Female genital mutilation: Managing the complications, your safeguarding duties and the Law

You are in the middle of a busy morning in the practice, and your next patient is a new patient at the surgery, due to attend for cervical screening. As you begin to examine her, you realise – or at least you think – that she has underdone female genital mutilation. What should you do?

Managing a patient presenting with female genital mutilation (FGM) or at risk of FGM may seem daunting but general practice nurses need to feel confident in the management of patients who may have had FGM or be at risk of this abusive and harmful practice in order to support survivors in coping with the complications of FGM, safeguard those at risk of FGM and because the practice is illegal in the UK.

The World Health Organization defines FGM as ‘all procedures involving the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons’.¹

The practice entails the removal and/or damaging of normal female genital tissue and can interfere with the normal function of the female body.

There are four types of FGM, all of which are illegal in the UK.

Type 1. Clitoridectomy Partial or total excision of the clitoris, and in a few cases of the prepuce only.

Type 2. Excision Partial or complete excision of the clitoris and labia minora, with or without the removal of the labia majora.

Type 3. Infibulation Narrowing of the vaginal opening by forming a covering seal by cutting and repositioning the inner or outer labia. It may also involve removal of the clitoris. This is the most extreme physical type and tends to lead to the most physical complications for the woman or girl and at childbirth.

Type 4. Other This type of FGM entails all other harmful practices to the female external genitalia for non-medical reasons, including pricking, piercing, incising, scraping and cauterising. Type 4 includes labial stretching, as well as genital tattoing and piercing.

FGM is not associated with any health advantages and may lead to physical and psychological complications, and in the worst cases death of a woman or girl who has had FGM and/or death of her child due to complications in pregnancy and/or labour. FGM may be performed at any age, though the peak prevalence is five to eight years of age. However, it is important to be aware that FGM may be undertaken on much younger girls, including newborns. In addition, women may undergo the procedure repeatedly after each time they give birth in order to restore the narrow vaginal opening created by type 3 FGM and widened in childbirth. This is called reinfibulation. Clinicians should be aware that many patients may not know that they have had FGM.

The practice of FGM is deeply rooted in certain cultures and communities and undertaken for a range of different motives with one of the chief themes being that FGM is viewed as a rite of passage performed in order to ensure that girls and young women remain pure and chaste in preparation for marriage. The practice is seen as necessary for social acceptance and respectability for the girl and her family, and those who reject it may risk being ostracised by their family and community. Other motives include the following: hygiene, aesthetics, to avoid harm to the baby at childbirth and religious and cultural reasons. It is, however, important to highlight that there is no basis for the practice of FGM in Muslim, Christian or Jewish religious texts.

FGM is a form of abuse of women and children, and has been illegal in the UK since the Female Circumcision Act of 1985. The 1985 Act was superseded by the Female Genital Mutilation Act of 2003, which extended the offence to FGM performed abroad, and which makes FGM punishable by up to 14 years in prison. The Serious Crime Act 2015 introduced new provisions to tackle FGM, including the Mandatory Reporting Duty. (Box 1)

Failure to comply may result in Fitness to Practise proceedings. Remember you are required to report genital piercing and tattooing in under-18-year-olds, in the same way as you would report any other type of FGM. Mandatory reporting is separate to your safeguarding duties, which may require involving the police if your safeguarding risk assessment identifies the need for urgent or emergency safeguarding action.

FGM is prevalent in 28 African countries, parts of the Middle East and Asia. Between 100 and 140 million girls and women worldwide have undergone FGM. In Africa approximately 3 million girls each year experience FGM

Bearing in mind the increasingly multi-cultural nature of the UK, FGM is becoming more prevalent and it is estimated that approximately 137,000 women and girls in England and Wales are survivors of FGM.²

The Department of Health is gathering data regarding UK figures for FGM. Where FGM is identified in NHS patients, it is now mandatory to record this in the patient’s medical record. Since September 2014, all acute trusts must provide a monthly report to the Department of Health on the number of patients who have had FGM or who have a family history of FGM. This information is anonymous and no personal confidential data is shared as a result of the data collection. This data collection is referred to as mandatory reporting but is entirely separate from the mandatory reporting referred to in the Serious Crime Act 2015, requiring the reporting to the police of FGM in young women and girls under 18 years old.

COMPLICATIONS OF FGM

FGM tends to be undertaken by female elders or cutters in non-sterile conditions, without the administration of an anaesthetic. A woman or girl may need to be restrained forcibly by several women in order to carry out the procedure. In addition, the same implement (including stones, knives, razor blades or broken glass) may be used repeatedly on different women and girls. In some countries, such as Egypt, the practice has become more medicalised, with the use of sterile equipment and anaesthetic, yet long term physical and psychological complications may still arise.

Physical Complications

Early physical complications include death; damage to soft tissues, organs and bones as a result of physical restraint; haemorrhage; severe pain; urinary retention; and local and systemic infections, such as HIV, hepatitis B and C, tetanus.

Late physical complications may include difficulty passing urine, urinary retention; infections, including recurrent vaginal, pelvis, urinary and systemic infections; renal failure, particularly in type 3 FGM; dyspareunia and lack of pleasure during sexual intercourse; menstrual problems, including blockage of menstrual flow in type 3 FGM; infertility; infibulation cysts, neuromas and keloid scarring locally; complications in pregnancy and delayed second stage of labour, particularly in type 3 FGM, which may result in the death of the mother and baby; obstetric fistulas.

