A new legal requirement to notify the police of cases of female genital mutilation (FGM) has now come into effect. The word ‘cutting’ is sometimes added to the word ‘mutilation’ so that the initials may be seen as ‘FGM/C’. The new law, which applies in England and Wales, commenced on 31 October 2015, and requires doctors, nurses and midwives to inform the police if they believe FGM has been carried out on a girl under the age of 18 years. The requirement also includes teachers and social workers (social care workers in Wales). The Act does not apply in Scotland or Northern Ireland, although political pressure exists to tackle this issue. In March 2015, funding was announced for community engagement projects in Scotland, which are designed to raise awareness, pay for training, and provide for support services.
The new law complements other measures, such as Parental Liability for FGM, and specific protection orders introduced earlier in 2015 that are designed to prevent families from sending or taking a daughter abroad to have the procedure performed. These are known as FGM Protection Orders, and come under the remit of the Serious Crime Act 2015 [s.73] (Ministry of Justice/Home Office, 2015). So why is a new law needed, and what effect will it have on midwives?
The law is needed, partly, because existing measures have not been enough to halt the practice. FGM has been illegal in the UK since 1985, although to date there have been no successful prosecutions under this legislation (the Female Genital Mutilation Act 2003 replaced the 1985 legislation). Earlier in 2015, the first attempt to prosecute ended with the defendants, both doctors, being acquitted (Rogers, 2015). One had been charged with re-infibulation—restoring FGM—following a vaginal birth; the other was charged with being his accomplice.
It is difficult to know how many women in the UK are affected by FGM, but estimates suggest 137 000 in England and Wales (Trust for London, 2014). The UK government stresses that it is committed to ending what the public health minister called ‘this abusive and illegal practice’ (Department of Health, 2015). Many midwives will have encountered FGM/C, which ranges from the partial or complete excision of the clitoris or clitoral hood (known as type 1) to the hugely destructive type 3, where all external genitalia including the labia majora have been removed. A recent addition, type 4, refers to ‘all other harmful procedures to the female genitals including pricking, piercing, rubbing, scraping and the use of herbs or other substances’ (Orchid Project, 2015). Apart from its physical and psychological effects (Berg and Denison, 2013), the practice can cause varying degrees of clinical complication in pregnancy and especially in childbirth (Berg and Underland, 2013).
Mandatory reporting should allow for more effective monitoring of the incidence of FGM in England and Wales, but there is a potential danger that a woman might be deterred from seeking health advice because she is aware of the health professional's duty to notify. It would be unfortunate if an unintended consequence of the new legislation was the prevention or disruption of a trusting relationship. The Royal College of Obstetricians and Gynaecologists (RCOG) is clear that passing on this information does not represent a breach of confidentiality, nor does it breach data protection laws. The report must be made because a crime has been committed on someone—a minor in England and Wales—to whom a duty of care is owed.
For most midwives, unless the woman or girl discloses this information herself, the issue may not arise until an examination is required. This means that the first time recognition occurs is likely to be when the woman or girl is in labour. There is a balance to be struck when discussing this issue, given its intimate nature and the fact that an affected woman or girl is likely to feel loyal to her family (Trust for London et al, 2015). Midwives need to consider what the consequences might be for the woman or girl when a report is made. If the procedure has been carried out on a minor, this will have been with her family's knowledge and, presumably, their consent. Given that the procedure is heavily associated with particular ethnic and cultural groups, and is concentrated in certain parts of the country, some midwives may have yet to encounter FGM and may wonder why it is carried out.
The practice varies, depending on the cultural group involved. It is not a religious requirement, but reflects cultural assumptions about encouraging girls and women to be, as Gallagher (2015) reports, ‘hygienic, chaste and faithful’. Such a defence of the practice cuts no ice with the royal colleges, however. The Royal College of Midwives (RCM) recently published guidelines co-authored with obstetricians, nurses, the UNITE union and Equality Now (RCM et al, 2013). Their top recommendation for tackling FGM in this age group is to ‘treat it as child abuse’. Next is to collect and collate information so that reliable statistics can be used to track its incidence. The guidelines acknowledge that practitioners need to be adequately trained if they are to be part of this process of tackling FGM. These recommendations, which reflect a broad political consensus that the practice must be eradicated, also raise questions of resources: how much extra time and training is required to ensure that all relevant staff have the knowledge and competence to be part of the solution?
Notification of FGM is a legal requirement, so practitioners must be prepared for their actions to be scrutinised. You are always accountable for what you do, but you are also accountable for what you do not do. Failing to notify a case (or, in reasonable circumstances, a suspicion) of FGM could be seen as a dereliction of duty. For doctors, a failure to report will result in a referral to the General Medical Council (RCOG, 2015). The RCOG notes that practitioners should contact the police's non-emergency 101 number. You cannot delegate this task to another professional, but if you reasonably believe that another professional has already made the notification then the obligation to notify falls.
Crucially, you must strive to safeguard a sound professional relationship with the woman or girl concerned—it is to her that you owe a duty of care.
