Thousands of women living in this country have suffered genital mutilation, a practice classed as ‘torture’ by the United Nations.
Nurses have been given specific legal duties to help put a stop to the barbaric procedures that can leave young girls with life-long pain, urinary problems, trauma, infections such as HIV – and can even cause death.
Since last November, it has been mandatory for nurses to inform the police whenever they come across a patient aged under 18 who has been subjected to female genital mutilation (FGM), which involves partial or total removal of the external genitalia, or other injury to the genital organs for non-medical reasons.
This duty to report observations to the police is in addition to nurses’ duty, introduced in April 2014, to record FGM in a patient’s healthcare record whenever it is observed.
Although there is no question in the minds of lawmakers, or many professionals, that FGM constitutes child abuse as well as an extreme form of violence against women, experts say nurses can feel anxious about broaching the topic.
"There are a lot of misconceptions," says Carmel Bagness, women’s health professional lead at the Royal College of Nursing (RCN). She explains: "People still believe it’s something that’s required by a religious group, but there’s no evidence of that." Although FGM tends to be practiced in Muslim communities, the traditions are cultural rather than religious. In 2014, the Muslim Council of Britain condemned FGM, stating that it was unsupported by Islam.
However, Bagness says: "Some nurses and midwives are very nervous about asking the question [of whether someone has FGM]. They’re worried about upsetting people or being accused of racism."
But girls may be at risk if their mother was subjected to FGM, and conversations with families are crucial to the safeguarding role, says Bagness. "FGM is child abuse. You wouldn’t allow anxieties about race and culture to impact the quality of your care if you were dealing with another form of abuse. So why would you in this case?"
The number of FGM cases being reported to police as a result of the 2015 duty is unclear. The Home Office does not collect figures for the number of referrals from professionals to police, and the Metropolitan Police did not respond to Nursing in Practice’s queries in time for this article.
Between 2010 and 2013, before the duty came in, 34 FGM-related referrals to police were made by healthcare staff, according to a Home Affairs Select Committee report published in July 2014. The report also referred to the need to "overcome practitioners" own reluctance to address FGM.
Failing to report a case of FGM in a child can result in a nurse having their fitness to practise investigated by the Nursing and Midwifery Council (NMC). The NMC was unable to say how many nurses had been investigated for this reason.
Jackie Mathers, designated nurse for safeguarding children at Bristol clinical commissioning group, feels nurses should be comfortable talking about FGM considering the wide range of other sensitive topics they discuss with patients.
But she highlights the limitations of the reporting duty, for example the need for a nurse to have seen physical signs of FGM before it can be referred to police, unless the patient has disclosed it themselves. She says: "You have to be quite skilled if it’s a type 1 [the partial or total removal of the clitoris]." Procedures usually take place before puberty, but children of this age would have had few, if any, intimate physical examinations as part of standard checks by health visitors or school nurses.
The duty also applies only to registered professionals, so healthcare assistants are not under any obligation to report instances of FGM to police. The reporting requirement is ‘quite narrow’, says Mathers.
Mathers is also disappointed that the government decided not to apply the duty to FGM cases in over-18s. This was partly because of fears that it would discourage affected communities from talking about FGM openly, but Mathers argues: "It’s underground anyway; you can’t get any further underground."
Separately, the recording duty has provided a better idea of the number of women in the UK who are living with FGM, even if the real figures are believed to be higher than official statistics suggest.
Data released by NHS Digital in March shows that between October and December 2015 there were 1,316 newly reported cases of FGM, and 2,238 total attendances where FGM was identified or a procedure for FGM was undertaken, including 35 girls under the age of 18.
Around half of all cases related to women or girls from London, and a third were born in Eastern African countries, particularly Somalia.
Midwives were most likely to record cases, followed by staff in obstetrics, gynaecology, mental health, maternity neonatal, paediatrics, physiotherapy and community paediatrics.
