Tackling female genital mutilation in the UKBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7150 (Published 04 December 2013) Cite this as: BMJ 2013;347:f7150
- Sarah M Creighton, consultant gynaecologist and honorary clinical professor,
- Lih-Mei Liao, consultant clinical psychologist and honorary reader
As a result of the diaspora of communities that practise female genital mutilation, many more women are now living with genital mutilation in the United Kingdom, and many more girls are at risk. The campaign to end the practice in the UK has been spearheaded by committed and experienced activists (www.forwarduk.org.uk, www.equalitynow.org with wide institutional endorsement),1 as reflected in recent intercollegiate recommendations for dealing with the problem.2
The document results from collaboration between the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Nursing, Equality Now, and the Unite union. It merges key points from several existing guidelines3 4 5 6 into a single paper that reiterates the core message: female genital mutilation is a form of child abuse. It points to the importance of data collection and sharing between relevant agencies for effective action. It stipulates appropriate professional care for girls and young women affected by the practice. For the recommendations to be implemented (we hope urgently), a strategic implementation plan with a tight time frame is needed. Disappointingly, this gap remains unfilled.
It has been suggested that female genital mutilation should be part of the mandatory training in child protection for NHS staff,7 implementation has been inconsistent. Being born into a community that practises genital mutilation is the most important risk factor for girls, so pregnancy presents an opportunity for prevention. However, this remains unexplored. Most pregnant women receive antenatal care in the UK, but maternity staff need knowledge and skills to identify genital mutilation. Thus far there has been little impetus for methodical research on attitudes, knowledge, skills, and confidence among maternity staff in relation to this practice. Even if there is a stronger drive to improve training, there is no evidence base on which effective training methods can be formulated.
Currently, whether a pregnant woman is asked about genital mutilation—and what to do if it is identified—depend entirely on the awareness and confidence of the booking midwife. It is therefore not surprising that this practice is under-detected in pregnant women and that follow-up action is haphazard.8 This failure can be remedied by including routine questions about the practice in a minimum maternity dataset for every pregnant woman, regardless of ethnicity or country of origin. However, currently no designated codes, diagnostic or procedural, can record or identify female genital mutilation from NHS activity data. An international classification of diseases code for a history of female genital mutilation and an Office of Population Censuses and Surveys code for deinfibulation should be introduced without delay.
Care providers need to know what to do when female genital mutilation is identified and the intercollegiate document is inconsistent with regard to this. It states that “all girls and women presenting with female genital mutilation within the NHS should be referred to the police and support services.” Yet it also recommends considering referral of pregnant women who have undergone the practice to the police “with the woman’s consent.” Individual practitioners continue to be responsible for deciding whether to refer, with no criteria to help them weigh up each situation. Half of women would have undergone genital mutilation under 5 years of age and might not remember the details.9 It is neither helpful nor fair to expect maternity staff to guess which families are likely to practise female genital mutilation. Routine referral of all identified women to designated social services personnel could provide an opportunity for preventive education. The service pathway should also include psychological care for women who report serious or enduring distress in relation to the practice.10 This would require investment.
There is no guidance for the police and social services on follow-up action. For example, for how long should an unaffected girl who remains at risk be followed up, how often, and by whom? Or, if information is to be collected on all women with genital mutilation where no crime has been committed, who should have stewardship of the information? These major decisions should not be left to the discretion of individual practitioners or services.
Criminal prosecution is considered central to prevention, and the UK has been compared unfavourably to France, where identification of female genital mutilation in children has resulted in more than 100 prosecutions since 1979. Without a single prosecution in the UK, the people who procure or perform female genital mutilation remain unpunished and girls remain at risk. Successful prosecution of offenders requires successful inter-agency collaboration. Once again, who is responsible for coordinating the information sharing envisaged in the new document?
The intercollegiate recommendations reinforce the core message of previous ones. It could be argued that the message is so important that professionals cannot hear it often enough. However, without a detailed action plan, an explicit time frame, and mechanisms for monitoring effectiveness, the new document once again spells out the “what” without offering “how.” Misguided cultural sensitivity among professionals is rightly deemed unacceptable, but this is unlikely to be the only factor that prevents the practice being eradicated in the UK. Professionals need to be more aware of the problem and acquire the skills and confidence to translate principles into action. Designated pathways of action need to be embedded in the service structure and integrated with social services and the police. The new document lists desirable outcomes but leaves to chance the necessary processes for consistent quality delivery.
Cite this as: BMJ 2013;347:f7150
Competing interests: We have read and understand the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.