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Tackling FGM on the ground

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Female genital mutilation (FGM) has received almost regular coverage in the media and increased governmental attention in the past few years. Given that the practice has been illegal since 1985 and yet the first prosecutions only took place earlier this year, health professionals need support to help protect women and girls from this practice.

The very first Girl Summit in London last month and the ongoing support from a number of high profile figures such as David Cameron, Stephen Fry and actress Charlize Theron illustrates the urgency that FGM generates. It is becoming a growing global concern.

Following the Girl Summit, prime minister David Cameron, promised on social media that it will become a legal obligation for doctors, teachers and social workers to report any concerns relating to FGM. The absence of nurses and midwives in this tweet raises questions around how they are being supported on the ground.

The prevalence of this practice requires nurses and midwives to be adequately supported to help the estimated 137,000 women and girls with FGM, living in England and Wales.

Current guidelines for FGM

The DH created a set of guidelines in 2011 advising health professionals on how they can approach the sensitive issue of FGM with families and girls that they believe to be at risk. Midwives, school nurses, health visitors and practice nurses have been named as key groups that can have an impact.2

The RCN is in the process of updating its current guidelines on FGM. 'The RCN guidelines will be updated by the end of 2014 and will focus on professional responsibilities, clinical care, as well as safe guarding pathways. It will emphasise the need for all nurses and midwives who come in contact with girls, whether in primary care or acute care settings, to understand their responsibilities and the care required,' says Carmel Bagness, midwifery and women's health advisor at the RCN.

An intercollegiate report was updated earlier this year, combining the findings of several royal colleges entitled Safeguarding children and young people: roles and competences for healthcare staff. The standards are split into levels of skills, which outline exactly what nurses in community services and practices should be able to do. They include being able to identify and refer a child suspected to be at risk of FGM or having been a victim of FGM; being aware of the legal, professional and ethical responsibilities around information sharing; being able to document concerns; and knowing what to do about them.

Practice nurses

The 2011 DH guidelines break down how each different group of healthcare professionals can take steps to identify and tackle FGM. The guidelines state that practice nurses can ask any new patients registering with a practice about FGM when a routine patient history is being taken from girls and women from communities that traditionally practice FGM.2 Information about FGM should be given as a welcome pack to any new patients at a practice, and nurses should be aware of the risk of FGM having been performed on girls and women when administering travel vaccinations for countries were FGM is practiced. 'All practice nurses need to be aware of the groups of women who may have undergone FGM and they need to be vigilant against it,' says Marie-Therese Massey, a senior lecturer in adult nursing at Sheffield Hallam University and a practice nurse who has specialised in sexual health. 'In areas where there is a high proportion of women from African, Middle Eastern and some Asian communities, nurses can be vigilant within.'

Practice nurses are most likely to come across women that have undergone FGM when taking a cervical smear or vaginal swabs, she says. 'However, the fact that the age for cervical smear screening starts at 25, can limit the ability to identify younger women that have had it or are at risk. If younger girls present with frequent urinary tract infections, vulval infections or menstruation problems than this could be how they are identified as having had FGM,' says Ms Massey.

Midwives

The guidelines also explain how midwives and antenatal nurses are likely to be the first healthcare professionals to come into contact with women presenting with FGM. They should take histories to identify women who may have had it or are at risk and use the appropriate care pathway for women during pregnancy, delivery and postnatal care.2 Even if a woman has had previous vaginal births, midwives should always consider the presence of FGM and check for re-suturing. If a woman has had FGM and gives birth to a daughter she should be provided with the information that FGM is illegal and should not be performed on her daughter in a sensitive manner.2 The type of FGM a woman has had should be recorded on the medical records including a detailed account of the genitalia and identifying the presence and absence of each structure. A midwife should inform the woman's health visitor and GP that she has undergone FGM so that they can ensure that she received the medical and mental support that she needs.2

Alison Byrne, an FGM specialist midwife at Heart of England hospital in Birmingham, says location can dictate how often midwives might come across it. 'Some midwives may go their whole careers without ever seeing FGM, depending on the area in which they practice. I work in a hospital three or four miles from the centre of Birmingham and we have roughly five or six women come into the clinic, which I set up in 2002, a week. Education and knowledge is key to tackling FGM. However all midwives, nurses and practice nurses should receive clear training and education to ensure that they are equipped to deal with it.'

Ms Byrne says that although she lectures regularly to midwifery students she has never once lectured other nursing students about FGM. 'This needs to change and it needs to be made mandatory for all nurses and midwives,' she says.

Debora Alcayde, an FGM specialist midwife, agrees that all healthcare professionals should have training to recognise the signs of FGM. 'Every trust should include training for everyone. It should be included in pre-and post-registration training for all healthcare professionals.'

Midwives are then in a position to work with other health professionals such as health visitors and GPs once a woman has left their care. Health visitors are able to work closely with families in the home and either alone or as part of multi-professional teams.

They might visit a mother that has undergone FGM and would be required to ensure that the family is aware that the practice is illegal and consider whether any girls in the family need safeguarding.

The Institute of Health Visiting has launched new guidance to provide information to raise awareness among health visitors on how to protect babies and young girls. The resources can be downloaded from the website. iHV director Dr Cheryll Adams said: 'We saw there was a need for up-to-date information specifically for health visitors from a trusted source. Every family with a girl child under five has a health visitor, so it is vital that professionals have access to high quality information to positively promote girls' and women's health nationwide.'

