Have you encountered a patient that had FGM?

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Staryy

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Have you encountered a patient that had female genital mutilation?

There is an interesting article that discusses how to interact with a patient that has had FMG.

Education
Female genital mutilation: an overview
  • By: Jane Simpson
  • Published: 30 October 2013
  • DOI: 10.1136/sbmj.f6381
  • Cite this as: Student BMJ 2013;21:f6381
In this article:

Figures:

Boxes:

  • Box 1: Classification of female genital mutilation (WHO 2008)
  • Box 2: Short and long term health consequences of FGM
  • Box 3: Tips for consultations
  • Box 4: UK law and female genital mutilation (FGM)
  • Box 5: Additional educational resources
  • Box 6: Alternative “what if?” scenarios
How much do you know about female genital mutilation (FGM)? You may have heard about it in the news, but would you know what to do if you thought a child was at risk? With increasing numbers of girls in the United Kingdom thought to be affected, the medical establishment has finally woken up to the need for a comprehensive and wide reaching approach. In 2011 the government published multiagency guidelines on FGM detailing the role of health professionals in offering high quality care to those affected and preventing future cases.[1] In May 2012, the chief medical officer issued a declaration that all health professionals should familiarise themselves with the actions they should take where they believe that a girl has undergone or is at risk of FGM.

These moves have established learning about FGM as integral to the basic medical curriculum. However, familiarity with how to manage a case is rather harder to acquire. No published data exist on the overall numbers who present to health services with FGM. Women tend to present to maternity services, whereas children tend to present as a child protection issue: the Metropolitan Police Service was involved with 135 so called incidents of concern relating to FGM in London between April 2008 and April 2011.[2]FGM is a sensitive and complex matter and few medical students will have direct exposure. Senior doctors will often exclude students and junior trainees from child protection consultations and specialist adult FGM clinics do not often welcome student observers. Although this might be understandable from the point of view of the patient and her family, it has obvious consequences for teaching and training. This article aims to offer medical students an overview of FGM and a clinical approach to its assessment, management, and prevention.

What is FGM?
FGM describes a range of procedures, often involving partial or total excision of the external female genitalia, for non-medical reasons (see box 1 and figures 1-4 for more detail).[3]Terminology can sometimes cause confusion in this area. The term “female genital mutilation” replaced “female circumcision” to emphasise the gravity of the act and distinguish the practice from male circumcision. It was adopted by the United Nations in the early 1990s and is now the most widely used term in the international literature.[4]Some groups advocate the use of “female genital cutting” to avoid the negative connotations of the word “mutilation” and the expression “female genital mutilation/cutting” is used by Unicef and the United Nations Population Fund. FGM is classified into four types by the World Health Organization (see box 1). “Clitoridectomy” literally means the surgical removal of the clitoris and equates to FGM type 1, and the terms “infibulation” and “pharaonic circumcision” are often used to describe type 3 FGM. 1 2 3 4




Fig 1 Unaltered female genitalia






Fig 2 Tissue removed in type 1 female genital mutilation (top) and type 2 female genital mutilation (bottom)






Fig 3 Appearance of type 2 female genital mutilation (top) and type 3 female genital mutilation (bottom)




Box 1: Classification of female genital mutilation (WHO 2008)
Type 1—Partial or total removal of the clitoris and/or prepuce

Type 2—Partial or total removal of the clitoris and the labia minora +/- excision of the labia majora

Type 3—Narrowing of the vaginal orifice with creation of a covering seal by cutting and opposing the labia minora and/or majora with/without excision of the clitoris (infibulation)

Type 4—All other harmful procedures to the female genitalia for non-medical purposes—for example, pricking, piercing, cutting

Why is FGM important?
FGM is a form of child abuse. Its practice on children constitutes a breach of the UN Convention on the Rights of the Child[5] and wider international human rights legislation. It is also banned by national criminal law in much of the world, including the UK (see box 4), the United States, and many African countries where FGM is traditionally practised.

Who is affected?
FGM is thought to affect 100-140 million women worldwide.[6] It is practised in more than 26 African countries, and a few populations in Asia and the Middle East. The type of FGM which predominates tends to vary geographically, with the most severe form largely confined to the countries of northeast Africa—particularly Somalia, Ethiopia, and Sudan.

Generally, FGM is not practised in the West, but because of migration there are now thought to be considerable numbers of women and girls undergoing this procedure illegally. Accurate, up to date prevalence data on the scale of the problem in Western countries are conspicuously absent,[7] but figures have been generated by extrapolating from the prevalence data of African countries combined with national statistics on the number of female migrants from these practising countries.

