Anti-FGM legislation has been in place in the UK since the Female Circumcision Act (1985). The law was further refined by the implementation of the FGM Act (2003), which extends to cover FGM abroad in certain circumstances.
It is noteworthy that type 4 FGM refers to pricking and piercing of the external female genitalia for non-medical reasons and is illegal. This creates a challenge when a patient presents with genital piercing for aesthetic reasons.
There have been no convictions for FGM in the UK, despite the possibility of FGM being one of the most prevalent forms of child abuse in the country. Reporting is also low, and the Home Affairs Select Committee has called for the reporting of FGM to be statutory.
So what can GPs do?
It is imperative that GPs undertake regular mandatory Safeguarding Children level 3 training as stipulated by the intercollegiate guidelines of 2014, as well as specific training in the management of FGM. The DH MultiAgency Practice Guidelines on FGM of 2011 is an important guide in the management of FGM.
A high degree of sensitivity and expertise is required in eliciting that FGM may be planned, including an awareness of the risk factors for FGM, such as the patient being a member of a practising community, and/or the mother having undergone FGM. If FGM has already been performed patients may present with recurrent UTIs, painful periods, infertility or even post- traumatic stress disorder (PTSD). Sometimes, a girl or woman may be unaware that she has undergone FGM and it may only come to light when symptoms are explored or an examination is performed. It may not be evident until a woman presents in labour.
There are also issues around the reporting of FGM, which may culminate in profound consequences for the individuals involved, including being cut off from their community. A lack of due sensitivity and expertise in managing patients who have undergone FGM, or are at risk of FGM, may result in patients, their families and even their communities being fearful of confiding in doctors in the future. They may avoid appointments for acute and chronic medical problems – including the physical and psychological sequelae of FGM – and may miss other routine appointments, such as for antenatal care, cervical smears and vaccinations. The impact of this carries huge individual and public health implications.
NICE guidelines on FGM are being developed and efforts are underway by the relevant statutory and voluntary agencies to ensure the necessary information and support is in place for clinicians and patients.
GPs have a crucial role in safeguarding the survivors of FGM and those at risk of this practice. We must strive to ensure we are all versed in the correct management of FGM so that we fulfil our duty of care to patients and protect the public interest.
Bearing in mind the limited consultation time, GPs should consider using the three Cs questionnaire*:
- Do you come from a community that practices cutting (FGM)?
- Have you, or any of your family members, been cut?
- Do you plan to have your daughter(s) cut?