Female Genital Mutilation- On your radar?
Female Genital Mutilation (FGM) is a hot topic in the world of paediatrics at the moment. Having recently completed the Royal College learning modules on it myself, I was shocked by the extent of this practice worldwide but also how it had escaped my notice for so many years…
There are staggering 200 million people living worldwide with FGM and although the majority live in Africa recent data means that we now know roughly 1.5% of all women giving birth in the UK have undergone FGM. From a paediatric viewpoint, there are currently estimated to be at least 70000 girls aged 0-14 years who have had or are at risk of FGM. This makes this our problem.
So what is it? And what does it mean for our patients? FGM, sometimes referred to as ‘cutting’ or ‘female circumcision’ is the ritual removal of all or some of the external female genitalia. It is classified from type 1-4. Counter-intuitively type 4 is actually the least severe with type 3 being the most. Wounds caused by type 4 FGM may heal and be difficult to detect later in life.
See information below and link to WHO classification system and diagrams.
Type 1 = Partial or total removal of the clitoris, and in very rare cases only the prepuce (the fold of skin surrounding the clitoris)
Type 2 = Partial of total removal of the clitoris and labia minora, with or without excision of the labia majora
Type 3 = Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner or outer labia with or without removal of the clitoris
Type 4 = All other harmful procedures to the female genitalia for non-medical purposes- e.g. pricking, piercing, incising, scraping and cauterizing the genital area
Unlike with some forms of male circumcision, the rationale behind female mutilation is non-medical often stemming from social or cultural convention with motivations such as reducing the female libido or preparing women for marriage. It has also been associated with the idea of ‘feminine modesty’ implying that girls are only clean or beautiful after removal of such body parts.
There is no known religious text that refers to the practice of FGM and no known health benefit. The United Nations recognises this and states clearly that FGM is contrary to any conception of human rights and is a form of child abuse. In addition to violating a child’s rights it can also lead to both short and long term physical and psychological health problems. In the immediate period following FGM, complications such as haemorrhage, infection, urinary retention and even death can occur. In addition to this, significant bony fractures have been recognised in victims secondary to being held down for the procedure. In the long term victims may have difficulties with voiding, recurrent pelvic and urinary infections, sexual intercourse, and fertility and menstruation. There is also a recognised association between the most severe forms of FGM and obstetric emergencies with increased morbidity and mortality for both mother and baby. That’s all in addition to the adverse psychological effects of FGM such as post traumatic stress disorder, anxiety, fear and problems with body image.
So what can we do? Well FGM itself has been illegal in the UK since 1985 following the introduction of the Prohibition of Female Circumcision Act. However prior to the introduction of the Female Genital Mutilation Act 2003, it was not illegal to take girls or women abroad to undergo FGM. The 2003 act closed this loop hole but also introduced a statutory reporting duty for health, social and education professionals to report known cases of FGM (in under 18’s) that they identify to the police. This duty has only come into force fully since October 2015 so is still hot off the press. As professionals, we are also obliged to report those children who we feel may be at significant risk of FGM to social services so that further risk assessment can be carried out.
So how and where are we likely to identify these children? After a child is born, one of the first contacts with the paediatric team is for their neonatal check. Midwives are trained to ask about and may recognise FGM in mothers and therefore can be a vital source of information at this point in time. Risk factors for FGM include a mother or other members of the family who have undergone FGM, or that the child comes from a community where FGM is practiced. It is also recognised that in such groups, having a dominant paternal or maternal grandmother can increase the risk.
Although FGM is recognised to be practiced throughout Africa, the countries with the highest rates include Somalia, Egypt, Guinea, and Djibouti all with FGM rates of over 90%! The age at which FGM occurs varies between countries. In Malaysia, the majority of those undergoing FGM are infants whereas in Egypt the majority are in their teens (see below)
Later on these girls may present to paediatric settings with frequent urinary, menstrual or stomach problems and may be reluctant to be examined. They may present through the Child and Adolescent Mental Health service with depression, anxiety or behavioural disorders. Children may also be identified as being at risk by those in the education setting; For example, young girls may be taken abroad on a ‘family holiday’ for a prolonged period or withdrawn from sexual health education.
Its worth having a look at the FORWARD website, an organisation tackling FGM in the UK and Worldwide. They’ve recently written a letter to Theresa May asking the government to introduce compulsory sex and relationships education in school and improve teacher training to empower schools to fight FGM.
The overwhelming message is that if you are concerned; refer. The simple act of informing a family that FGM is illegal in this country and carries a prison sentence of up to 14 years may stop this child from becoming a victim in the first place.