Fewer than five cases were thought to have had their procedures in the UK, but this does not mean that professionals do not need to be on their guard, as some families living in this country are known to send girls back to their country of origin for a ‘holiday’ to undergo FGM.
This means travel nurses have an important safeguarding role when they treat girls visiting a country where FGM is prevalent, according to recently updated RCN guidance. But travel nurses, who often work alone in the independent sector, may find the reporting duty "more challenging" than nurses who work with hospital-based services and multi-disciplinary teams, according to Bagness.
Another group who potentially face challenges is nurses in sexual health services, who may come across FGM in adults but be bound by confidentiality agreements, making it difficult to share information with other professionals such as midwives.
Carole Jackson, nurse lead in safeguarding at Brook – a service that provides sexual health services and advice for people under 25 – says FGM is one of the topics that patients are routinely asked about. Young women "talk about the fears of being social outcasts if they don’t have it done. One girl said [refusal] was seen as promiscuous," she explains.
In many cases, the young people who come through Brook’s doors don’t confess what is really on their mind until their second or third visit, she adds, demonstrating the importance of building relationships with patients and taking the time to listen.
This is an area where health visitors can also come into their own. Although they may not spot the physical signs of FGM, the rapport they can build up with families may help to uncover potential risks. Elaine McInnes, fellow of the Institute of Health Visiting, says: "Listening is one of a health visitor’s core skills. [Some girls] may feel they’re not welcomed into their family until [FGM] has happened. For us to come in and say 'this is unlawful in this country', it’s very tricky. You have to build a relationship."
This rapport can also lead to conversations that help to connect patients with support groups in their community, she adds. It is important to note that there are dozens of different names for FGM, varying by culture and locality.
Jackson explains a particular referral case. She was working as a health visitor when a woman with several daughters revealed that she had FGM done to her as a young girl. A referral to social services was made, leading to protection orders for the children.
But referrals do not always have a clear or satisfying outcome. Royal College of Midwives professional advisor Janet Fyle says there is often little or no feedback from police once a referral has been made. "It can be like putting information into a black hole," she says and adds that police should be releasing information on how many referrals they have investigated, and why these have not led to prosecutions. Nursing in Practice’s request to the Metropolitan Police for information on the outcomes of referrals was, like the request for the overall number of referrals, unanswered at the time this article was being prepared.
Fyle fears that without information on the impact of referrals, or a tangible increase in awareness of FGM laws among affected communities, the momentum that grew since Prime Minister David Cameron’s Girl Summit in 2014 might wane. "I’m concerned we’re going backwards," she says, and emphasises the need for a greater focus on engaging with communities.
There has been only one prosecution over FGM, and it resulted in the acquittal of Dr Dhanuson Dharmasena, a junior registrar at Whittington Hospital in north London who was accused of sewing a Somalian woman’s vagina back up following childbirth.
The Home Affairs Select Committee has raised concerns over the lack of prosecutions, pointing out that in just one hospital – Heartlands in Birmingham – doctors were seeing six patients each week who had undergone FGM. The report said: "There seems to be a chasm between the amount of reported cases and the lack of prosecutions. Someone, somewhere is not doing their job effectively." Ultimately, however, a prosecution is a sign that a woman or young girl has been made to endure a procedure that is likely to cause any number of complications including genital ulcerations; haemorrhaging, recurrent urinary tract infections, painful intercourse, infertility, postnatal infections and vaginal fistulae. Often the practice is carried out in poor light, without anaesthesia, and using blades, knives, broken glass or
shared non-surgical instruments, according to the latest RCN guidance.
The guidance states: "Girls have to be forcibly restrained and, following more extensive forms of FGM, their legs may be tied together for days to aid healing. Accidental damage, infection and haemorrhage are common, and long-term physical and mental health problems may follow if the child survives – death is not uncommon."
The aim, surely, should be to prevent such acts ever occurring, wherever possible.
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