FGM is recognised as “child abuse” and “violence against women” but yet thousands of women in the UK have been subjected to it. Nursing in Practice speaks to FGM specialist nurse Juliet Albert about why she thinks it is still happening and how the UK can eradicate it
In 2003 Juliet Albert, a then qualified midwife was rushing to an unplanned home birth of a Somali woman expecting her second child in Acton, west London.
“On arrival I remember putting a light to look at her perineum and immediately noticed that she had female genital mutilation (FGM), I really didn’t know what it was. Nobody had ever mentioned FGM to me in my training as a midwife and I’d never seen it before, but I realised very quickly there were lots of women with this,” she said.
The practice which is classed as ‘torture’ by the United Nations has been in the limelight over the past few years. Last November it became mandatory for nurses to inform the police when they come across a patient aged below 18 who has been subjected to FGM, raising the profile of the illegality of the procedure.
So why is FGM still prevalent in the UK? And what can and should nurses be doing to put an end to this practice? Nursing in Practice asks these questions to Juliet Albert, a specialist FGM nurse who has worked tirelessly to open services and raise awareness on this form of violence against women.
Q: Why do you think the prevalence of FGM is so high in the UK?
A: I don’t think the prevalence has increased, but why do I think it’s so high? Because FGM is a thing that is practised worldwide and it’s really just an extension of violence against women – subjugation of women, historically, I think.
The fact that it’s in the UK is due to migration. It seems like obviously war, poverty, all of those circumstances contribute to the fact that now FGM is something that’s very prevalent. I think, as I said, it’s a form of violence against women and a way of ‘keeping women in their place’.
Also, the practice originates perhaps in countries where there isn’t access to education for women, health promotion, knowledge about the body and health, so… if women don’t understand the health consequences of FGM that’s a reason why it’s been perpetuated over the centuries.
Q: With the UK, what do you think the root of theproblem is?
A: Well I think it’s been brought here, as in, it’s not indigenous to the UK. Although historically, I think, women did have clitoroidectomies for hysteria in the past. But we see that as something that’s a long time ago, whereas I think the reason why it’s still relevant and topical is because it is very prevalent in countries like Africa, where we now have lots of immigrant populations from there who are living here.
Q: FGM is illegal in the UK, but yet it’s still happening. Why do you think that is?
A: I don’t think it’s happening that much in the UK. I think what we’re seeing is an understanding and a sudden recognition of the prevalence of really mainly historic cases. And don’t forget, we didn’t have any data beforehand, so it’s a guesstimate, it was clinicians saying ‘we’re seeing this very frequently’, but now suddenly, we actually have real numbers that demonstrate that actually it is something that lots of women have in this country.
In the past we know that women were actually being cut in this country, but I think that’s going to be extremely rare nowadays because of the awareness of how illegal it is, and the health consequences as well. But certainly, 20 years ago in the UK, there were girls being cut. Luckily, it doesn’t really seem to be happening very often at all now.
Q: What do you think the next steps to eradicating the practice are?
A: Well, education about the law and about the health consequences; engagement with community groups, where families may be under pressure to carry it out. We need to also be careful; we need to take care that we don’t alienate people and make people think that we’re not here to help them overcome. By being proactive here [in the UK], hopefully it will help to eradicate it worldwide as well.
Q: Do you think there are any certain taboos hindering the process of it being eradicated?
A: I think training could be improved worldwide, for women to be active in education and to have improved access to health services. There also needs to be input from religious leaders. It has to be people working together to stop it happening. I do think grass roots is terribly important; it probably needs to come from communities themselves that practice FGM, there’s no point in lots of people wagging their finger saying ‘We don’t think you should do this’. They’ve got to understand themselves why it shouldn’t carry on. Part of the obstacles in general is funding – there’s not enough money going into it. Education and community engagement, training for clinicians [are all key]. It’s still not part of mandatory training for nurses, doctors, teachers and social workers – it should be. Community groups don’t get enough funding, so it’s not really seen as enough of a priority, even though it has been much more in the media in the last few years.
FGM is complex as well; it’s not straightforward, it’s difficult, because people sometimes say, ‘Oh, it’s child abuse’, and it’s actually more complicated than that, because often, in families where FGM has taken place, it’s not ongoing child abuse, it may have just been a one-off event when a family felt under a lot of pressure to do it. So labelling everybody with the same brush actually doesn’t really benefit anyone, it just alienates members of the community. If anything, by alienating people, it may end up resulting in the practice continuing. So I think sensitivity and awareness of the complexity of FGM is important.