The estimate for England and Wales is that 66 000 women have undergone FGM, with a further 20 000 children at risk.[8] But this does not show the whole picture, as minority ethnic communities are highly concentrated geographically in the UK. Most of those affected live in or around London, with other smaller populations found in large cities particularly Birmingham, Manchester, Bristol, and Leicester. This means that although a medical student on placement in rural Wales is unlikely to encounter a case, students training in central London may find that up to 10% of births on their maternity ward are to women subject to FGM.[8]

Why is FGM performed?
FGM is performed as a means of control over the sexuality of women. It is a manifestation of sexual inequality and a form of gender based violence. Within practising communities FGM is considered a tradition; a rite of passage, which is often justified by assertions of religious requirements, cleanliness, improved marriage prospects and preserving chastity.[9] It is a type of child abuse that differs from most others, because parents arrange it for daughters believing that it is in their best interests. It is an ancient practice that is not unique to any one religion. Although many of the practising communities are Muslim, the evidence for its support by Islamic teaching is inconclusive and controversial,[10] and FGM has been widely condemned by senior Muslim clerics.[11] [12]

How is FGM performed?
Most women and girls with FGM in the UK are immigrants who have undergone the procedure before their arrival. It is also suspected that some girls undergo FGM in the UK or during holidays overseas to the family’s country of origin.[13] Girls of any age are at risk.

FGM is mostly performed by traditional practitioners, often older women, using crude instruments in unhygienic conditions. Doctors have been strongly condemned by the international medical community for any involvement.[3]

What are the health consequences of FGM?
FGM has no known health benefits. Its negative effects broadly follow a dose-response relationship: more complications are likely to arise as the degree of mutilation and trauma of the circumstances increases.[14] [15] Box 2 lists short and long term health consequences of FGM as described by the World Health Organization.[4]

Box 2: Short and long term health consequences of FGM
  • Immediate risks—pain; shock (caused by pain and/or haemorrhage); excessive bleeding; difficulty passing urine or faeces; infection (including tetanus inoculation and the transmission of bloodborne viruses such as HIV, hepatitis B, and hepatitis C); psychological consequences (caused by pain, shock, or physical restraint); unintended labial fusion; death (caused by haemorrhage or infection)
  • Long term risks—pain (chronic neuropathic pain); keloid scarring; infections (including chronic pelvic infections, recurrent urinary tract infections, and an increased incidence of certain genital infections); birth complications (caesarean section, postpartum haemorrhage, and episiotomy) and danger to the newborn (including death); decreased quality of sexual life; psychological consequences (including post traumatic stress disorder, depression, and anxiety)
  • Long term risks particular to type 3 FGM— urinary and menstrual problems; painful sexual intercourse; infertility; need for later surgery (deinfibulation or an anterior episiotomy in labour) to allow vaginal delivery or to restore the vaginal opening
Box 3: Tips for consultations
Asking a woman about FGM is difficult but you can take steps to make it easier and more successful:

  • Optimise the environment; ensure privacy, consider a female chaperone and the need for a translator
  • Ensure a professional and sympathetic approach
  • Use appropriate and value neutral terminology
  • Recognise that the law creates a barrier to open communication. FGM is a crime committed by close family members. Women might not seek help for fear that disclosure will cause trouble for their family. Women with FGM who are recent immigrants to the UK and lack a confirmed immigration status might be afraid that involvement with any statutory agency will lead to deportation, but this is not the case
Box 4: UK law and female genital mutilation (FGM)
A person who performs FGM or aids, abets, counsels, or procures FGM has committed an offence under UK law (Female Circumcision Prohibition Act 1985). Since 2003 this also includes anybody who aids, abets, counsels, or procures FGM outside the UK on any UK national or permanent resident (Female Genital Mutilation Act 2003). This attempts to close the loophole whereby children are taken overseas for the purposes of FGM. FGM is a serious crime attracting a punishment of up to 14 years in prison

Managing a consultation about FGM
The following scenario illustrates the role you might play in identifying a case of FGM, and touches on all of the main aspects of management and prevention. For more information, in particular a broader discussion of child safeguarding, please refer to the resources listed in box 5. For alternative scenarios see box 6.

When should I suspect FGM?
Imagine that you are a foundation year 2 doctor working in general practice in east London. A 23 year old woman walks into the surgery and tells you that she thinks she has a urine infection and needs antibiotics. She reports that she often gets urine infections and your records confirm that she has had several proved infections over recent years. She also reports that she is about 10 weeks pregnant and would like you to book her in at the local hospital.

You confirm that the woman has symptoms consistent with a urine infection and ask her to provide a urine sample. While she is out of the room, you look back through her records and find out that she was born in Somalia and arrived in the UK 10 years ago with her family.

What should you be thinking?
Type 3 FGM is almost ubiquitous in Somalia and it is highly likely that the woman underwent the procedure before her arrival in the UK. Because infibulation narrows the vaginal orifice it can interfere with the passage of urine and could be responsible for the woman’s recurrent urine infections. Type 3 FGM also has implications for her pregnancy because a vaginal delivery would necessitate elective deinfibulation or an anterior episiotomy in labour. The woman comes from a large family with several female siblings, all of whom may be at risk or have already undergone FGM. It is essential for you to discuss FGM in this consultation.

How can I ask about FGM sensitively?
When the woman returns, you dipstick the urine and confirm her pregnancy and the likelihood of a urinary tract infection. With the tips listed in box 3 in mind, you open the conversation by saying: “It appears that you do have another urine infection, and your records confirm that this is a recurrent problem. When this happens we look for reasons why this might be. I can see that you came to the UK from Somalia. Many women from your community have been circumcised as children. Is this something that happened to you?” You could also have asked “Have you been cut or closed?” or “Have you been circumcised?”

The woman reports that she was cut and sewn up when she was a young girl in Somalia. She wonders why it is relevant.

How should I advise the patient?
You take the time to explain the anatomy and why her circumcision might relate to her urine infections. You also mention its relevance to childbirth and tell her about a clinic run at the local hospital for African women, which specialises in helping women with FGM. This is one of many that can be found in London and the large cities (www.forwarduk.org.uk/resources/support/well-woman-clinics). She can self refer or accept a GP referral. If necessary, the clinic can arrange for her to undergo a reversal procedure (deinfibulation) later in the pregnancy so that she can deliver her baby vaginally. This would involve a minor surgical procedure to divide the fused labia and could be carried out in clinic under local anaesthetic.

What should I say about the legal implications of FGM?
You then ask the woman whether she knows much about the law in the UK relating to FGM. She answers “no” so you start to explain that in the UK performing FGM is illegal. This means that doctors and midwives will not be able to sew her back up after childbirth even if she requests it. It also means she must not try to have her child circumcised, or she could be prosecuted. You make a point of acknowledging that she may have already decided not to have her own daughters circumcised. But you also mention that you are aware that it can be very difficult to resist pressure from family and the wider community. You explain that specialist midwives and community support workers can help her to protect her own children. You tell her that there are many non-governmental organisations that work on FGM issues, for example FORWARD (www.forwarduk.org) and Daughters of Eve (www.dofeve.org) are two UK based charities that provide help and information to woman affected by FGM.

When should I examine my patient?
The woman seems grateful for the information and would like you to refer her to the African Women’s Clinic. You know that the specialists at the clinic will want to examine the woman to confirm her diagnosis and you judge that further examination in this consultation is unnecessary. Identifying the various forms of FGM can be difficult. All doctors should be able to recognise FGM when women present with a clinical complaint that demands examination but where there is no pressing clinical need, intimate examinations should be left to the experts. This is especially true of children.

If the woman refuses examination, then her FGM will have to be managed at her delivery. Doctors have no right to examine women and children who refuse examination for FGM, even if a crime is suspected. So in cases where FGM is suspected in a child but is not able to be confirmed, social care involvement has to continue without a confirmed diagnosis.

What should I do if I suspect a child is at risk of FGM?
Finally, you ask the woman whether she knows if any of her sisters have been circumcised. She replies that she thinks her older sisters would have been circumcised back in Somalia, but she is not sure about her younger sister who is now 14. You encourage her to tell her older sisters about the African Women’s Clinic as they will be able to access services directly if they want to. You also explain that you will need to talk to social care about her younger sister because she is still a child and you have a duty to protect her. You explain that this is a legal requirement.

The woman is worried about her parents getting into trouble. You explain that it is important to find out whether her sister has had FGM, and if so when and where it took place. If her younger sister has not had FGM, any intervention is likely to involve a home visit by social workers and community advocates to discuss FGM and make sure that her parents are aware of its harmful consequences and the fact that it is illegal in the UK. They might then sign a contract saying that they will not try to procure FGM for their daughter and be given a “Health passport” for her to carry abroad. This is a document stating the law and potential criminal penalties that can be used against those allowing FGM to take place, which is designed for girls and their parents to help resist pressure when visiting family abroad.[16]

If her sister has already undergone FGM, she will need to be offered specialist paediatric care, including confirmation of the diagnosis, testing for bloodborne viruses, managing complications, and offering psychological support. Only if there is evidence that the law has been broken will the police consider a criminal investigation: in this case, evidence the FGM took place in the UK or that the child was taken overseas for FGM after her arrival.

