Seven days in medicine: 20-26 July 2016
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4148 (Published 28 July 2016) Cite this as: BMJ 2016;354:i4148All rapid responses
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There are surely few if any exceptions to the legal position that children - in the UK, those under the age of 18 - may not give consent at any point to clinically inessential or non-urgent physically or psychologically intrusive procedures; and there are even more surely no exceptions for people of any age to the position that consent may not be claimed as a basis for delivering procedures (in common parlance perhaps 'assault'?) which the law forbids. Presumably in these instances there is not even the required professional licence or insurance to proceed.
It is therefore difficult to see why doctors, whether referrers or those who offer such procedures, apparently continue to consider female genital cosmetic surgery on minors. In the words of the British Society for Paediatric and Adolescent Gynaecology Position Statement (2013),
"In the absence of any identifiable disease and until the evidence demonstrates to the contrary, labiaplasty should not be performed on girls under the age of 18 years."
... and many of us would argue that current FGM legislation in the UK says it should not, in the absence of severe physical or psychological pathology, be performed on women over the age of 18 either.
The debate on female genital cosmetic surgery on minors is at risk of being conducted in a vacuum. There are indeed adolescent girls with serious concerns about the appearance or 'normality' of their external genitals, but referral routes for almost all of them need to be non-escalatory: where are the child psychologists and school nurses who can address these issues in a less dramatic setting? Why is it not routinely expected that the genitals of all young children will be examined, and their normality (as it usually is) recorded overtly in the Red Book, to provide reassurance without unnecessary and perhaps more traumatic inspections later on?
Proper provision of these routine services would help to assuage the anxieties of some girls concerned about whether they are normal, and would also if necessary give them confidence to dismiss the voices of others who tell them differently. And the same services - school nurses, child and adolescent mental health services etc - would do much to support efforts to eradicate FGM and also to support children who experience other forms of abuse.
It could also be argued that the focus on possible surgical procedures to accommodate concerns about female juvenile genital normality offers an excuse to put aside issues around the elective male circumcision of minors. I invite anyone to explain why that, when not overtly clinically indicated, is also not assault.
There are numerous reasons why clarity on the legitimacy of procedures like female adolescent genital cosmetic surgery is urgently required. Prof Bewley is absolutely right to press this issue. The actual legitimacy of juvenile cosmetic surgery, the risks of intervention to young women's health, and wider questions such as whether cosmetic genital surgery is actually FGM, must be resolved.
Is the silence in part because those who have provided or are currently providing this 'service' are keen not to see the issues addressed? And also, from another perspective, because if such matters are fully acknowledged, the massive gaps and omissions in the provision of care, and especially of pastoral and psychological care, for young people would be even more starkly revealed?
Hilary Burrage
www.hilaryburrage.com
Competing interests: No competing interests
Prof Bewley (19 August) mentions a letter she wrote to a Journal - it was accepted but never published.
Important for two reasons:
1. The content which ought to be read by doctors, lawyers and of course Her Majesty's Govt in all its manifestations.
2. To discover why a Journal accepts an MS and then puts it, metaphorically, on the shelf.
Competing interests: No competing interests
The UK Female Genital Mutilation (FGM) Act 2003 states that “A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl’s labia majora, labia minora or clitoris”. However, “no offence is committed by an approved person who performs a surgical operation on a girl which is necessary for her physical or mental health” although “… it is immaterial whether she or any other person believes that the operation is required as a matter of custom or ritual.”
Thus, doctors do not decide the legitimacy of such surgery, which is a matter for the Courts. It is moot whether cosmetic genital surgery on minors in the UK might also come under the remit of the Act. Following publication of a case series detailing several labial reductions in girls under 16 in the UK (1), I wrote a letter about the failure to address the legality to the Journal of Adolescent and Pediatric Gynecology in 2013. The article was drawn to the attention of the police who investigated but did not pursue a criminal case as they found no evidence that the procedures referred to had contravened the Act. Gynaecologists operating on children's labia need clarity about the law, especially since the failed 2015 prosecution of a UK obstetrician. The febrile atmosphere in which misinformed debates about FGM take place do not aid understanding. The letter was accepted in 2014, but has still not been published despite repeated representations.
