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A complex crime: Female genital mutilation



Female genital mutilation, also known as female cutting or female circumcision, is a catch-all term that describes partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

Nurses are required to be vigilant for evidence of female genital mutilation but need to appreciate the cultural complexities that influence those subjected to it. Allie Anderson reports.

Back in March 2019, a woman from Walthamstow, in north-east London, was jailed for 11 years after being found guilty of performing female genital mutilation (FGM) on her three-year-old daughter. It was the UK’s first and, to date, only successful conviction for the practice; three previous prosecutions had all ended in acquittal. 

In the aftermath of the decision, hopes were raised that the high-profile case would serve as a deterrent against FGM – a form of child abuse – and that fewer girls would be subjected to it. Official data would seem to suggest that positive effect has taken place.

Figures from NHS Digital say the incidence of FGM in England is at its lowest since records began in 2015, when the Serious Crime Act 2015 made it mandatory for regulated health, social care, and teaching professionals to report it. The number of newly recorded cases of FGM in 2020 was 2,790 – a fall of more than a quarter (28%) compared with the 3,850 cases recorded in 2019.

However, there is concern that rather than representing a genuine decline in FGM, the figures could simply mean more cases are going unreported. While wordwide children’s charity Unicef last month stated the crime was increasing during the pandemic.  

What is certain is that this form of abuse isn’t restricted to the 27 African countries and the parts of Asia and the Middle East where it’s concentrated. It happens among diaspora communities throughout the UK and can have a devastating, lifelong impact on the lives of girls and women.

As well as being vigilant for the clinical presentations and health implications, nurses and midwives must also understand the cultural complexities that surround FGM. 

Carmel Bagness, the RCN’s professional lead for midwifery and women’s health, points out that this responsibility falls particularly on practice and community nurses, who are at the coalface of the affected populations. ‘Nurses in primary care are more likely to be in contact with whole families and therefore have a better understanding of the communities they’re working in,’ she says. 

What is FGM?

Female genital mutilation, also known as female cutting or female circumcision, is a catch-all term that describes partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. 

The World Health Organization classifies FGM into four main types:

1. Clitoridectomy the partial or total removal of the clitoris, or the removal of the prepuce (clitoral hood). This is rarely, if ever, performed without one of the other types.
2. Excision the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. 
3. Infibulation the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia, with or without clitoridectomy. 
4. Other all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping and cauterising.

Complications and presentations to services

FGM affects the physical and mental health of women and girls in manifold ways, in the short term and throughout their lives.

Immediate complications:
Haemorrhage, pain, shock.
Wound infection, septicaemia, tetanus.
Urine retention.
Tissue damage, ulceration.
Infection. 

Intermediate complications:
Delayed healing.
Abscesses.
Scarring/keloid formation.
Dysmenorrhoea/obstruction to menstrual flow.
Pelvic infections.
Obstruction to urinary flow.
UTIs.
Long-term complications 
Psychosocial trauma/PTSD. 
Vaginal closure.
Epidermal cyst/neuromata.
Pain and chronic infection. 
Recurrent UTIs/renal damage. 
Painful intercourse, lack of pleasurable sensations.
Infertility.
Prolonged/obstructed labour and childbirth trauma. 
Postnatal wound infection.

Many women present through maternity services, but primary care nurses are likely to come across women who have undergone FGM in their routine practice. ‘Anyone who is conducting cervical screening, for example, will need to have a clear understanding of what normal physiology looks like, and recognise a woman may present with evidence that she has had FGM performed,’ Ms Bagness says. 

She adds that any area of practice relating to women’s or girls’ health – particularly involving urology, gynaecology or mental health – could potentially include a conversation about FGM or trigger a disclosure. Nurses should also be alert when they encounter women and girls from diaspora communities who are travelling abroad to any region where FGM practices are concentrated.

Legal and professional responsibilities

As mentioned above, the law requires nurses and other regulated professionals to make a report to the police if, in the course of their professional duties, they discover FGM appears to have been carried out on a girl aged under 18 years (at the time of discovery). 

The duty applies where the professional is informed by the girl that an act of FGM has been carried out on her, or observes physical signs that appear to indicate FGM, and has no reason to believe it was necessary for reasons of physical or mental health, or connected with labour or birth.

Note that the mandatory duty to report applies if FGM is discovered and not if it’s merely suspected, and only in under-18s. Uncertainty may arise when caring for a pregnant woman who has had FGM, and whose child – if female – might therefore also be at risk of FGM. In this case, an individual risk assessment should be undertaken.

Such policies can cause immense distress, and risk alienating diaspora communities. Earlier this year, the Foundation for Women’s Health Research and Development, known as FORWARD, published research with the University of Huddersfield, which outlined that women can feel criminalised by ‘heavy-handed’ FGM safeguarding measures. 

