Dr Louise Newson, Medical Editor for Women’s Health, argues that GPs have a crucial role to play in tackling female genital mutilation
As a GP I have a responsibility in safeguarding and providing support to women who have experienced, or who are at risk of, female genital mutilation (FGM). FGM is still widely practised in more than 29 countries across Africa, the Middle East and Asia.
FGM is done for many reasons; although there is no single religious basis. In some cultures, a woman who has not undergone the procedure may be thought unmarriageable. Female genital cutting is a deeply rooted tradition that confers honour on a woman and her family, yet also a traumatic experience that creates significant dermatological, gynaecological, obstetric and infectious disease complications The World Health Organization (WHO) defines it as ‘all procedures that involve partial or total removal of the external female genitalia, or another injury to the female genital organs for non-medical reasons’.
Traditionally, the procedure is undertaken by women with no medical training, anaesthetics are not used and various techniques have been described. These involve the use of knives, scissors, razor blades and pieces of glass. I cannot begin to imagine the emotional trauma this causes to so many young, innocent girls. It is no surprise that these women have an increased risk of developing depression, anxiety and post-traumatic stress disorder.
There are no health benefits from FGM
The statistics regarding FGM are staggering and worrying. More than 140 million girls and women worldwide have undergone FGM and around 137,000 girls and women are living in the UK with the consequences of FGM.
FGM is illegal in the UK and can result in up to 14 years in prison. There are no health benefits from FGM and FGM can lead to considerable harm and even, in some cases, death. Over recent years, there has been a large increase in the number of migrants and this has resulted in an increasing number of GPs seeing women with health consequences of FGM and also young girls who are at risk of FGM. Those at increased risk are those born to a mother who has had FGM and also siblings of those children who have had FGM.
As healthcare professionals, we need to be familiar with current guidelines regarding FGM. New NHS requirements for the reporting of FGM are being implemented, but there is still much confusion as to how this is formally done in practice. So, how do we identify these women and girls in our practice?
4Cs risk assessment tool
They are unlikely to tell us about their experience of FGM and many of these women will not understand the term mutilation. I have recently read about the 4Cs risk assessment tool, which I thought was excellent.
The 4Cs are: “Do you come from a community that practices Cutting?”, “Have you or any member of your family been Cut?”, “Does anyone intend to Cut you or anyone you know?” and “Do you or anyone you know intend to have your daughter(s) Cut?” These are all questions that I can use without feeling too awkward or embarrassed. We should consider asking women opportunistically – for example, at antenatal booking, sexual health screening, vaccination clinics and even at new patient registration appointments.
We should be training other members of our practice team to ask these or similar questions in a sensitive and non-judgmental manner.
It is then important that we all know what to do with the information. Current recommendations state that if there is a concern that a child is at immediate risk of FGM, or has had FGM, then a referral must be made to either social services or the police. However, what we should do regarding adult women who have had FGM seems to be less clear. We should make appropriate referrals to manage the psychological and physical complications of FGM. We all need to ensure we have fulfilled our professional safeguarding duties in line with our duty of care, in accordance with current national and local guidance. In addition, patients should be informed about the illegality of FGM, which is a clear abuse of women and children, and outline the potential complications of FGM, highlighting the possible harm that this procedure can cause.
Patients and their families should be directed to contact community groups or the NSPCC Helpline (0808 800 5000/0800 1111), which can support both professionals and family members. GPs are not currently required to record FGM in patients’ notes.