Q: What do you think nurses can do to help prevent and stop FGM from occurring?
A: I see it as becoming knowledgeable and then really explaining in a sensitive way to women and families from FGM practicing communities why there are health problems associated with the practice. For example, not just telling them it’s illegal but explaining to them why we want it to be illegal. For women who have had FGM, often it’s normal to them. They think that having pain during sexual intercourse for example is normal, having recurrent urinary tract infections is normal. So it’s helping them join the dots to realise this isn’t something that they have to be subjected to.
Q: Statistics released by NHS England showed that 5,702 cases were newly recorded in England between 2015 and 2016. But yet, no convictions have been made in the UK. What do you think about this?
A: I think that we need a conviction because it is a deterrent. But on the other hand, I don’t see that we need it to be such a big priority. It’s a sensitive subject: you’ve got a lot of girls who have been cut a long time ago, back in their home country where everybody did it – it was normal.
Now, prosecuting those parents is something that is going to be very tricky, and really, is it relevant to break up a loving family? Of course if there’s cases of ongoing abuse and domestic violence and early and/or forced marriage, it’s totally different, but I think that focusing on a prosecution as if that’s the be all and end all isn’t necessarily helpful.
The fact that we investigate cases in a way that’s very sensitive to the family dynamic is more important than ticking that ‘we’ve got a prosecution’ box; although, obviously it does send a strong message.
And I think with people and families being referred to social care, that information is being spread around communities and people are fearful. People do know that it’s illegal here now, so I think we’re getting that message across really.
Q: With mandatory reporting, the police are now involved, but do you think the police should be doing more to stop/prevent FGM?
A: With mandatory reporting, the new legislation means that the police have been yanked right into the equation. It’s difficult because part of me thinks that mandatory reporting is a good idea, however they should have made it mandatory to involve social services. I’m not sure whether making healthcare professional ring the police is really benefiting anybody, because it makes families and women really scared to access health services.
I think the police are responding in a sympathetic way, which is good. We don’t want to be taking families to court and taking children away from parents unless there’s a really good reason to do so. So no, I don’t think the police should play a bigger role than they already are.
Q: Does the new statistical publications from NHS England make a difference in bringing FGM into the wider conversation? If so, what difference?
A:Well, I have done 12 conferences around the country, 10 workshops and we have an NSPCC FGM helpline. There is a lot more training and there should be a Trust lead in hospitals nowadays. It is getting talked about and noticed. I definitely think it’s made a difference but I still think there’s work to do.
Like funding for services, we’ve seen one clinic that’s been set up, but relatively speaking there are few services for women and families, and most of the clinics don’t have a health advocate and a counsellor as well linked to the services, which there should be in every FGM clinic. So we’ve still got a way to go.
Q: Do you think it is important to have healthcare professionals, such as yourself, specialising in FGM?
A: At my trust, we have approximately 50 pregnant women a month disclosing that they have had FGM, so numbers are very high. If you don’t have a specialist then you’re not able to first of all make sure the women know about the law and the consequences and you need to make a plan for intrapartum care.
Now maternity services have been leading the way with FGM in a lot of respects but gynaecology services, A&E departments and GUM clinics need to catch up.
The worry is always that you end up with everybody else not being knowledgeable because you just leave it up to the specialists; this is always a concern within healthcare, with any specialist role.
However, I do think there’s significant numbers, enough to warrant a specialist role.
Q: Do you believe FGM can be stopped in the UK and worldwide, if so, how?
A: I hope so. Sometimes you feel really confident, and you think ‘Wow, there’s been amazing changes, it really has brought change’. However sometimes, I think ‘Gosh, it’s so endemic to communities in some places’.
The worry is that, for example, type one will continue because it’s less severe, people might think it’s OK. That’s a real risk, and I think we’ve got to be very, very clear that no type of FGM should be carried out, and that it really is of no benefit whatsoever to women.
But will it ever totally disappear? At the moment, it’s really in the limelight? It might become less popular and disappear. But I think let’s be positive – yes, eventually hopefully it will stop.