School nurses and children's community nurses are well placed to receive disclosures from girls and young women and would need to be prepared to discuss the subject professionally and sensitively.2

What is FGM?

Female Genital Mutilation, also known as female genital cutting or female circumcision comprises 'procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural religious or other therapeutic reasons.' 3

The practice is most common in a number of African countries with the high prevalence rates in countries such as Egypt, Ethiopia, Somalia and Sudan where rates can be as high as 98 per cent.4 In other African countries such as Nigeria, Kenya, Togo and Senegal prevalence rates can be between 20 and 50 per cent.4 However, it is important to note that prevalence rates can also vary between cultural communities rather than across specific countries and it can also take place in some parts of the Middle East such as Yemen, Oman, Iraqi Kurdistan and Israel. Due to immigration and refugee movements FGM is now practiced in ethnic minority populations across the world in Europe, America, Canada, Australia and New Zealand.

FGM is considered to be linked to controlling the sexuality of women, chastity, femininity and aesthetics. It is usually performed on a young girl before she reaches puberty. In some communities, FGM is rooted in custom and tradition, family honour and religious belief. The removal of the external female genitalia is believed to reduce sexual urges in young women and ensure that they remain pure until marriage. FGM is sometimes thought to be linked to Islam, but it has been discovered that FGM predates the religion.5 Some women are unaware of the health consequences of FGM and will undergo the procedure due to the insistence of the older women or men who wish to continue the practice.4,5

3. Health complications of female genital mutilation including sequelae in childbirth. A systematic review. (2000).

4. FORWARD. http://www.forwarduk.org.uk/key-issues/fgm.

5. Female Genital mutilation: An RCN educational resource for nursing and midwifery staff.

Invoking a response

The government is now investing time and resources to tackle the training issue surrounding FGM. A Home Affairs Committee report released in July of this year questioned the accessibility of the training and multi-agency guidelines stating that one of the main barriers to identification and intervention is a lack of understanding among health, education, social care and other professionals of the risk factors, signs and how to respond to them.6

Ms Byrne thinks that not many nurses and midwives are aware that such guidelines exist. 'I use them when I am training midwives and very often they will be unaware that these guidelines have been published and that they were published three years ago.'

The Home Affairs Committee report stated that mandatory and high-quality training is the only way to ensure all practitioners are capable of recognising the risks of FGM, and how to respond to those who have already had it. Ms Bagness agrees. 'There are a number of elements to FGM, which nurses and midwives need to be aware of. Nurses and midwives need to fully understand their role, which may require them to have additional training and education, to ensure they manage all these situations with great sensitivity and clear understanding of the legal as well as professional obligations they have to act, knowing what their options and care pathways are.'

'The RCN is creating opportunities to increase nurses and midwives awareness around the subject because it is critical they understand their role and the support available through established safeguarding processes,' she adds.

According to the Home Affairs Committee report, the record of referrals by healthcare practitioners and others is poor and a lack of training, awareness and ethical concerns can no longer prevent positive action being taken. To support this the DH has been asked to improve the accessibility of the guidelines, rather than simply publishing them online. They are also working with the RCN to provide funding for the development of e-learning materials for healthcare practitioners.

The Home Affairs Committee report also stated that this summer, a two-year pilot has launched in six London boroughs where midwives provide information to social workers on mothers who have undergone FGM. All families will receive literature on the long-term effects of FGM and the consequences of allowing a child to go through FGM. Depending on the scale of the risk, healthcare workers and social workers will work together to ensure that girls and families are well- informed.

Home Secretary, Teresa May announced at the Girl Summit that £1.4m is to be spent on an FGM prevention programme in partnership with NHS England to help care for survivors and safeguard those at risk. She also said that a special government unit will be set up in England to support criminal justice partners, children's services and healthcare professionals to tackle FGM. Laws will also be strengthened so that parents will be prosecuted if they are found to be compliant in administering FGM to their daughters.

The aim is to change the pattern of FGM in a generation and the key to this is to continously raise awareness among the public.

Ms Bagness, says: 'The amount of media coverage is fantastic as it is increasing everyone's awareness, not just for nurses and midwives but also for local communities where it may be practiced and for the general public.'

However, 'In order to keep the momentum going, it is important to incorporate FGM in all sexual health programmes in pre- and post-registration nursing, and for local CCGs to keep it as a priority,' says Ms Massey.

Engaging on social media and holding summits to attract attention to the widespread risk that is facing so many girls and the physical and mental consequences of the practice is a good start to eradicating FGM. However, if nurses and midwives do not receive adequate support and guidance, they will not be equipped to help the girls and women at risk.

References

1. City University. Female Genital Mutilation in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk. July 2014

2. Department of Health. Multi-agency practice guidelines: female genital mutilation. 2011. accessed July 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216669/dh_124588.pdf

3. WHO. Health complications of female genital mutilation including sequelae in childbirth. A systematic review. 2000. Accessed 12 August.

4. FORWARD. http://www.forwarduk.org.uk/key-issues/fgm. Accessed 8 August.

5. RCN. Female Genital mutilation: An RCN educational resource for nursing and midwifery staff. 2006. https://www.rcn.org.uk/__data/assets/pdf_file/0012/78699/003037.pdf

6. Home Affairs Committee Female genital mutilation: the case for a national action plan. July 2014. Accessed July 2014.

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