Female genital mutilation - caring for patients and child protection


Guidance for UK doctors Girls at risk of female genital mutilation
If it becomes apparent that a girl is at risk of female genital mutilation, the GP or other doctor caring for her, for example the community paediatrician, must ensure that there is discussion with the family about the health and legal issues. This might also involve counsellors, supportive local community groups, or other clinicians with experience of working with communities that have a tradition of female genital mutilation. Doctors must ensure that their approach is sensitive to the beliefs and culture of the family, whilst remembering that female genital mutilation is illegal in the UK and that participation by any person, including a doctor, is a criminal offence. The aim is to find effective mechanisms for ensuring the protection of the child in a way that promotes her overall welfare. Doctors are unlikely to be able to initiate all of this work as individuals and should consider seeking help from social services, counsellors and other health professionals. In initial enquiries to seek general help, advice and information, it is unlikely to be necessary to identify the child or family.

Female genital mutilation is perceived in the UK as a form of child abuse; it is illegal, performed on a child who is unable to resist, medically unnecessary, extremely painful and poses severe health risks. Members of communities that practice female genital mutilation do so, however, with best intentions for the future welfare of their child and do not intend it as an act of abuse. Where parents cannot be persuaded that their daughter should not be subjected to female genital mutilation, doctors will have to find sensitive ways to explain that steps may be taken to prevent the child from being mutilated. It is usually appropriate for doctors to contact social services where they believe a girl is at risk of female genital mutilation, for example where a mother becomes pregnant again in a family whose existing daughters have been mutilated in infancy.

Parents’ rights to control information about their young children may be overridden where this is necessary to protect the child from serious harm, although wherever possible, their permission for disclosure of information to social services or another appropriate agency should be sought. In judging how to broach the issue with parents, doctors must bear in mind the likely attitude of parents in such circumstances and the risk that the child may simply disappear by being concealed within the community or sent to relatives abroad. This is can be extremely difficult and doctors must take great care to ensure that their reactions are supportive of the child’s overall welfare wherever possible.

Girls being taken abroad for genital mutilation
Where there are fears that a girl may be taken abroad for genital mutilation, doctors should counsel the parents, explain the health and legal issues, and try to persuade them not to do it. Involving community paediatricians may be helpful. Ultimately, a doctor might have to consider initiating child protection proceedings if there is no other feasible way of protecting the child.

As noted under Regulation above it is an offence under both the Female Genital Mutilation Act 2003 and the Prohibition of Female Genital Mutilation (Scotland) Act 2005 to take a child out of the country to procure female genital mutilation. Under the Children Act 1989 the local authorities can also apply to the court for various orders to prevent a child being taken abroad for mutilation.[reference 23]

Child protection
The steps that should be taken to initiate child protection proceedings where there is concern about the welfare of a child are set out in Government guidance 'Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children'.[reference 24] A summary of the relevant points from this is appended to these guidelines. The guidance states that a local authority “may exercise its powers under s.47 of the Children Act 1989 if it has reason to believe that a child is likely to suffer or has suffered female genital mutilation”. However, despite the very severe health consequences, parents and others who have this done to their daughters do not intend it as an act of abuse. They genuinely believe that it is in the girl’s best interests to conform with their prevailing custom. So, where a child has been identified as at risk of significant harm, it may not be appropriate to consider removing the child…where a child appears to be in immediate danger of mutilation, consideration should be given to getting a prohibited steps order. If a child has already undergone FGM, particular attention should be paid to the potential risk of harm to other female children in the same family”. [reference 25] Section 47 requires local authorities to make or initiate enquiries to establish whether action is needed to protect a child’s welfare, and to take such action as necessary. [reference 26] A prohibited steps order is a court order prohibiting the person or persons specified in that order from taking certain actions. In this case, to prevent parents from subjecting their daughter from genital mutilation either in the UK or abroad.

Guidance for doctors involved in child protection proceedings is also published by both the BMA and the Department of Health. [reference 27] Other useful sources of information are given below.