Reference
Jothilakshmi PK, Salvi NR, Hayden BE, Bose-Haider B. Labial reduction in adolescent population-a case series study. J Pediatr Adolesc Gynecol. 2009 Feb;22(1):53-5
Competing interests: I was paid for expert advice in the defence of R v Dharmasena 2015
These are truly shocking statistics irrespective of any denominators. However, without identifying those female children and young women at risk, but who have not been subjected to FGM, we not only have great difficulty in understanding why any caring parent would seek this outcome for their daughter; we also fail to understand what persuades very many similar parents, with seemingly identical cultural and religious backgrounds, that observance of this traditional ritual is no longer necessary for the future wellbeing of their child.
Being shocked is understandable, but not enough. We need to know how best to promote necessary change, whilst allowing parents to care for their children in a way that maintains respect in the eyes of their families, friends & communities.
Competing interests: No competing interests
Nearly 6000 cases of FGM were identified last year
Some 5700 new cases of female genital mutilation (FGM) were recorded in 2015-16 in the UK, 18 of which were performed there, the first annual statistics from the Health and Social Care Information Centre showed. FGM was most common in girls aged 5 to 9 (43%), and more than one third (37%) of the girls were born in Somalia"
My response (which incorporates part of your Guardian article and some of Susan's comments)
Your report on the Health and Social Care Information Centre’s statistics (Nearly 6000 cases of FGM identified last year, 22th July) is misleading as it implies that 5,700 new cases of female genital mutilation occurred in England during the year April 2015 to March 2016. On the contrary, the Health and Social Care Information Centre’s website and reports make it clear that “Newly recorded women and girls with FGM are those who have had their FGM information collected in the FGM Enhanced Dataset for the first time” and that “Newly recorded” does not necessarily mean that this is the woman or girl’s first attendance for FGM.
Most of these women will have been subjected to FGM an unknown number of years ago in their country of birth before they moved to England, and they form a very small subset of the estimated 134,600 women with FGM born in countries where FGM is practised and living in England. This calls into question the usefulness of the statistics for planning services, especially as the reports repeatedly emphasise that “Caution is advised when interpreting these findings because data completeness is often low and varies by submitter.” For example, the country of birth was reported for only 2,193 of the 5,702 women covered by the report data on other topics are similarly incomplete. More over less than 50% of acute NHS trusts and under 0.5% of GP practices contributed to this data collection. One reason for the incompleteness is that clinicians are uncomfortable with ministers’ requirement that confidential information from women with FGM should be reported to the system without asking their consent. We and others have previously raised ethical and practical concerns in the letters/rapid responses pages of this Journal.
It is hugely disappointing that a journal such as the BMJ with an excellent track record in challenging shoddy research and preposterous claims from pharma falls victim to peddling yet again sensationalist headlines without actually looking at the data and the serious flaws within these data. It is outrageous that these shaky statistics are repeatedly misrepresented in the media. It does women who do need healthcare for longstanding problems in the past a disservice to present poor government data collection in this way. There is also a risk that irresponsible reporting of the current data collection will fuel racist perceptions towards new communities whose next generations are rapidly rejecting FGM. Better science, less propaganda, please.
Competing interests: No competing interests
Re: Seven days in medicine: 20-26 July 2016
It is good that female genital cosmetic surgery is being publicly discussed but I do not accept ".. and many of us would argue that current FGM legislation in the UK says it should not, in the absence of severe physical or psychological pathology, be performed on women over the age of 18 either.”
But I believe it is good that female genital cosmetic surgery is being publicly discussed. Why should vaginal surgery be a no-go area in the absence of any identifiable pathology? Why have we just accepted that the 2003 FGM law is right in viewing it as mutilation and that adult women can be treated as children with an inability to consent to surgery?
I hope this law will be tested in court soon if the Crown Prosecution Service tries for a second time to secure that much desired FGM conviction. It’s been reported* that it is considering prosecuting doctors for carrying out requested genital procedures on consenting adults. What business is it of anybody else if a woman wants cosmetic surgery like labial trimming, for example?
The reality of course is that very little vaginal or vulval surgery is cosmetic. Most of it is done to e.g. repair injury after deliveries or for prolapses for other reasons. Most women then have problems related to function that leads them to want surgery.
*http://www.standard.co.uk/news/crime/doctors-face-prosecution-over-genit...
Competing interests: No competing interests