Contributions to APPG on PDRH – FGM

The year’s first APPG on PDRH (All-Party Parliamentary Group on Population, Development and Reproductive Health) was held on March 2nd in the House of Commons. It aims to support national and global initiatives that increase access to sexual and reproductive health and rights. The meeting’s focus was FGM.

The APPG on FGM which aims to scrutinise the government and public sector’s work in seeking to end FGM in the UK and abroad, no longer appears to function.

A number of ‘stakeholders’ had applied to contribute at the meeting and others were in attendance. We were asked to speak on a topic, in groups, for a maximum of three minutes.

Present were the Baronesses Anne Jenkins, Dr Jenny Tonge, Liz Sugg, Liz Barker and Pauline Latham MP.

Agenda:

1. Welcome by Baroness Jenkin, Treasurer APPG on PDRH (1 min.)
2. Stakeholders round table introduction – name and organisation only (4 min.)
3. Opening remarks by Baroness Sugg, PUSS for DFID (3 min.)
4. NGO present their priority advocacy points international with link to national (3 min. per group)

A. FGM prevalence abroad and the UK – what are the numbers?

B. FGM cutters abroad and the UK – are there changes in practice and if so what changes and by whom?

C.  FGM criminalisation and prosecutions abroad and the UK – what are the benefits and are there any downfalls?

D. FGM education in communities and schools abroad and the UK – are the messages correct, informative and beneficial and from the best service providers?

E.  SRHR/FGM services abroad and in the UK – are women getting the right SRHR/FGM services at the right place/time?

F.  Safe guarding potentially at risk children abroad and the UK – mandatory reporting: does it work?

G. Other important FGM topic that must be raised?

Zainab Nur, Hidden Voices UK,  Amy Abdelshahid (FORWARD) and Bríd Hehir (ShiftingSands) were allocated to Group F.

Zainab Nur 

Safeguarding girls from the ancient practice of female circumcision is something I am passionate about and have over 30 years experience in. I don’t use the derogatory term FGM.

As a result of the ‘FGM awareness raising’, the coalition government brougt in additional legal measures to safeguard girls in 2015.

Through my work with communities, I have seen the negative impact of these safeguarding measures. African women who have had historical circumcision are being victimised and stigmatised. I have compiled details of cases to show how FGM safeguarding is negatively impacting on marginalised communities. Families have being wrongly targeted and have had children removed just because they belong to a particular ethnic group.

Many have encountered these interventions through the misue and/or misunderstanding of the ‘mandatory reporting’ duty. This has led to children being placed on FGM Protection Orders. The orders are difficult to contest due to lack of legal funding, or misrepresentation of FGM prevalence in Africa and the U.K.

Some of the cases I have worked with were highlighted by BBC Wales, June 2018 and the Victoria Derbyshire show, January 2020. For example, a young mother discloses that she’d been circumcised. She is automatically referred to social services because she and her daughter are deemed ‘at risk’. 

Referrals like these have caused a lot of distress to families. The system that claims not to discriminate, in reality racially profiles African communities. They are viewed with suspicion, not believed, made to feel like criminals, stigmatised and blamed. They told us so in a recent public meeting in London. 

Yet, since the introduction of these safeguarding measures, we have not seen any data about how effective they are. Or the outcome of the cases reported.

Bríd Hehir 

A child’s safeguarding interest is paramount and we invest a lot in trying to ensure this.

As a clinician, my inspiration were Goldstein et al who advised that we put ourselves in a child’s skin as we try to decide what guiding principles would best serve her interests.

As autonomous professionals we were not expected to just follow procedures when considering these interests. But to behave responsibly and make judgment calls.

In regard to FGM, some girls’ best interests are overlooked in favour of policy dictats and legal imperatives.

Mandatory Reporting of under 18s to the police e.g. prevents professionals from exercising judgement and undermines their autonomy. And may even breach patient confidentiality.

I believe families would be better served through informal and low-profile interventions.

FGM safeguarding measures need reviewing. Using the child’s ‘best interests’ criterion would be a good place to start.

Dr Brenda Kelly, Consultant Obstetrician and Clinical Lead for the Oxford Rose Clinic also made an important contribution to the discussion about mandatory reporting in the context of the need to evaluate the impact of FGM legislation.

In her experience, reporting under 18s with FGM to police had had unintentional harmful consequences on their health seeking behaviour. Some failed to return for care while others were deterred from seeking help in relation to other health concerns for fear of being reported to police.

Participatory Action Research in Oxford in 2018 had identified that some women in the community didn’t seek help in relation to their FGM, believing (mistakenly) they would be reported to the police.

Some colleagues have allowed me to share their oral statements.

Alison Macfarlane (Group A)

Exact numbers of women who have been cut is unknown but at least 200 million women living in the 31 countries which collect data through representative surveys have been affected. FGM is also practised to some extent in some other countries which do not have representative data.

