Female genital mutilation (FGM) is a form of abuse against women and girls (HM Government, 2014). The UN Convention of the Rights of the Child (UNICEF, 1989: 8) states that: ‘Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.’ FGM is often carried out on babies and girls and is a violation of the rights of the child. The Nursing and Midwifery Council (2015)Code requires that nurses and midwives work cooperatively, and safeguarding policy and procedures identify that working together is the cornerstone of child protection. This article will identify how collaborative working is fundamental to the ending of the practice of FGM.
Female genital mutilation
FGM (also called female genital cutting) refers to all procedures involving partial or total removal of the external genitalia or other injury to the female genital organs for non-medical reasons (World Health Organization (WHO), 2008) and, until recently, the nature and extent of this cultural practice had not been widely discussed or quantified in the UK. The FGM National Clinical Group (FGMNCG) was set up in 2007 with the intention of bringing greater attention to FGM, with the goal of ending the practice. The FGMNCG is a registered charity and comprises medical and health-care practitioners who voluntarily work to raise issues regarding FGM in the UK. In my capacity as Chair of the FGMNCG, I have raised awareness of FGM and contributed to the Department of Health (DH) and Health Education England working groups on elimination of FGM.
Prevention of FGM
Every year on 6 February, member states of the UN observe the International Day of Zero Tolerance for FGM. The day is used to raise awareness regarding FGM as well as to enhance actions, interventions and campaigns to eliminate FGM.
The intercollegiate recommendations for tackling FGM in the UK (Royal College of Midwives (RCM) et al, 2013) identify a growing consensus that the system is failing to protect girls from FGM. The number of communities affected by FGM is growing (owing to increased migration from countries that practise it) and girls in the UK are at risk of undergoing FGM. The intercollegiate guidelines identified that FGM was still not ‘fully integrated into the child protection system’ (RCM et al, 2013: 6). Key recommendations from this collaborative report state that much more needs to be done to tackle FGM in the UK.
On 22 July 2014, the UK Government and UNICEF collaborated to host the first Girl Summit, an event that accelerated the global movement in support of girls, supported and empowered those affected by FGM, identified actions for change, and gave young people the chance to identify their plans and ambitions to tackle FGM. The Girl Summit Charter and pledges identify that it is everybody's business to end FGM. The FGMNCG pledged, along with many other national and international organisations, to work together across borders to end FGM and to protect anyone at risk. The UK Government pledged that it would design and implement effective, properly funded policies and clear legislation, and work with communities to enable every girl and woman at risk of or affected by FGM to have access to appropriate services such as education, counselling, shelter and reproductive health and medical care. The UK Government identified that the strategy to eliminate FGM requires collaboration across the health, social and education departments, as well as inclusion of local government and law enforcement agencies.
Criminalisation of FGM
UK legislation in the form of the Prohibition of Female Circumcision Act has existed since 1985. The Female Genital Mutilation Act 2003 strengthened and amended the 1985 Act to make it an offence for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM. All health and social care professionals have a responsibility to ensure that families know that FGM is illegal. The laws relating to FGM are not there to be defied, yet to date the Crown Prosecution Service (CPS) has been unable to secure a successful prosecution. Law enforcement agencies (police and the CPS) are unable to enforce FGM legislation and secure a prosecution when FGM cases are not reported.
Policy
Girl Summit demonstrated the extent of the feelings of girls and young women regarding FGM. The aim of the event was to help rally a global movement to end FGM everywhere within a generation. Governments, faith groups, traditional leaders, non-government organisations and civil society groups, young people, practitioners, people affected by FGM, communities, international organisations, media and the private sector have to work together to end FGM. Without the collaboration of all (including law enforcement agencies, health and social care workers, education and training, community groups and families that practise FGM), we will be unable to end the tradition of FGM.
Safeguarding children, young people and vulnerable adults is a fundamental part of health and social care. The public, communities and groups share the responsibility with statutory agencies for protecting children and reporting abuse. Communities that practise FGM do not consider themselves to be vulnerable or at risk of abuse generally, but the cutting or excision of female genitalia constitutes abuse. FGM is unlike any other form of physical abuse as it is a traditional practice, which affects both physical and psychological health, is used to control sexual behaviour and has economic consequences for communities which advocate the practice.
For many years the FGMNCG has campaigned and worked hard to identify the specific care needs of women and girls who have experienced FGM. The FGMNCG (2013) publication of national standards regarding care needs for FGM identifies the services necessary for girls and women accessing health and social care. There are concerns regarding the lack of education and training around FGM for health professionals and the FGMNCG has campaigned to ensure this is addressed in undergraduate education.