The consultation concludes with you giving the woman a prescription for antibiotics for her urine infection and confirming that you will make referrals to maternity services and the African Women’s Clinic. You write down the contact details for the charities you previously mentioned and encourage her to visit again if she would like to discuss the issue further. After the consultation, you refer to the recommendations made by the London Safeguarding Children Board about protecting children from FGM (www.londonscb.gov.uk/fgm/), and then contact social care to discuss your concerns about the younger sister.

Box 5: Additional educational resources
Box 6: Alternative “what if?” scenarios
  • The woman attends the consultation with a friend or relative: ask to speak to the woman alone at first. She was not expecting to discuss FGM and may feel inhibited
  • The woman does not speak much English: clarify her native language and arrange to see her again with a translator. Do not rely on a family member to translate and avoid someone from her community as this may prevent open discussion
  • The woman refuses to talk to you about FGM:provide information on the African Women’s Clinic and emphasise that this can be accessed without a GP referral. The woman might choose to disclose when the midwife routinely asks her about FGM at her booking appointment. Failing that, FGM will be picked up during labour, when it is still possible to perform deinfibulation
  • The woman tells you that she wants everything she says about FGM to remain confidential: you cannot make this promise, as it depends on what she says. It is your duty to break confidentiality if a child is thought to be at risk of serious harm. It can also be broken in the public interest and or when a serious crime is suspected
Jane Simpson, specialist training year 4, paediatric trainee

1Whittington Hospital, London, UK

Correspondence to: [email protected]
Acknowledgments: This article draws heavily on a review article published in the BMJ in 2012, Female Genital Mutilation: the role of health professionals in prevention, assessment, and management. Written with co-authors Kerry Robinson, Sarah Creighton and Deborah Hodes.BMJ 2012; 344:e1361

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

References
  1. Foreign and Commonwealth Office. Multi-agency practice guidelines: female genital mutilation. 2011.www.fco.gov.uk/fgm.
  2. Simpson J, Robinson K, Creighton SM, Hodes D. Female Genital Mutilation: the role of health professionals in prevention, assessment and management. BMJ2012;344:e1361
  3. WHO. Global strategy to stop health-care providers from performing female genital mutilation. 2010.www.who.int/reproductivehealth/publications/fgm/rhr_10_9/en/index.html.
  4. WHO. Eliminating female genital mutilation. An interagency statement. 2008.http://whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf.
  5. Unicef. Fact sheet: a summary of the rights under the Convention on the Rights of the Child.www.unicef.org/crc/files/Rights_overview.pdf.
  6. World Health Organization. Female genital mutilation. Fact sheet no 241. 2012.www.who.int/mediacentre/factsheets/fs241/en/.
  7. European Institute for Gender Equality. Female genital mutilation in the European Union and Croatia. European Union 2013. http://eige.europa.eu/sites/default/files/EIGE-Report-FGM-in-the-EU-and-Croatia.pdf.
  8. Dorkenoo E, Morison L, Macfarlane A. A statistical study to estimate the prevalence of female genital mutilation in England and Wales. FORWARD, 2007.www.forwarduk.org.uk/download/96.
  9. Yoder PS, Abderrahim N, Zhuzhuni A. Female genital cutting in the demographic and health surveys: a critical and comparative analysis. DHS comparative Reports 7, 2004. www.measuredhs.com/pubs/pdf/CR7/CR7.pdf.
  10. Asmani IL, Abdi MS. Delinking female genital mutilation/cutting from Islam. Population Council, 2008.www.popcouncil.org/pdfs/frontiers/reports/FGM_Islam.pdf.
  11. Gomaa A. Female genital mutilation, 2006.www.aligomaa.net/fatwacollection.html.
  12. International Islamic Center for Polpulation Studies and Research, Al-Azhar University, Unicef. Children in Islam: their care, development and protection. 2005,www.unicef.org/media/media_30158.html.
  13. Foreign and Commonwealth Office. Multi-agency practice guidelines: female genital mutilation. 2011,www.fco.gov.uk/fgm.
  14. Obermeyer CM. The consequences of female circumcision for health and sexuality: an update of the evidence. J Culture Health Sexuality 2005;7:443-61.
  15. WHO Study Group. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367:1835-41.
  16. UK government. A statement opposing female genital mutilation. 2012,www.gov.uk/government/uploads/system/uploads/attachment_data/file/208440/fgm-v12-web.pdf.
Cite this as: Student BMJ 2013;21:f6381
 
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