The proportions of women aged 15-49 who have been cut range widely from over 90 per cent in in Djibouti, Somalia and Guinea to under 10 per cent in Benin, Cameroon, Ghana, Iraq, Niger, Togo and Uganda. Rates are usually lower in younger women. They have been falling in most countries to a varying extent. Rates  among girls aged 0-14 have fallen more quickly suggesting that recent elimination campaigns have been successful.

FGM rates vary widely between regions within countries. In Ghana, FGM is practised in only one region and in Iraq it is practised only in Kurdistan. Recent analyses of data from successive surveys within the same countries have identified ‘hot spots’ where rates have remained high. In many of these high proportions of girls have been cut as very young babies.

Most of the women with FGM living in the countries of the UK were born in countries where FGM is practised so the numbers depend on numbers of women who have migrated here. It has been estimated that in 2011 in England and Wales, there were 103,000 migrant women aged 15-49, nearly 10,000 girls under the age of 15 and 24,000 women aged 50 and over with FGM. The Department of Health collects data and about women with FGM who receive hospital care in England. The data are of poor quality but suggest strongly that very few of them were cut in this country or while living here.

Marge Berer (Group C)

In countries where it is practised, female genital cutting (FGC) is a traditional practice based on shared values of family honour, female virtue, sexual restraint, and other codes of conduct. Ostracism of the family and being unable to marry for the girl are the punishments for not conforming. Criminalisation aims to prevent and punish harmful behaviour. In countries where there is a very high prevalence of FGC, such as Egypt and Sudan, families with girl children are all potential criminals. No one wants their own family members to be prosecuted. Research I published in the journal Reproductive Health Matters from a range of African and Middle Eastern countries in the past 25 years and recent research by the Population Council shows that eliminating FGC needs positive policies with social and cultural legitimacy for those practising FGM, alternative rites of passage, improved status of women, public education and discussion, and the involvement of trained health professionals to provide appropriate care during pregnancy and for other FGC complications. Where people fear prosecution, the practice goes underground.

In the UK, criminal prosecution has also not succeeded because (admittedly scarce) evidence indicates that FGC is not much done here. Last year, however, a woman living in the UK from a country that does not practise FGC, and who was not cut herself, was sentenced to 14 years in prison for FGC of her three-year-old daughter; I have published an in-depth analysis of why her conviction was unsafe and must be appealed.

Susan Bewley (Group B)

LANGUAGE. We need to emphasise the ‘wrongs’ rather than ‘harms’ of the practices. Otherwise, we will see what’s happening outside the UK with the age of cutting (so it’s less a puberty rite and more of a healthcare procedure). Because of the emphasis on short-term dangers (pain/ bleeding/ infection/ mortality), parents might be tempted to use Doctors to carry on the tradition but with a “less harmful” practice. This should be called out and characterised as MEDICALISATION as condemned in UNFPA 2018 briefing.

It turns a social norm into a profitable medical procedure. It might be presented as ‘harm minimisation’ but is sinister. It might be less harmful, or more or differently harmful? There are still complications. Also new, supposedly ‘safer’ practices are evolving as healthcare professionals might use clean instruments and antibiotics or even anaesthetics and diathermies. Doctors might be able to remove more tissue and do more damage that is harder to reverse later. It certainly betrays the trust of the profession ‘first of all do no harm’ while embedding and giving authority/rationalising and embedding the practice. All the while getting paid, of course.

Zainab Nur, Hidden Voices UK and Bríd Hehir, Shifting Sands collaborated on a briefing paper (below) to expand on points made in their oral statements. A digital copy is with Ann Mette Kjaerby – Parliamentary and Policy Advisor, for circulation to APPG members.

FGM Safeguarding

• NHS Digital data (limited as it is) demonstrates that fewer new FGM cases are being identified in Under 18’s and that most happened before their arrival in the UK

• Genital piercings are the main type now being identified in under 18’s. And anecdotally we believe this is in pregnant, caucasian teens

• The negative effect of years of safeguarding interventions is well illustrated in Bristol University’s Policy Report which can be accessed here. These have resulted in a community’s loss of trust in health services, anger at school’s misuse of power and being scared and mistrustful of social services and the police

History

FGM has been a specific offence since the Prohibition of Female Circumcision Act 1985. The Act applied to the whole of the UK. It was replaced by the Female Genital Mutilation Act 2003. This was further amended by the Serious Crime Act 2015.

A raft of measures were introduced via this 2015 Act in response to what has been termed a ‘silent epidemic’ of FGM. Despite being promoted by the police as ‘Community Driven Solutions’ many within targeted communities find them hugely problematic.

The Serious Crime Act made provision for:

• Guidance about FGM
• An offence of failing to protect girls from risk of FGM
• A duty to notify police of FGM
• FGM Protection Orders
• Extra-territorial acts
• Anonymity for victims of FGM

FGM Protection Orders

Their aim was to protect girls against the commission of an FGM offence and protecting them from it. They were fast-tracked before the 2015 ‘cutting season’ and to address the ‘tip of the iceberg’ problem. It was also hoped they would make successful prosecutions more likely.   