Requests for female genital mutilation
It is rare that doctors are asked to perform female genital mutilation on young girls. Instead families might seek a traditional circumciser or other member of their own community to do it. Requests are more likely to be faced from women asking to be re-infibulated after childbirth, although it is not known how common such requests are. As is explained above, re-infibulation is illegal under the Female Genital Mutilation (England, Wales and Northern Ireland) Act 2003 and the Prohibition of Female Genital Mutilation (Scotland) Act 2005, with certain exceptions, including during childbirth if necessary for the physical or mental health of the patient. This must be explained to the woman. If she agrees, it may also be important to explain the reasons why re-infibulation, which is not medically necessary, cannot be carried out to her husband, particularly if there is pressure from him for the procedure, although the main impetus for mutilation often comes from female members of the community.

Reversal
In some communities, it is traditional for infibulation to be reversed immediately after marriage. This is carried out by a midwife or birth attendant and facilitates consummation of the marriage. Many women living in the UK, however, find it difficult to obtain this service, or erroneously believe that it is not available to them. Experiences with de-infibulation at the African Well Woman Clinic at Northwick Park Hospital lead to the conclusion that encouraging women to have infibulation reversed before pregnancy is to be encouraged.[reference 28] The clinic found support for this from both women and their husbands.

Services for patients
It is essential that communities likely to practice female genital mutilation are given information about what services are available and how to access them. This should include information about reversal procedures. Information and attempts to raise awareness need to focus on the health and well being of all girls and women who are affected, including expectant mothers.

Asylum seekers
UNICEF and other agencies of the United Nations have stated that refugee and asylum status should be granted to women and girls fleeing their country to escape genital mutilation. The BMA supports this position. The UN Refugee Convention, to which the UK is a signatory, defines a refugee as someone who “owing to well-founded fear of being persecuted for reasons of … membership of a particular social group … is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country”.[reference 29] Where the persecution is feared from a person or group that is not an agent of the state (as would be the case with female genital mutilation), as well as a fear of serious harm or ill-treatment, there is “persecution” only if the state is unable or unwilling to protect the victim. An application for asylum would be unlikely to succeed if protection was available.

In guidance from the UK’s Immigration Appellate Authority it is noted that:

“Social, cultural and religious behavioural requirements, traditions and norms may consider gender-related harm to be acceptable practice. In such circumstances there will be a failure of state protection where the state is unwilling or unable to give protection. It is irrelevant whether such failure is due to state approval of such social/religious/cultural behavioural norms/practices and traditions, state indifference or impotence.”[reference 30]

In a letter to the British Refugee Legal Centre dated 8 July 1994, the United Nations High Commissioner for Refugees (UNHCR) outlined its position on female genital mutilation. The letter states that female genital mutilation (FGM), “which causes severe pain as well as permanent physical harm, amounts to a violation of human rights, including the rights of the child, and can be regarded as persecution. The toleration of these acts by the authorities, or the unwillingness of the authorities to provide protection against them, amounts to official acquiescence. Therefore a woman can be considered a refugee if she or her daughter/daughters fear being compelled to undergo FGM against their will; or, she fears persecution for refusing to undergo or allow her daughters to undergo the practice”.[reference 31]

World-wide, only a very small number of women have been granted refugee status on the grounds that they would be at risk of female genital mutilation if they returned to their country. In a 1998 publication, Amnesty International noted a case in Canada, one in the US and two in Sweden.[reference 32] A second application was successful in the US in 1999.[reference 33] No statistics are available for the UK, but the Home Office reports that there have been successful asylum claims in the UK based on the threat of female genital mutilation, where removing the applicant could be contrary to Article 3 of the European Convention on Human Rights that protects the right to be free from torture, inhuman or degrading treatment.[reference 34]

Guidance on the rights of asylum seekers to health care in the UK is available from the BMA.[reference 35]

An inter-agency approach
The approach to eradicating female genital mutilation amongst UK residents involves the health care team, counsellors, social services, educators and members and leaders of communities that practice female genital mutilation. Doctors should co-operate with local initiatives providing information and advice. As well as making efforts within communities to stop mutilation, doctors must work with individual patients. This requires an awareness of who may be at risk, either of being mutilated at a future date, or of suffering health complications as a result of mutilation.