Amy Abdelshahid, the charity’s head of evidence and co-author of the report, Do No Harm, says it highlights that, paradoxically, safeguarding often undermines the welfare and safety of the women and girls it is designed to protect. 

‘It’s required to record on a girl’s health record that she is at risk of FGM if she is born to a mother who has had the practice. That suggests any girl born to a mother with FGM is automatically at risk,’ Ms Abdelshahid says. ‘A lot of women who are pregnant or recently gave birth have to endure repetitive, uncomfortable conversations about their FGM or about their intention to have FGM done on their daughters. 

‘That’s not necessarily done only once, but routinely, because the girl is considered at risk until she’s 18. That can be very difficult, because mothers who have had FGM have gone through trauma and feel they are not necessarily treated as survivors of FGM, but as potential perpetrators.’

These experiences erode rather than build trust between healthcare professionals and diaspora communities. Women often end up avoiding medical appointments as a result, potentially putting themselves and their families at greater risk.

Difficult conversations

Ms Abdelshahid highlights that meaningful progress in eliminating FGM will only happen if interventions are culturally sensitive and inclusive. ‘We recognise that a community-centric approach to FGM safeguarding and prevention is very important and has a significant impact on changing attitudes to FGM and protecting girls,’ she says. 

Practice nurses have a crucial role to play here, and adopting a sensitive approach begins with reflecting on how they talk about FGM with patients. Aneeta Prem, campaigner and founder of Freedom charity, says getting the language right can encourage women to open up. 

‘If you’ve never seen an FGM case, it’s difficult to know what language to use and how to speak to someone,’ she says. ‘When I talk to someone who has been through FGM, my first question is always: “How do you want to talk about this?” Depending on where they’re from, they’ll often prefer to say they’ve been “cut” and “sewn”, or they might use a native word. As professionals, it’s essential that we use the language women are happy with.’

Many patients for whom English is not their first language take a relative or friend to consultations to translate. As Ms Bagness points out, nurses should exercise caution here. ‘That would not be agreed policy – you should have an independent interpreter – and you need to be clear about providing the woman with a safe opportunity to talk about it if she wants to,’ she says.

Main points

  • FGM is a cultural practice, not a religious one.
  • There is no health or medical benefit from FGM.
  • It is usually performed on girls between infancy and the age of 15, typically before puberty.
  • The physical and psychological harms to girls and women who have undergone FGM are often severe and lifelong.
  • Girls and women are often unaware of what has happened to them.
  • Different cultures may use different terms to describe and talk about it, so might not understand terminology like ‘female genital mutilation’.
  • Nurses must be familiar with FGM guidelines and duties, know their safeguarding lead and understand local risk assessment and safeguarding processes.

Has the pandemic allowed FGM rates to rise?

One possible reason for the drop in recorded FGM cases is the Covid-19 pandemic. Evidence suggests that, worldwide, Covid has enabled gender-based violence and abuse, including FGM, to be perpetrated behind closed doors while victims and those at risk have reduced access to medical and support services.

According to Orchid Project, a UK-based non-governmental organisation whose aim is to end FGM globally, rates in parts of the world are in fact on the rise because ‘lockdowns are being seen as an opportunity to carry out [FGM] undetected’. The UN Population Fund (UNFPA) estimates that ‘due to pandemic-related disruptions in prevention programmes, two million FGM cases could occur over the next decade that would otherwise have been averted’.

Freedom charity founder Aneeta Prem believes this is being borne out in the UK. ‘We’ve had a 45% increase in calls to our helpline,’ she says. ‘Previously, those people might have spoken to a nurse or someone else.’

Those missed encounters may have given rise to concerns that would be covered by the mandatory reporting duty, which falls on all regulated health, social care and teaching professionals. With schools closed for a significant part of 2020 and face-to-face visits with frontline health and social care workers limited, at-risk girls could certainly have fallen through the gaps.

Declining official numbers of cases also threaten specialist FGM services, Carmel Bagness warns. ‘Healthcare across the NHS is provided and commissioned on the basis of identified need,’ she says. ‘If there isn’t hard evidence to show there is a need, then there is a real risk that it will have a negative impact on services that are commissioned, set up or maintained.’

As Ms Bagness suggests, the absence of data to demonstrate a service need puts funding in jeopardy. Notwithstanding the impact of Covid-19, official NHS figures have shown a steady, year-on-year reduction in recorded cases of FGM since the first published data in 2016. Government money to eradicate the practice has plummeted in parallel – from £2.7m in the year to April 2016, to just £432,000 four years later.

As a result, frontline healthcare workers face an even greater responsibility to be on guard and fully understand their obligations when it comes protecting their patients who have undergone or are at risk of FGM.

Allie Anderson is a freelance journalist