FGMPO’s have been described as putting ‘protective bubble wrap’ around a child. They may contain conditions like surrendering a passport to prevent the person deemed at risk from being taken abroad to undergo FGM, or requirements that no one arranges for FGM to be performed on the person being protected. An order can also seek the return of an FGM victim from abroad being prevented from returning.

Between July 2015 – June 2019, 418 were made. We don’t know how many were subsequently withdrawn. Reasons for the applications or details in regard to them are not easily accessed or readily available, so there is no public accountability in this regard.

Parents have reported their distress at what they perceive as the unfair granting of some POs. While much of this is kept private, things are slowly changing as the Victoria Derbyshire programme illustrated in Jan 2020.

Particular families say they are being targeted and viewed with suspicion when applying for a visa for African countries, irrespective of where they intend travelling there. It’s as though Africa is viewed as one country where all children are ‘at risk’ of the most severe type – infibulation.

Other concerns include the perceived low level of evidence that seems to be required when court applications are made, and the damage that these PO’s can inflict on children, families and communities.

Community representatives have expressed particular concerns about the unprofessional way in which ‘suspects’ are treated by professionals, some of whom are considered overly zealous in their determination to identify girls/young women ‘at risk’.

There is an urgent need to obtain accurate data about FGMPO’s and to review their use and efficacy. This should include gathering feedback from families, community representatives and professionals.

Mandatory reporting

Regulated health and social care professionals and teachers are subject to this legal duty – to report to the Police when in the course of their professional work under 18s ‘verbally disclose’ FGM, or professionals ‘visually confirm’ it. 

Complying with the duty is said not to breach confidentiality requirements or other restrictions on disclosure which might otherwise apply, although this is contestable.

Reports have to be made within a month of the initial disclosure/identification. Failure to comply is dealt with via professionals’ disciplinary frameworks.

There is not publicly available data about these referrals. In June 2018, Freedom of Information requests were sent to all 45 UK police authorities and to health and social care organisations, asking the number of cases of FGM reported between specific dates, victims’ ages, the occupation of the person reporting and the age and gender breakdown of the police force.

Of 45 police authorities, six responded, with three stating that no cases of FGM had been reported. The remaining police authorities either provided partial information or declined the request.

In order to determine how useful the mandatory reporting duty is, and whether it should continue, legislators and the public need to know from: 

The Police

• How many reports they have had as a result of this duty?
• Which professionals made the reports?
• How many and what type of FGM were visually confirmed? 
• How many were disclosures? 
• What age were the referred girls?
• How many had undergone FGM abroad?
• How many had undergone FGM in the UK? 
• What actions did the police take following receipt of the reports?
• How many were referred to specialist centres at UCLH, Birmingham or Manchester?
• What was the outcome of each referral?

Referred children and families

• How did each under 18 experience the referral?
• How did their families experience the referrals?
• What was the outcome for them?

Professionals who’ve made referrals

• What was their experience of this duty to report?
• Did any feel they were breaching patient confidentiality and how did they reconcile this with their practice?
• Have any been disciplined in regard to the duty?

Mandatory recording and centralisation of sensitive patient data: differential care?

Since 2015, a ministerial directive by then public health minister Jane Ellison, has obliged clinicians to collect specific patient information from children and women who have undergone FGM, and to centralise it to NHS Digital. This, in addition to an NHS number, includes identifiable personal information like name, date of birth, address and post code. 

While each patient must be told that her personal data is being collected, she does not have to give consent for this to happen. This is the only known patient group that such a directive applies to.

Women are understandably concerned at being singled out for differential NHS care and being denied the same rights to privacy as other patients. 

Operation Limelight’s predictive role?

This is a joint operation between UK Police & Border Forces to identify girls at risk of FGM (and forced marriage) and to help prevent them. 

This is a contentious development and even officials consider the overall impact of the operation limited. They approach people traveling from countries where they believe FGM to be common and encourage them to report concerns. Staff look for anything unusual in a person’s demeanour, e.g. whether they are uncomfortable walking, standing or someone else is holding their passport.

But innocent people from ‘countries of prevalence’ who are simply taking advantage of long school holidays to take children to see relatives overseas, believe they are being unfairly targeted and have to jump through hoops just to go on a family holiday. 

Is the Operation going to be evaluated and against what criteria?

FGM-IS – A deterministic approach to health care?

The FGM-IS (Information Sharing system) is a national digital system which shares information within the healthcare record of a girl under 18 – if she has a family history of FGM – between authorised healthcare professionals and administrative staff across England. 

FGM-IS ‘supports effective early intervention and ongoing safeguarding of girls who are potentially at risk of FGM.’ Permission is not sought about adding or sharing this information however.

But predicting that a girl is ‘at risk’ of FGM can only be done through an individual level assessment, not by making deterministic assumptions based on her mother’s status.

Recommendation

All FGM safeguarding measures need reviewing. Using the child’s ‘best interests’ criterion described by Goldstein et al would be a good place to start.

The contributions and roundtable discussion were recorded but as the meeting was not a public one, notes from it cannot be posted here.