We should all be anti-FGM activists, but our activism needs to be in the community not in our consultations.

The issue of female genital mutilation (FGM) has been one that has risen in the public consciousness over recent years. The Serious Crimes Act 2015, consolidated and extended previous legislation targeting the practice; placing an obligation on healthcare professionals, social workers and teachers to notify police if they believe children under their care are vulnerable to FGM.¹ Within healthcare, what does the law require from professionals and how should healthcare workers be expected to handle such cases?

Firstly, a brief overview of what FGM is. In short, any procedure to remove part of or all of the external female genitalia for non-medical reasons is classified as FGM. There are many assumptions and prejudices that are common in discourse surrounding FGM and it is important to address these.

The ‘non-medical’ aspect of FGM is vital as it has no health benefits whatsoever (I will come back to this shortly).² Labels such as ‘female circumcision’, although more palatable than ‘mutilation’, are incorrect as circumcision suggests potential health gains, which in the case of FGM there are emphatically none. Furthermore, the label ‘circumcision’ has a sanitising effect which is damaging. Language is powerful, and unless we make an effort to call it what it is, how can we effectively demonstrate that this is an assault on young women? Traditionally the practice was carried out by prominent local community members however, in recent years there has been an alarming rise in the number of medical professionals around the world who perform the procedure.³ Not only is this worrying with regards to Hippocratic non-maleficence, but undoubtedly this only serves to further legitimise the practice amongst those who seek it.

There is also an assumption that FGM not only has a cultural basis but a religious one also. This too is incorrect, with no religious canon sanctioning it. Although FGM is practiced in parts of the world where Islam is prevalent, it is not an Islamic custom. FGM is common amongst Christians also. While FGM does not originate from faith, many faith leaders promote it in the parts of the world where it is common, to devastating effect.^{3, 4} Particularly in today’s climate, as health professionals it is important to make this distinction between eastern faith and eastern cultural practices. FGM is cultural.

Advocates of FGM suggest that it prepares girls for marriage and protects them from sexual promiscuity. Indeed, in some cultures men refuse to marry women who have not been mutilated (I know it’s not easy to read that word, but again, language is important in our advocacy) believing it to be an indication that she may not be a virgin or be unclean.⁵ Although this practice historically has origins in authoritative patriarchy, women are often advocates of FGM with many mother’s insisting that their daughters be mutilated, even though they bear the physical and mental scars of having been mutilated themselves.⁴ This epitomises how deep the cultural roots of FGM are and the significance it holds amongst its supporters. People genuinely believe that this practice is in the interests of the people they love. Despite the trauma it may cause and the trauma it caused them themselves, as based on their value system they feel duty bound to ensure that their daughters are mutilated because, they believe it to be of the upmost benefit. Families do not do this to their children out of malice but paradoxically out of love. This is important to be aware of when encountering families who are supportive of FGM.

The original questions of what the law requires and how health professionals should be expected to handle cases of suspected FGM, is an issue which needs further examination.

 FGM for many health professionals, in parts of the world where FGM is culturally alien, is a very emotionally provocative issue. And indeed in a previous post Rani Chowdhary eloquently presented a call to arms to address this on a community level. What I suggest now may be uncomfortable for some, but I believe that it is important in how within a health context, we address this practice amongst our patients effectively. I encourage us all to become active anti-FGM campaigners, let us just remember that our personal views, emotions and activism has no place in the consultation room. Our patients require our professional services and our humanity. A distinction needs to be made between the cultural practice and the patient in front of us. When dealing with a victim of FGM in our clinics, surgeries, hospitals and schools we should have one concern and one concern only: the girl or woman’s health.

When treating our patients who have suffered from FGM, what is required of us is to attend to the patient’s medical (physical and mental) needs that arise out of this non-medical procedure.⁶ Let us attend to the patient medically, remembering that she does not need to be burdened with our horror at what has happened to her. Remembering she too may sincerely believe that what has happened to her was both important and necessary. Remembering that there is a vast social web surrounding this event and the people responsible for what happened are likely to be the people she cares most about.

I would like to stress that I am not advocating shedding safeguarding responsibilities. If your patient is a child, this is a criminal offence and the case must always be referred to the police and social services,¹ and the department of health has a clear algorithm on how to escalate the situation.⁷ For the women we encounter we need to do our utmost to ensure that she has access to all the support that is available. As healthcare professionals though, the extent to which we need to deal with the criminal aspect is by making that referral.  As healthcare professionals what our patient requires of us is our expertise to treat her medically. If we feel moved towards activism for changes on a social level, all the better. But that can only start when she leaves the consultation room.

John Bartoli-Abdou is a research pharmacist and PhD candidate in the Institute of Pharmaceutical Science. His research focusses on adherence to medication. He has a special interest in global health and development and has previously spent time working in Egypt, Kenya and Nigeria

References

1. Mandatory Reporting of Female Genital Mutilation – procedural information [Internet]; c2016 [cited 2017 02/28]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/573782/FGM_Mandatory_Reporting_-_procedural_information_nov16_FINAL.pdf.
2. Sunday-Adeoye I, Serour G. Management of health outcomes of female genital mutilation: Systematic reviews and evidence syntheses. Int J Gynaecol Obstet 2017 Feb;136 Suppl 1:1-2.
3. Global strategy to stop health-care providers from performing female genital mutilation [Internet]; c2010 [cited 2017 02/28]. Available from: http://apps.who.int/iris/bitstream/10665/70264/1/WHO_RHR_10.9_eng.pdf.
4. Female Genital Mutilation: Caring for patients and safeguarding children. Guidance from the British Medical Association [Internet]; c2011 [cited 2017 02/28]. Available from: https://www.bma.org.uk/advice/employment/ethics/children-and-young-people/female-genital-mutilation.
5. Men’s and women’s perceptions of the relationship between female genital mutilation and women’s sexuality in three communities in Egypt: Social science policy brief [Internet]; c2010 [cited 2017 02/28]. Available from: http://apps.who.int/iris/bitstream/10665/70468/1/WHO_RHR_HRP_10.17_eng.pdf.
6. WHO guidelines on the management of health complications from female genital mutilation [Internet]; c2016 [cited 2017 02/28]. Available from: http://apps.who.int/iris/bitstream/10665/206437/1/9789241549646_eng.pdf.
7. FGM mandatory reporting duty: guidance for healthcare professionals [Internet]; c2017 [cited 2017 02/28]. Available from: https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare.