Female genital mutilation and a GLOBAL assessment

Like all general practice nurses, those involved in travel health have a crucial role in safeguarding against FGM, but the travel health nurse has a unique opportunity to identify girls who are also at imminent risk of being taken overseas to have FGM performed

As healthcare professionals, we live and work in a multicultural society and over the past 20 years the need for travel health services has grown significantly.¹ This is a fast developing area of medicine, partly due to the care of migrant communities, but it is also where nurses provide travel advice to individuals, families and groups, travelling for a variety of reasons such as business, leisure, pilgrimage and those visiting family and relatives (VFRs).

Female Genital Mutilation (FGM)-practising communities are now viewed as a global concern.² Growing migration has increased the numbers of women and girls living outside their country of origin and who have under gone FGM.³ Women and girls from FGM-practising communities whose families have settled in the UK, may also be affected or could potentially be at risk.

Travel health nurses, together with other frontline staff, are crucial in identifying and protecting against FGM.⁴ The travel health nurse has the opportunity to identify girls who are also at imminent risk of being taken overseas to have FGM performed.

The United Nations High Commissioner for Refugees (UNHCR) estimates at least 200 million girls and women, in 30 countries throughout the world have been subjected to this practice.² Exact numbers who have undergone FGM or Cutting (FGM/C) worldwide are difficult to quantify, due to the sensitivity of the subject.

The first statistics on FGM prevalence since reporting became mandatory in 2015 show that in the past year, 5,700 cases of female genital mutilation (FGM) were recorded in England. It is thought that the increasing numbers of cases seen in the UK are the result of increased immigration of some ethnic groups.⁵

CHALLENGES

Travel health nurses are part of a multidisciplinary team that includes nurses, doctors and pharmacists, who deliver health advice and treatments in different settings, across the NHS, and in independent or private clinics.

This can pose a number of challenges: for example, they may not see a complete family for consultation as some services may only provide travel health for adults and not for young children.

They may not have access to a traveller’s medical records with details of medical and obstetric history, and other relevant information that would inform the pre travel risk assessment.

Since October 2015, it has been mandatory for healthcare professionals to record if a woman is a survivor of FGM or if there are concerns relating to FGM. It is therefore imperative that we start to include the subject of FGM in the travel health consultation.⁴

THINKING GLOBAL

One way to do this is to think of the acronym GLOBAL:

• Geography
• Language
• Origin
• Beliefs
• Assessment, and
• Legal requirements.

This enables you to ask appropriate questions and record relevant information (Table 1). It builds up a complete assessment for woman and girls who are planning on travelling overseas. In addition, it acts as a reminder that the topic of FGM should be introduced into the consultation, providing a way of raising awareness, and of exploring the issues around safeguarding.

The following questions should be part of a normal travel health risk assessment. Best practice in travel health consultations would include a pre-travel consultation questionnaire, gathering and recording all relevant information about the traveller and the nature of their trip. More information on how to conduct a full pre-travel health risk assessment and risk management can be found in the RCN Travel Health Nursing Competences document.¹

Geography

The implications of geography are essential in identifying the health risks at that destination and the advice that will be needed. Thinking about FGM, you want to know exactly where the traveller is planning to visit, which country and all the destinations including rural or urban locations.

Are there plans to visit family or relations? When will they travel? Which time of year? Is it in the school holidays?

Jane Ellison, Minister for Public Health, suggests that anyone removing girls from the UK with the intentions of having them cut is likely to do so at the start of the school summer holiday. This gives the families the opportunity to travel abroad, and also allows time for recovery before school recommences after the summer break. This is commonly known as the ‘cutting season’.⁶

Language

Does this traveller speak and understand English or does this consultation require the assistance of an interpreter? When booking an interpreter you should book an accredited, female interpreter. Some family members may offer their services to help with the communication. This can be difficult as you cannot be confident that all the questions asked and advice given has been interpreted correctly for the traveller. Engaging a child as an interpreter is not recommended,4 particularly in this situation, as disclosures can be a traumatic and a distressing experience.

When asking the FGM question directly, consider the use of appropriate words: in many areas of the world different terms are used to describe the procedure, such as cutting, closing or circumcision. Using the term ‘mutilation’ may cause offence. Some women and girls who have undergone FGM prefer to be described as ‘survivors’.⁷ (See Resource page or go to https://www.gov.uk/government/publications/safeguarding-women-and-girls-at-risk-of-fgm)

Effective communication is pivotal in everything we do as nurses. Asking the correct questions can be an art form. In accordance with the NMC Code, we must communicate clearly using a range of verbal and non verbal communication methods, and consider cultural sensitivities.⁸ Nurses can develop their own non-judgemental style of framing important sensitive questions. Open questions are essential to allow the individual the opportunity to expand on a topic area giving you more information than you appear to be initially asking about.

For this to be effective you must listen carefully to all the responses and maintain eye contact. Communication with travellers from different ethnic groups can be fraught with dangers, and it is important that nurses get beyond the initial difficulties of language barriers and engage with their travellers.⁹ However, it can be difficult to have a conversation about FGM if a women is being accompanied by a male relative, or if an older child is present and listening. As nurses we must try to isolate the woman and allow her privacy and space to talk freely. However, when dealing with children, we should never feel inhibited from acting in the child’s interest. The basic requirement that children are kept safe transcends cultural boundaries.¹⁰

Origin

Being born into a community that practises FGM/C is one of the biggest risk factors for young girls in the UK.¹¹ The ‘dispersal’ programme in the UK has located asylum seekers in areas where healthcare professionals may not have previously cared for these communities, and therefore increasing numbers of health professionals are likely to encounter women and children affected by FGM. Ascertaining country of origin is essential as this may differ from the country from which they are recorded as seeking asylum.

Belief system

Throughout the consultation it is important to be ‘culturally competent’ and sensitive to the needs of the traveller.¹² You have the one opportunity to ask the important questions about FGM and initially you need to establish whether the traveller understands the meaning of FGM. If so, what are her beliefs and opinions? Women may not know that they have been subjected to FGM, or they may be reluctant to speak about their past traumatic experiences, and care should be taken not to re-traumatise these women.

Assessment

All travel health information from the consultation – outcomes, vaccines, anti-malarial chemoprophylaxis and advice – is then recorded in the appropriate documentation. If a child were part of this consultation you would record the outcomes in the Parent Health Record (Red Book). This is shared with other professionals – paediatricians, GPs, health visitors – and you may find that others have already recorded information about FGM in female records.¹³

If, during the consultation, you become aware that there is an issue regarding FGM, then you have a duty to assess that risk and follow the prescribed procedures. The RCN document, FGM Pathways for Pre Travel Health Risk Assessment, due to be published shortly, will identify the actions that need to be taken. Awareness of processes and procedures at a local level is also needed.

Legal

Healthcare professionals in England and Wales have a personal and mandatory duty to identify and report cases of FGM in children and young people under the age of 18 years, or in vulnerable adults, to the police. Failure to do so can lead to NMC Fitness to Practise proceedings.

In Scotland and Northern Ireland there is a multiagency approach towards identifying women and girls at risk of FGM.⁴ Although there is variation in recording mechanisms in the UK countries, best practice would be that all travel health practitioners’ records include the FGM question in their pre travel risk assessment.

To safeguard children and young people it may be necessary to give information to people working in other parts of the health service, or outside of it. This may feel like a breech of confidentiality, but the law allows for disclosure where it is in the public interest, or where a criminal act has been perpetrated, or when a child is at risk.⁴

CONCLUSION

This article can only give a summary of some important issues involved when asking the traveller questions about FGM during a pre travel health consultation. All healthcare professionals have a duty of care to safeguard and protect woman and young girls. In order to do this effectively you must take the opportunity to gain knowledge, raise awareness and educate others.

