girl who had not had the operation. The procedure is arranged by the mother or grandmother and in Africa is usually performed by a traditional birth attendant, a midwife making a little extra money, or by a professional exciser. Female genital mutilation is supported and encouraged by men; indeed the operation can be regarded as an exercise in male supremacy and the oppression of women.
The situation in Britain
During the past three or four decades ethnic groups who practise female genital mutilation have immigrated to Britain, mainly as refugees. The main groups are from Eritrea, Ethiopia, Somalia, and the Yemen. It has been estimated that in their own countries over 80% of women have had the operation,4 which is invariably infibulation. There is evidence that the operation is being performed illegally in Britain (see below) by medically qualified or unqualified practitioners and that children are being sent abroad for a “holiday” to have it done. In Britain the procedure is usually performed between the ages of 7 and 9 years.
Female genital mutilation was made illegal in Britain by the Prohibition of Female Circumcision Act 1985. Under this act it is an offence to “excise, infibulate, or otherwise mutilate the whole or any part of the labia majora or labia minora or clitoris of another person” or “to aid, abet, or procure the performance by another person of any of these acts on that other person's own body.” A person found guilty of an offence is liable to a fine or to imprisonment for up to five years, or to both, if convicted on indictment before a judge and jury in a crown court, or on summary conviction in a magistrate's court to a fine or imprisonment for up to six months, or to both. In Britain there have been no prosecutions under the act, but convictions have been obtained in France. In 1993 a medical practitioner was brought before the General Medical Council charged with performing female circumcisions while knowing that the operation was illegal; he was struck off. Legislation prohibiting female genital mutilation has also been passed in Sweden and Belgium and in some states in America.
In 1959 the general assembly of the United Nations adopted the Convention on the Rights of the Child, which states (article 24, paragraph 3) that “States Parties shall take all effective and appropriate measures to abolish traditional practices prejudicial to the health of children.” In 1982 the United Nations human rights subcommission of the World Health Organisation assured governments of its readiness, together with Unicef, to support national efforts against female genital mutilation. The practice was again condemned by the WHO in 19865 and by the International Planned Parenthood Foundation and in the African Charter on the Rights and Welfare of the Child. The Foundation for Women's Health, Research, and Development (FORWARD) has campaigned tirelessly in Britain and elsewhere for the abolition of female genital mutilation. FORWARD receives some financial support from the Department of Health. The whole subject has been comprehensively reviewed by Dorkenoo and Elworthy.6 Recently the World Medical Association condemned female genital mutilation,7 and the problem has been discussed in this journal, though with little mention of the problem in Britain.7 8
Child protection and female genital mutilation
In Britain female genital mutilation is regarded as a form of child abuse, though this term should not be used when discussing the procedure with families as it would be greatly resented. Female genital mutilation differs from other forms of child abuse in that it is done with the best intentions for the future welfare of the child, there is no possibility of its repetition during childhood, and it is approved by sections of the communities in which it is practised. As Korbin has put it, “The first level encompasses practices that are viewed as acceptable within the culture in which they occur, but as abusive or neglectful by outsiders.”9 Female genital mutilation in Britain presents a cross cultural problem.
Female genital mutilation may present in a variety of ways. Firstly, it may be known that a woman who has had the operation herself also approves of it for her daughters, who are therefore at risk. Secondly, a doctor, nurse, teacher, social worker, or other professional (or a neighbour or friend) may discover that a girl has had the operation; though there is little point in prosecuting the parents for something which has already occurred, younger girls in the family would be at risk. Thirdly, one of the categories of people mentioned above may suspect that a family is preparing to have their child sent away to have the operation.
It is not easy to make the right decision when it is suspected or known that a child is at risk; action should depend on the degree of urgency. As with other forms of child abuse, a child likely to suffer “significant harm” is subject to a joint police and social services investigation and case conference and her name should be put on the child protection register; this alerts social workers and others, allocates a key worker, and requires a review case conference. Anyone, not necessarily a health professional or social worker, can report their suspicions to the social services department.
Under the Children Act 1989 various procedures are available.10 As a preliminary measure a child assessment order can be made if the parents do not agree to an informal assessment; the assessment order is made by the court, with specific conditions attached. An assessment order provides no protection for the child and lasts for seven days from the date specified in the order. If further action is thought necessary by the court a “prohibited steps order” can be taken out; this prohibits the parents or any other person from carrying out a specified action without the consent of the court; this order ceases when the girl reaches the age of 16 years. Alternatively, a supervision order may be made; this lasts initially for one year, with a maximum of three years. In a more urgent situation an emergency protection order (replacing the place of safety order) may be taken out; this authorises removal, if necessary, of the child from the place where she normally lives. It lasts for eight days with a possible extension for a further seven days. Finally, a care order can be made; this would be used only in extreme cases. The Children Act now restricts the use of wardship where the act provides appropriate remedies.
In such sensitive cases any action aimed at interfering with the customs and traditions of a particular ethnic group may be regarded as racist. Equally, a failure by a social services department to pursue a proper course of action for fear of an accusation of racism or because of antagonism in the community is in a perverse way a form of racism in that it is a retreat based on racial considerations to the detriment of the welfare of the child.
Social services departments should take the lead in developing awareness of female genital mutilation and how to approach it. The departments should have a policy for the education, by meetings and circulation of advisory literature, of its own staff, health professionals, and teachers.11 In areas with a sizeable number of families belonging to an ethic group which practises female genital mutilation a joint consultative body should be set up, to include community leaders in addition to the relevant professionals. Hedley and Dorkenoo have suggested that specially trained advisers should be available to give support and advice to social workers and others in contact with families in whom female genital mutilation is an important issue.4 These advisers would normally be health visitors, midwives, or social workers. Whenever possible there should be close liaison with local community groups, which should be supported in campaigns against female genital mutilation; such groups may be able to supply someone of the appropriate ethnic group (or in the case of the Somalis, tribe) to talk to parents. The cooperation of local press and radio stations should be sought, and help should be requested from local newspapers and news sheets in the relevant languages.
As with other conditions largely confined to certain ethnic groups (for example, sickle cell disease and thalassaemia), services are likely to be well developed in areas with a large population of groups who practise female genital mutilation, whereas in areas with a small population of these groups services may be inadequate or non-existent. Such areas should seek advice and skill from better organised areas.
Female genital mutilation tends to be considered mainly from the woman's point of view and has become identified as a feminist issue. This seems a mistaken policy as female genital mutilation would die out if men ceased to insist on it. It is therefore important that men should be included and involved in educational programmes.
Assuming that the size of the population in Britain of ethnic groups practising or favouring female genital mutilation remains more or less unchanged, it seems probable that, as adaptation and acculturation occur, the practice will die out within a few generations. This is not, however, an argument for complacency or inaction.
Meanwhile, there is much to be done. From our own inquiries there seems to be a conspiracy of silence in medical circles; there is also widespread ignorance. None of a number of well known obstetric and paediatric textbooks mentions female genital mutilation. The National Society for the Prevention of Cruelty to Children has no information or instructional material.
It is time that this problem was more widely and openly discussed.
FORWARD is based at Africa Centre, 38 King Street, London WC2E 8JT.