The current UK policy to eliminate FGM focuses on the need to protect girls from being cut; identifying girls and women who have been cut and securing a successful prosecution to demonstrate to communities who undertake FGM that it is illegal in the UK. Working together to safeguard girls and women from abuse associated with FGM requires a multi-agency approach, covering strategy, education, response and community change support.
Practice
In 2013, the Parliamentary Under-Secretary of State for Public Health identified that improving the NHS response to FGM is a priority. The DH established the FGM Prevention Programme, a cross-government effort to eradicate FGM. The NHS and partner organisations will collaborate to protect future generations of girls from FGM. The FGM Prevention Programme has strengthened the legislation (such as the inclusion of FGM in the Serious Crime Act 2015), identified health and social care needs (recording of FGM, prevalence dataset, enhanced dataset) and addressed the commissioning of services (education, training and research). The FGMNCG contributes and actively engages in the working groups.
Supporting women with FGM
Specialist clinics such as those at Heart of England NHS Foundation Trust have been providing care for women and girls affected by FGM. Collaboration across the health service requires staff who can work inter-professionally, and health education can do a great deal to prepare practitioners to work together to protect and safeguard against FGM. Specialist midwives, such as Juliet Albert and Alison Byrne (both members of the FGMNCG), provide care for women affected by FGM—but the provision of services varies across the UK, and many areas do not have a specialist or access to appropriate care.
The midwifery profession and maternity services need to provide appropriate and sensitive care to all childbearing women and cannot negate the responsibility to safeguard babies and children. Working together with our different communities, partners from the voluntary and statutory sectors as well as individuals, will enable the commissioning of specialist services and the delivery of appropriate care. Collaborating with safeguarding partners should enhance our knowledge and understanding as well as contributing to the elimination of FGM. The relentless work of charities and non-governmental organisations such as FGMNCG, FORWARD, Daughters of Eve and Integrate Bristol has ensured that the voices of survivors, as well as those vulnerable to FGM, are heard.
Collaboration
Collaborative working has been the mainstay of safeguarding procedures. Communities need to take action to work towards the elimination of FGM. The NSPCC has produced posters to increase awareness of FGM and identify what health professionals can do if they are worried about someone who may be at risk of FGM or has had FGM.
‘When it comes to preventing FGM and prosecuting those who undertake FGM, there must be no room for complacency’
Ignorance of the law is not an excuse, and health and social care workers have a duty to ensure that individuals, communities and nations are cognisant of the law regarding FGM. The subject should be openly discussed to ensure that young people are able to be protected, empowered to speak out and safe from a breach in their fundamental human rights.
The Serious Crime Act 2015, which applies to England and Wales, updates the existing legislation regarding FGM and, in sections 70–75, identifies the new requirements around mandatory reporting and the new FGM order. The new mandatory reporting duty for FGM was introduced following a public consultation. It is not the role or responsibility of midwives to investigate child abuse, and midwives are required to share their concerns with social care (HM Government, 2014). The new duty, which came into force on 31 October 2015, requires regulated health and social care professionals and teachers in England and Wales to report known cases of FGM in girls under 18 years old to the police. The implementation and enforcement of this legislation requires agencies to continue to work together to safeguard women at risk of FGM. Data collection regarding the prevalence of FGM involves the recording of information around FGM prevalence and extent across the UK. Health Education England has provided e-learning conferences to prepare staff for the new requirements. Professional midwifery practice requires midwives to fulfil their duty regarding law enforcement (birth and deaths), and the mandatory reporting of FGM now adds to these legal responsibilities. Only when midwives collaborate with other agencies regarding FGM will young girls and women be protected against the practice.
Conclusion
Safeguarding babies and girls at risk of FGM poses specific challenges for health, social care and educational professionals, as the families involved may not give any other causes for concern. Implementation of the intercollegiate recommendations (RCM et al, 2013) is dependent on strong leadership at local and national levels, collaboration among all agencies and communities, a willingness to share information and a change in the culture and attitudes of front-line staff. When it comes to safeguarding against FGM, preventing FGM and prosecuting those who undertake FGM, there must be no room for complacency. Courage, collaboration and commitment are necessary for the elimination of FGM and could lead to ‘female genital mutilation being abandoned within a generation’ (WHO, 2008: 21). Preventing and ending the traditions of FGM will only be achieved if we collaborate and work together.
Resources
Some useful websites, e-learning and other resources around FGM include: