FGM: the epidemic that never was

As of 31 October 2015, it is mandatory for UK frontline health professionals and teachers to report to the police ‘visually confirmed’ or ‘verbally disclosed’ cases of FGM in under 18 year olds.

This measure is likely to create anxiety among health workers and teachers, because if they fail to report a suspicion they could face internal disciplinary action.

While health professionals’ concerns are valid, it is important to understand that mandatory reporting is the logical outcome of the high-profile campaigns against FGM, many of which were supported by UK health bodies. These campaigns suggest there is a hidden epidemic of FGM. They claim it is therefore necessary to introduce more intrusive and interventionist measures to identify and expose this epidemic – hence mandatory reporting.

For an example of this alliance between health bodies and FGM campaigners, take the under-18s national referral centre, ‘the UK’s first female genital mutilation (FGM) clinic for children and adolescents’, which opened in University College London Hospitals (UCLH) in September 2014. At the time, consultant paediatrician Deborah Hodes said the centre’s formation had been ‘prompted by the increasing number of cases that she and colleagues were receiving’. (I questioned the claims of FGM’s prevalence here.)

Now, one year on, UCLH has published a report on the clinic’s work, with the press-released headline, ‘Almost half of patients at young people’s clinic had suffered FGM’. But that headline doesn’t tell the whole story.

How many patients were seen?

The report stresses that the national referral centre is ‘the only [clinic] for children and young people in the UK’. So you would expect it to have been swamped by potential patients. After all, the NHS estimates that 20,000 girls under the age of 15 are at risk of FGM in the UK each year – 6,000 girls are assumed to be ‘at risk’ in London alone. But the clinic was not swamped by thousands of FGM victims. In fact, over the course of the past year, just 38 patients were seen. Of these, 30 were physically examined and eight were for ‘DVD review’ (that is, medical photographs of suspected ‘victims’ were sent by less experienced clinicians to their UCLH colleagues).

How many referrals had undergone FGM?

Of the 38 referrals, just 18 were found to have undergone some form of FGM. And 11 of those 18 had undergone Type 4, the most minor form of FGM according to the World Health Organisation’s classifications. Type 4 refers to a nick or tiny clitoral cut, which leaves little or no scarring, as opposed to the more extensive genital cutting associated with Types 1-3. Those with evidence of Type 4 FGM would be unlikely to suffer from the health problems, such as urinary tract infections, associated with more invasive cutting, nor would they have needed genital surgery or counselling. As Dr Sonia Grover, an Australian medical expert on FGM, said during Australia’s first FGM trial, a ‘minimal’ nick or cut to a girl’s private parts could ‘hardly count as trauma’. Indeed, it is non-invasive and much less severe than male circumcision which, rightly, is not illegal.

I know through contact with clinicians working in the field that many Type 4 referrals are made out of fear, not conviction. Health professionals worry about missing a case, which could result in a criminal prosecution, as happened to a medical colleague recently. While he was cleared, the prospect of a criminal trial remains a frightening prospect. Little wonder many health workers opt to cover their backs and refer possible FGM cases rather than use their professional judgement.

Still, only seven of the young girls referred to UCLH had undergone more serious forms of FGM. And, according to the report, ‘of these, three had been carried out illegally, while four had been done before the children had come to the UK’. No information is provided about the illegal cases, but even if they were carried out in the UK, three cases does not represent an FGM epidemic.

The NHS’s own data on FGM prevalence among under-18s supports the conclusion that there is no epidemic: between April and June 2015, only nine out of 1,036 new cases recorded involved under-18s.

Are FGM clinics full?

One UCLH consultant stressed that ‘our clinics have been full throughout the last year’. As the FGM clinic is held monthly, it’s probably fair to assume that, allowing for staff leave etc, 10 out of a possible 12 clinics were held during the year. As the clinic received 30 under-18s who were physically seen and examined over the course of the past year, that works out an average of four patients per monthly clinic. By the standards of an NHS out-patient clinic, that doesn’t sound ‘full’.

Of course there is more to seeing FGM patients than physical examinations. UCLH clinicians are also attending to ‘the physical and psychological suffering caused by FGM’, for which they provide ‘sensitive treatment, advice and counselling for those affected’. While it is positive that care of this nature should be available to those who need it, is a national clinic really the right way to provide it, especially given the tiny attendance figures?

What needs to be done?

The zero-tolerance approach promoted by campaigners against FGM in the UK seems excessive given how few under-18s have actually been referred. Although it remains unknown how many females in the UK have undergone FGM, it is likely to be a far lower figure than predicted, based on how few were reported by UCLH during their high-profile campaign and the Department of Health’s own data.

The under-18s who have undergone FGM are likely to be distributed throughout the UK where communities that have traditionally practiced FGM live. It would seem sensible, therefore, to invest in the established and trusted specialist FGM services already in existence, to deal with the needs of children as well as adults. While it may be helpful to continue to have a national referral centre, the need for specialist services should be based on an objective assessment of need.

Above all, FGM needs to be depoliticised, which would stop funding being allocated disproportionately. It would also mean that people who have undergone FGM are no longer made to feel either mutilated or criminal. In Sweden, for example, dialogue, not coercion, seems to be working rather well. This might also help reduce the fear and suspicion that has developed in some communities.

For those concerned about FGM, the aim should be to develop a non-judgemental climate in which girls and women who have undergone the practice feel able to approach healthcare providers and receive sensitive and expert care, without fear of reprisal. Everybody else is encouraged to believe they will receive that kind of healthcare; why should girls and women who’ve undergone FGM be treated any differently?

In this vein, the new mandatory-reporting duty is a major concern. Even before implementation, it was already having a detrimental effect on the health of some under-18s who have undergone FGM and need to see their GP about related or even unrelated health problems. I know of teenagers who are postponing going to their GP’s surgery until they are 18, because they are fearful of the potential consequences for themselves and their families if they disclose that they have undergone FGM. They fear that they or their family will be reported to social services or the police.

The good news is that FGM among under-18s seems far less prevalent than has been asserted. So let’s acknowledge that FGM is not an epidemic, and concentrate on supporting those who need support.

This was first published here 30 October 2015