FGM - USEFUL RESOURCES FOR THE TRAVEL HEALTH PROFESSIONAL

KEY LEARNING RESOURCES to improve your knowledge

eLEARNING PROGRAMMES

• Education for Health
  http://www.e-lfh.org.uk/programmes/female-genital-mutilation/'

• The Home Office
  http://www.safeguardingchildrenea.co.uk/resources/female-genital-mutilation-recognising-preventing-fgm-free-online-training/

VIDEOS

• Mandatory reporting of FGM

• Women talking about their personal experiences of FGM

• FGM and mental health https://www.gov.uk/government/publications/fgm-video-resources-for-healthcare-professionals

KEY PUBLICATIONS
(See References and http://www.janechiodini.co.uk/news/help/fgm> for additional links and reading)

• Flowchart - RCN FGM Pathways for Pre Travel Risk Assessment (for publication later in 2016)

• RCN Guidance for Travel Health Services on Female Genital Mutilation (for publication later in 2016) https://www.rcn.org.uk/clinicaltopics/female-genital-mutilation/professional-resources

• NaTHNaC http://travelhealthpro.org.uk/factsheet/3/female-genital-mutilation-fgm

• Fitfortravel http://www.fitfortravel.nhs.uk/advice/general-travel-health-advice/female-genital-mutilation.aspx

TERMS USED FOR FGM IN OTHER LANGUAGES

GEOGRAPHICAL LOCATIONS

Communities that perform FGM are found in many parts of Africa, the Middle East and Asia. Girls who were born in the UK or are resident here but whose families originate from an FGM practising community are at greater risk of FGM happening to them.

Communities at particular risk of FGM in the UK originate from:
Egypt, Eritrea, Ethiopia, Gambia, Guinea Indonesia, Ivory Coast, Kenya, Liberia, Malaysia, Mali, Nigeria, Sierra Leone, Somalia, Sudan, Yemen

FGM has also been documented in communities in:
Colombia, Iran, Israel, Oman, The United Arab Emirates, The Occupied Palestinian Territories, India, Indonesia, Malaysia, Pakistan and Saudi Arabia.

FGM has also been identified in parts of Europe, North America and Australia.

https://www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genitalmutilation

REFERENCES

1. Chiodini J, Boyne L, Stillwell A, Grieve S. Travel health nursing: career and competence development, RCN guidance. RCN: London, 2012.

2. Female Genital Mutilation/Cutting: A Global Concern http://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf

3. WHO prevalence of FGM http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/

4. Royal College of Nursing. Female Genital Mutilation. An RCN resource for nursing and midwifery practice. 3rd edition.RCN.London. https://www.rcn.org.uk/professional-development/publications/pub-005447

5. HSCIC NHS DIGITAL http://digital.nhs.uk/article/7180/First-ever-annual-statistical-publication-for-FGM-shows-5700-newly-recorded-cases-during-2015-16

6. Department of Health. Letter from Jane Ellison 10/7/2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/443992/PSPH_FGM_letter

7. Braddy CM, Files JA. Female genital mutilation: cultural awareness and clinical considerations. Journal of Midwifery Womens Health 2007;52 (2):158-63

8. Nursing and Midwifery Council. The code: professional standards of practice and behaviour for nurses and midwives, 2015. https://www.nmc.org.uk/standards/code/

9. Transcultural Health Care Practice: An educational resource for nurses and health care practitioners Editors: Charles Husband and Bren Torry 2004

10. House of Commons Health Committee. The Victoria Climbié inquiry report: sixth report of session 2002-3, report and formal minutes together with oral evidence, 2003. http://www.publications.parliament.uk/pa/cm200203/cmselect/cmhealth/570/570.pdf#page=1&zoom=auto,0,-214

11. Macfarlane A, Dorkenoo E. Female Genital Mutilation in England & Wales. Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk 2014. Interim report on provisional estimates, 2014. http://www.equalitynow.org/publications

12. Chiodini JH, Anderson E, Driver C, et al. Recommendations for the practice of travel medicine, Travel Medicine and Infectious Disease 2012;10:108-128 www.travelmedicinejournal.com

13. Geoff, D. 2016. Female Genital Mutilation, Making the case for good practice. Arch Dis Child 2016;101:207-209 http://adc.bmj.com/content/101/3/207