Articles on Shifting Sands
Clinicians unable to detect FGM in under 18’s
Despite that experts find it impossible to confidently distinguish ‘FGM’ from tiny irregularities that may exist due to congenital variation, it is being diagnosed in under 18’s.
Professor Dame Sally Davies, the Chief Medical Officer for England, published her 2014 Annual Report in December 2015. In it, she focuses on women and their health: the 51%, and specifically on violence against them, health in their reproductive years and in later life.
In doing this, she admits her interest in addressing ‘taboo’ and ‘below the waist’ problems that she believes are not discussed enough. FGM is one of these subjects.
Following publication, obesity generated most interest, compounded by her suggestion in the ensuing media flurry that it was ‘as dangerous as the terror threat’ She considers it so serious that she recommends the Government includes obesity in its national risk planning.
Violence against women gets prominence immediately after her Chapter 1 summary and recommendations. So, in the second and third chapters, gender-based violence against women and FGM are discussed.
As in all chapters of the report, developed with the help of expert academic and/or clinician input, the one on FGM was co-written by lead consultants at University College London Hospital (UCLH): Sarah Creighton, Consultant Gynaecologist and Honorary Clinical Professor and Deborah Hodes, Consultant Community Paediatrician.
In it, they cite the much quoted 137,000 women in England living with FGM. Their source is the work of researchers associated with London’s City University who estimated that there were also 70,000 girls under 15 living in England and Wales who had undergone, or were at risk of FGM.
One wonders why Dame Sally, known as having made ‘an outstanding contribution to science through her exceptional leadership in health research’, appears willing to collude in the citation of these estimates and projections almost as fact?
The clinicians suggest that the risk of FGM for girls living within the diaspora communities remains real, whilst acknowledging that it is unquantified. To support this, they refer to their specialist clinic for under 18’s at UCLH, the only one in the UK. They confirm that they see there what they understand to be a broader trend – the medicalisation of FGM.
They suggest a less severe form of FGM (type 4) is being performed and at a younger age. They describe small cuts or pricks made on or lateral to the clitoris, causing little tissue damage or scarring. They admit that this makes it impossible, even for experts like them, to distinguish confidently from tiny irregularities that may exist, due to congenital variation.
They however believe it is being done for devious reasons: to ensure less objection or disclosure. The trend has been confirmed in 27 girls seen in their clinic. The reference given is for an ‘in press’ report.
However, in the annual review about their specialist clinic at UCLH, published September 2015, they reported that 38 children and young people were referred there with suspected FGM during the previous year, 18 of whom had undergone some form of FGM. Of these, three had been carried out illegally (details not provided), while the remaining 15 had been done before the children came to the UK.
In 11 of the 18 cases, they found that patients had undergone type 4 FGM. While the figures in the two reports do not tally, it seems that a possible nick or cut is the commonest type seen in the clinic. And because they classify it as FGM, it is by definition, illegal.
So, between 11 and 27 girls may have undergone type 4 FGM nationally. The figures do not appear to support their contention that ‘the risk for girls living within the diaspora communities remains real’. Particularly, as I reported here, many suspected type 4 referrals are being made out of fear, not conviction.
We also know that only 26 under 18’s were reported over a six month period between April -Sept 2015 to the Department of Health’s Health & Social Care Information Centre. These figures are a far cry from the ‘thousands of ‘cut’ teenage girls as ‘tip of the iceberg’ being reported.
Dame Sally recommends that the social science community applies for funding to investigate relevant social issues and how to change attitudes to FGM in diaspora communities in England, from countries where FGM is practised.
It would appear however that the communities are ahead of her and are already well on their way to changing their attitudes and practices independently. Surely they should be credited for their endeavours instead of continually reporting over-the-top estimates of prevalence? And criminalising people for a practice clinicians cannot even be sure has occurred, must stop.
The paper – Multidisciplinary approach to the management of children with female genital mutilation (FGM) or suspected FGM: service description and case series was written by UCLH clinicians and published March 2016.
It concluded that mandatory reporting and increased media attention may increase the numbers of referrals of children with suspected FGM. This patient group have complex needs and management in a dedicated multidisciplinary service is essential. Paediatricians and gynaecologists should have the skills to carry out the consultation and detect all types of FGM including type 4 which was the most common type seen in this series. This is the first dedicated FGM service for children in the UK and similar clinics in highprevalence areas should be established.
Update September 2018.
Following a Freedom of Information request, a Mail on Sunday journalist reported Britain’s first clinic for young victims of FGM, has seen just five girls in the past year.
In total, the service – which has cost more than £70,000 over and above staff salaries – has treated just 43 patients since it opened in 2014.
Asked for more details, the trust said all the girls referred to the clinic had confirmed FGM but would not say how many underwent the practice in the UK, where it is illegal.
Figures suggest most cases take place overseas.
About the Author - Bríd Hehir
Bríd is a retired health professional. She started her career as a nurse and midwife in Africa where she worked for almost four years. She encountered FGM/C in Ethiopia. She then moved to London where she worked in the National Health Service as a midwife, community nurse, health visitor, reproductive and sexual health nurse and manager over a period of 30 years. She did not encounter FGM/C during that time despite working with immigrant communities who are reported to practice it still. She is puzzled by the current reported prevalence of the practice, the official response and associated activism. And is worried that they might cause more harm than good.