Articles on Shifting Sands
Genital piercings are the UK’s ‘FGM’
Sensationalist headlines that followed the publication of official NHS FGM data are now almost conspicuous by their absence. Previous examples included the Independent’s ‘FGM case reported in England every 109 minutes’, Barnardo’s ‘eleven newly recorded cases in England every day’. And ‘experts’ regularly warned that any data was likely to be ‘tip of the iceberg’. Now the Report goes almost unnoticed because the only ‘FGM’ occurring in the UK is genital piercings.
A valiant attempt was made to resurrect the tradition after the publication of the latest NHS FGM Annual Report for England on 25 July. The headline ‘Birmingham has highest female genital mutilation rate than anywhere in UK’ led the way. Other attempts were made in Devon and Coventry. Oxford resorted to the ‘tip of the iceberg’ doomsday scenario. Presumably charities like the NSPCC had sent targeted press-releases, including video clips, to media outlets. Some dutifully copied and pasted. Most don’t appear to have bothered however. This is no doubt disappointing when compared with their 2018 results.
The Annual Report re-confirms what many still find difficult to accept – that of the FGM cases undertaken in the UK, 85 per cent are known to be genital piercings. Some of the remaining 15 per cent may also be piercings but the data is incomplete. So why the continued attempts to ignore that but sensationalise mundane findings like the rate of NHS attendance?
Although the Report focuses primarily on attendances between April 2018 and March 2019, additional information about attendances in the four year period from April 2015, when data collection in this format began, is also included and provides useful comparative data.
Data is collected when the procedure is identified in a girl or woman attending a healthcare setting. It is mandatory for acute hospital and mental health providers as well as GP practices to collect and submit it to NHS Digital.
During the year, 118 NHS trusts and 64 GP practices submitted one or more FGM attendance records. Since 2015, records have been submitted from 150 NHS trusts and 175 GP practices.
Although almost 80 per cent of these attendances are in Midwifery and Obstetric services, some are also in Paediatric and GP settings.
NHS Digital always reminds readers that not all data fields are complete in the FGM Enhanced Dataset. So where there is a low level of completeness findings are less reliable. Much of what is presented is helpfully accompanied by a chart or table entry detailing completeness.
The average age at attendance was 32 years. Of these, where FGM was undertaken under the age of 18, it had occurred at least 10 years previously in 97 per cent of cases.
Between April 2018 and March 2019, 6,415 individual women and girls had an NHS attendance where FGM was identified. These accounted for 11,575 total attendances, an increase on previous years. The increase seems to be due to a change in recording practice as the number of distinct individuals has remained broadly stable.
- 4,120 women and girls were newly recorded during the year
- 20,470 were newly recorded over the 4 year period
Newly recorded means this is the first time they have appeared in the dataset. It does not indicate how recently they had FGM, nor does it mean that this is their first attendance for FGM. The number of ‘newly recorded’ women and girls has reduced over time. We are told this should be expected as the longer the data collection continues, the greater the chance of a women or girl having been recorded previously. In other words fewer new cases are presenting.
This is unsurprising because it’s been recognised for some time, and by experts like Professor Johnsdotter in particular, that migration results in broad opposition to FGM among concerned migrant groups in western countries. So the drop in new cases is to be expected.
Where was the practice undertaken?
Of the women and girls who reported where they were born and had FGM, 85 per cent were from an African country.
The highest numbers were from Somalia (815), the Sudan, (395) Eritrea (310), Nigeria (250), the Gambia (135), Ethiopia (105), Egypt (40), Sierra Leone (40), Guinea (35), Kenya (30). Djibouti, Guinea-Bissau and Senegal each had 10.
Others were from Iraq (130), the UK (100) and Saudi Arabia (20). Yemen, Indonesia, Iran, Malaysia and Sri Lanka each had 10.
The numbers are not always exact because they are rounded e.g. numbers 1-7 are rounded to 5. All other numbers are rounded to the nearest 5.
Type of FGM
Despite the limitations of the World Health Organisation classifications, they continue to be used to describe ‘Type of FGM’ in the Dataset. They are:
• Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
• Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
• Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
• History of Type 3: Current state where a woman or girl had FGM Type 3, but has since been de-infibulated.
• Type 3 – Reinfibulation identified: Current state where a woman or girl has been closed previously, opened and is currently closed again.
• Type 4: All other harmful procedures to the female genitalia for non-medical purposes, including pricking, piercing, incising, scraping and cauterisation.