It is essential that doctors work closely with appropriate statutory and other organisations, obtaining advice where necessary, when faced with an individual case. Initial approaches for general advice should normally be made on an anonymous basis, without identifying the child or family concerned.

Area Child Protection Committees (ACPCs) have responsibility for developing inter-agency policies and procedures for child protection. The Committees are also charged with scrutinising work related to inter-agency training and with making recommendations to responsible agencies and are therefore ideal for the co-ordination of education, training and mechanisms to deal with the risks and effects of female genital mutilation. Community leaders can help with understanding the nature and structure of the community that practises female genital mutilation, and why it does it. The Department of Health advises that local agencies should be alert to the possibility of female genital mutilation among the ethnic minority communities known to practice it and that in local areas where there are communities or individuals who traditionally practice female genital mutilation, ACPC policy should focus on a preventive strategy involving community education.[reference 36]

Sources of practical advice and information
It is clear that female genital mutilation has serious physical and mental health consequences for women. It is rare for women to survive mutilation without complications, be they short or long term, physical or psychological. Doctors must give their patients help and support, and provide psycho-sexual and gynaecological advice as appropriate. This section identifies sources of information and advice for doctors.

All key professionals working with communities which practise female genital mutilation should where possible receive specific training on the subject. The Department of Health has funded the production of a video and a guidance booklet on female genital mutilation.

A valuable source of advice and information, both for health professionals and patients, is people working at clinics with experience of caring for women who have been mutilated. The Foundation for Women’s Health, Research and Development (FORWARD) provides contact details for some such clinics on its website at www.forwarduk.org.uk under the heading What we do. At the time of writing, there are 13 hospitals and clinics in the UK which specialise in FGM health services.

The following organisations provide help and advice, and may be able to put enquirers in contact with local women’s groups.

Foundation for Women’s Research and Development (FORWARD)
Unit 4
765-767 Harrow Rd
London NW10 5NY
Tel: 020 8960 4000
Fax: 020 8960 4014
Email: forward@forwarduk.org.uk
Internet: www.forwarduk.org.uk

International Planned Parenthood Federation
Regent’s College
Inner Circle
Regent’s Park
London NW1 4NS
Tel: 020 7487 7900
Fax: 020 7487 7897
Email: info@ippf.org
Internet: www.ippf.org

Black Women’s Health and Family Support (BWHAFS)
82 Russia Lane
London E2 9LU
Tel: 020 8980 3503
Fax: 020 8980 6314
Email: bwhafs@btconnect.com

Rainbo
Suite 5a
Queens Studios
121 Salusbury Road
London
NW6 6RG
Tel: 020 7625 3400
Fax: 020 7625 2999
E-mail: info@rainbo.org
Internet: www.rainbo.org

Resources for health professionals
  • British Medical Association. Doctor's responsibilities in child protection cases. London: BMA, 2004.
  • Mwangi-Powell F (ed). Female genital mutilation: Holistic care for women. A practical guide for midwives. London: FORWARD, 2001.
  • Royal College of Nursing. Female genital mutilation: The unspoken issue. London: Royal College of Nursing, 1994.
  • Royal College of Midwives. Female genital mutilation (female circumcision). Position paper no. 21. London: Royal College of Midwives, 1998.
  • Hedley R, Dorkenoo E. Child protection and female genital mutilation: Advice for health, education, and social work professionals. London: FORWARD, 1992.
  • Toubia N. Caring for women with circumcision: A technical manual for health care providers. New York: Rainbo, 1999.
  • American College of Obstetricians and Gynaecologists. Female circumcision/female genital mutilation: Clinical management of circumcised women. Washington, DC: ACOG, 1999.
  • FORWARD Another form of abuse London: FORWARD, 1992. This video, produced by FORWARD with funding from the Department of Health, gives a general introduction to female genital mutilation and its health implications. It also includes an interview with a woman who had genital mutilation performed on her.

    © British Medical Association 2008

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