It may be appropriate to refer a woman who has undergone the most extreme physical type of FGM, type 3, for reversal surgery (deinfibulation), in order to widen the narrowed vaginal opening. Deinfibulation should be undertaken before pregnancy, or at least within the second trimester of pregnancy, rather than waiting until labour commences when the risks to both mother and baby may be increased.

The procedure is undertaken by FGM specialist nurses and midwives at a number of FGM clinics across the country, the contact details of which can be found in the resource links below.

Psychological Complications

FGM is perceived by families and communities as an ‘act of love’, undertaken for the amelioration of a girl’s life and to promote her inclusion into society as a chaste woman, in accordance with cultural mores. In the immediate aftermath of FGM, a woman or girl may be deeply shocked that the practice had been arranged by loving parents and a caring community.

Women who have undergone FGM have comparable rates of PTSD as adults who have experienced abuse in early childhood, and 80% suffer from affective or anxiety disorders.⁴ Psychological complications may comprise any or all of the following:

• Psychosexual problems, including sexual dysfunction and low libido
• Depression, including possible self-harm and substance misuse
• Anxiety
• Post Traumatic Stress Disorder

RISK FACTORS FOR FGM

When considering a woman or girls risk of undergoing FGM, consider the following:³

• Does she come from a practising community?
• Has any female member of her family had FGM, particularly her mother and sisters?
• How integrated is she and her family into UK society?
• Has she been removed from Personal, Social and Health Education to restrict her awareness of FGM?

Indicators of immediate risk of FGM

• A planned visit ‘home’ to see the family
• Mention of a special ceremony to mark entry to womanhood
• An older female relative visiting the UK
• Truancy
• Plea for help to a trusted adult outside the community.

SIGNS FGM HAS BEEN PERFORMED

A girl or woman may:

• Be in obvious discomfort
• Have difficulty walking, sitting or standing
• Spend long periods in the toilet due to problems passing urine
• Spend long periods off work or studies due to bladder or menstrual dysfunction
• Have frequent urinary, menstrual or abdominal symptoms, including pain
• Have prolonged or repeated absences from studies or work
• Be particularly reluctant to undergo normal medical examinations, including cervical screening and antenatal care

The woman/girl may also confide in a trusted professional, ask for help, but not reveal details due to fear or embarrassment, and/or experience pain in the genital area.

APPROACH TO MANAGEMENT

When managing patients who may have had or may be at risk of FGM you should consider the possible physical and psychological complications of FGM and how to manage them, including – where indicated – referral to secondary care and deinfibulation clinics and signposting patients to appropriate sources of support, as well as safeguarding duties, including any risk to other females in the family and wider community.

The management of FGM requires the same high degree of sensitivity and empathy as that employed in the management of any other safeguarding matter. Bear in mind that a patient may have a preference for a female clinician and one not from their own community.

One should consider language barriers and the appropriate terminology to use, as many girls and women may not understand what FGM means. It is important for clinicians to consider the fact that the term ‘mutilation’ carries with it negative connotations that women and girls may find impact on their self-esteem. Most would prefer to be described as ‘survivors’ rather than as ‘mutilated’. Many women and girls may not know what the term ‘Female Genital Mutilation’ means, but may understand the terms female cutting, closing or circumcision.

The 4 Cs questionnaire (©Dr Sharon Raymond 2015) may assist when assessing whether FGM has been performed and to assess the risk of FGM:

1. Do you come from a community that practises cutting?

2. Have you, or a member of your family, been cut?

3. For women and girls ask: does anyone intend to cut you or anyone you know?

4. For patients who are pregnant or mothers of daughters ask: do you or anyone you know intend to have your daughter(s) cut?

A ‘yes’ to at least one of these questions increases the risk of FGM and local safeguarding procedures should be followed.

If you do not ask the question, it may be that no one will. For guidance on a more detailed risk assessment refer to the Department of Health’s (DH) risk assessment tool. (See Resources).

For those patients you see who may have had FGM or are at risk of the practice, it is important to explain what the practice may involve, the possible health complications and the fact that the practice is illegal in the UK. Ensure you offer appropriate support, which may be both medical and psychological, and signpost patients to organisations that offer support and guidance. (See Resources)

CONCLUSION

Managing a patient with, or at risk of FGM may seem daunting, but following the advice in this article should give you more confidence, both in supporting survivors and in fulfilling your statutory obligations for safeguarding and reporting this abusive and harmful practice.

When you suspect FGM or a risk of FGM, always ask the questions, ‘Do you come from a community that practises cutting? Have you, or a member of your family, been cut? Does anyone intend to cut you or anyone you know? Do you or anyone you know intend to have your daughter(s) cut?'

Remember, if you do not ask, it may be that no one else will.

REFERENCES

1. World Health Organization. Female Genital Mutilation, 2016 http://www.who.int/mediacentre/factsheets/fs241/en/

2. Trust for London. Prevalence of Female Genital Mutilation in England and Wales: National and local estimates, 2015. http://www.trustforlondon.org.uk/research/publication/prevalence-of-female-genital-mutilation-in-england-and-wales-national-and-local-estimates/

3. Home Office. Female genital mutilation: guidelines to protect children and women. https://www.gov.uk/government/publications/female-genital-mutilation-guidelines

4. Behrendt A, et al. Post traumatic Stress Disorder and memory problems after female genital mutilation. Am J Psych 2005;162:1000-02

5. Serious Crime Act 2015. Fact sheet: Overview of the Act. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/415943/Serious_Crime_Act_Overview.pdf