• Unknown: When the FGM category could not be ascertained. It is acknowledged that even for experienced healthcare workers who frequently see women and girls with FGM it can still be difficult to determine the type.
Individual women and girls by FGM Type April 2018 to March 2019
Only 59 per cent of individual women and girls have a known FGM Type recorded. The ‘known’ category excludes “Not Recorded” and “Not stated or unknown”.
Of the 6415 recorded during the year:
Type 4: 320
Type 3: 830 and history of 120 = 950
Type 2: 1050
Type 1: 1435
Not recorded or stated: 2365 and 250 = 2615
*Reinfibulation means that a woman has been closed previously (infibulated), then opened (deinfibulated) and is currently closed. This is illegal in many countries, including the UK, where adults do not have bodily autonomy in this regard. But some women say they feel “naked” if their genital area is left open. So in an endeavour to feel whole again they revert to the way they used to look.
Type Four – genital piercings
The report re-confirms that of the FGM cases undertaken in the UK, 85 per cent are known to be genital piercings. Some of the remaining 15 per cent may also be piercings but the data is not complete. This year, a breakdown by subtype of the 320 FGM type 4’s identified is also provided. They include:
- Pricking: 30
- Piercing: 160
- Scraping: 15
- Incising: 20
- Cauterisation: 5
- Not recorded: 95
Although all of these subtypes are illegal in the UK, it is worth noting that there is no drive to prosecute. Maybe that’s because they are viewed as ‘cosmetic surgery’, not ‘FGM’?
Individual women and girls by FGM Type April 2015 to March 2019
Of the 25,530 recorded during the four year period:
Type 4: 1080
Type 3: 3015 and history of 535 = 3550
Type 2: 4070
Type 1: 5285
Not recorded 950 or stated/unknown 13,380 = 14,330
Daughters under the age of 18 are being recorded
This is presumably because girls born to mothers who’ve undergone the procedure are considered ‘at risk’. Many continue to cite initial estimates of 20,000 girls under the age of 15 at risk in the UK each year, 6,000 in London alone, to help justify the FGM Intervention Programme.
But according to Professor of Perinatal Health, Alison Macfarlane, the scale of the practice has continually been over-estimated and advises “Risks to girls have to be assessed through contacts with individual mothers and families.” Her warning that quantification of risk is not possible, is being ignored.
It is also important to note that there’s been only one successful prosecution for ‘FGM’ in the UK despite a number of trials. There are however serious concerns about the veracity of the guilty verdict.
We are reminded that newborn girls born to mothers who’ve had FGM have been recorded in the dataset in error and work is continuing to delete these records. Some entries of girls aged under 18 years may therefore be incorrect although the number is likely to be small.
I wrote previously that this may’ve happened because midwives felt under intense pressure to record newborns when the near hysteria about the predicted FGM epidemic in the UK was palpable and professional guidance unclear. They had after all been told that if a mother had undergone FGM, her daughter would automatically also.
While it remains useful to have a rough idea of the number of women and girls with FGM presenting in a variety of NHS services over the past four years, it is important to ask how useful it is to continue collecting data in this format? And if only just over half of all attendees have a known FGM type recorded, how worthwhile is it?
Since its inception, clinicians have raised criticisms and concerns about the Database in regard to what it was attempting to achieve as well as the consequence for their practice and for patients. Recent research with focus groups undertaken in Bristol by Karlsen and colleagues suggests that the requirements risk retraumatising women who have been cut with repeated questioning by health professionals about experiences they would prefer to forget.
For now, limited though it is, the data illustrates that FGM prevalence and estimation of those ‘at risk’ has been exaggerated in the UK and the response is disproportionate. The only beneficiaries appear to be the FGM industry.
Postscript 9th August 2019
Regional newspapers have continued to report and comment on the data. Links below.
North East: 105 new cases of female genital mutilation in the North East, reveal shock figures
Newham Dozens of FGM victims came forward in Newham last year, new figures show
North Derbyshire: Campaigners call for increased awareness as FGM victims treated in north Derbyshire
Metro: Teachers told to look out for signs of FGM during ‘cutting season’
North Kirklees: Campaigners call for increased awareness as victims of FGM treated in North Kirklees
Peterborough & Cambridgeshire: Dozens of healthcare appointments required by pregnant FGM victims in Peterborough and Cambridgeshire
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.