London’s Mayor pays half a million to do women with FGM a dis-service

London’s new Mayor, Sadiq Khan and his Assembly, hosted a first ever People’s Question Time in Brent’s Civic Centre in November 2016. Two children quizzed him about FGM awareness raising in schools and children’s centres. In response, he drew attention to specific work within five London Local Authorities funded by City Hall.

A research report about this work, The Mayor’s Office for Policing and Crime Female Genital Mutilation Early Intervention Model: An Evaluation (MOPAC FGM EIM), was published in January 2017. We are told the work aimed ‘to implement and refine an effective strategy to prevent new cases of FGM among women and girls, while supporting those affected by FGM’. The pilot work’s duration is unclear but may have been just over two years, possibly from October 2014 to December 2016 and while Boris Johnson was Mayor (2008-16).

The pilot was delivered across local authority areas in London estimated to have a high prevalence rate of FGM: an average of 22.7 cases per 1000 population. This compares with an estimated 4.8 for England & Wales. The areas included Hammersmith & Fulham, Kensington & Chelsea and Westminster (the Tri-Borough) as well as Tower Hamlets and Waltham Forest Boroughs.

Health and social service professionals and community organisations were brought together ‘to co-construct an effective and sustainable intervention delivering support to women who have undergone FGM and safeguarding those at risk of FGM.’ Much of the report focuses on positively assessing the impact on service delivery and on the working practices of the professionals. But the insight gleaned from the impact on the 237 women, and some men, is illuminating, and I will concentrate on these aspects.

I do not think spending £0.5M million is a good use of public money, because:
– Only 237 women were seen and their FGM status was not even reported
– Trusted community workers are being used to normalise official involvement in families lives
– Midwives’ professional judgement is being compromised
– Mothers, when not considered guilty of planning to have daughters cut, have suspicion about others’ intent sown
– Therapy is almost compulsory
– An additional £53,750 was spent in engaging men
– A recommendation to continue and extend the model was made

More than half a million pounds spent
More than £502,498 was allocated to the pilot and was shared equally across the three pilot sites. Because just over 237 women were seen, each had on average £1536 invested in them. Additionally, £53,750 was spent funding a male worker (or workers) to work specifically with men. So £556.248.00 was spent in total.

This is a long way from the estimated £25,000 spent annually, by the NHS, on FGM services, prior to the explosion of FGM ‘awareness raising’. But is it a good use of public money?

It’s difficult to assess based on numbers because there were ever only baseline estimates to draw on. Official data being collected by NHS Digital is not corroborating the FGM prevalence rates in England and Wales and local estimates, published by City University in 2015.

Although these estimates were not derived from a bona fide epidemiological study, they nevertheless continue to be cited and treated by officials, the media and campaigners almost as fact. And as for preventing new cases; that was impossible to assess but no doubt looked good in the proposal.

What was the pilot’s impact on recipients?
This is difficult to answer because only 10 (4%) of the 237 women provided feedback: six were interviewed and four were involved in a focus group. The number was fewer than researchers had anticipated because they ‘encountered obstacles to reaching and obtaining consent to be interviewed’.

Interestingly, frontline professionals from a range of services did not seem very interested either. Only eight (8.5%) responded to an e-survey sent to 94. This indicates perhaps that FGM is not as big an issue as the pilot’s membership thinks it is?

Guilty until proven innocent?
None of the women expressed support for the practice and all  unequivocally condemned it. Only two families had not know of its illegality in Britain and were anyway ambivalent about it. None felt pressurised by older relatives or community members to have their daughters cut.

Yet the pilot’s underpinning model stipulated ‘daughters of women who have undergone FGM should be considered ‘at risk’ until and unless a safeguarding assessment demonstrates low risk.’ In other words, the pilot assumed women guilty in their intent to harm their daughters until proven otherwise.

Even in a court of law, people remain innocent until proven guilty. So why do women who have undergone FGM have to prove the innocence of their intent until given the ‘all clear’ by safeguarding professionals?

It’s a pity that the researchers hadn’t included Cultural change after migration by Johnsdotter (2015) in their literature review. They would have learned that substantial change in the practice had occurred after migration because it had afforded migrants opportunities for cultural reflection and a re-examination of their motives for FGM.

Johnsdotter also reported ‘research informants in Sweden as far back as 2002 were already well aware of the legal ban on circumcision of girls and testified that few Swedish Somalis would dare, even though they, in principle, might approve of female circumcision, to have their daughters circumcised. While Somalia offers an environment where circumcision of girls is widely accepted, many Swedish Somalis express fear of the Swedish social authorities and their right to take custody of children by force. Thus, practically all informants testified that they were opponents of the practice, and they cited religion as the main motive: According to the Koran, man should not change what God has created.’ Isn’t it unlikely that 15 years later, the situation is so much worse in Britain?

Other concerns
Because different pilot sites had different policies in regard to how they dealt with a woman who had a daughter or was pregnant with a girl, a new standardised, approach was developed. This was to ensure ‘a new focus on pro-active intervention and safeguarding work, while providing holistic, woman-centred health, social care and therapeutic support to victims.’ The approach included some worrying aspects.

Midwives professional judgement is compromised
Through the pilot, midwives seem to have lost an important aspect of their role; their ability to exercise discretion, based on their professional judgement. Instead, any woman who has undergone FGM must be referred to a social worker, irrespective of need or circumstance. That this is viewed as a progressive development is worrying, and remains unchallenged by the Royal College of Midwives Professional Policy Officer, herself an FGM activist.

A valuable opportunity was missed
Considering the dearth of factual information about the type of FGM women have undergone, the pilot lost an ideal opportunity to report this in women seen by a midwife. I estimate from charts that 113 of 191 (59%) reported their country of origin as Somalia, Sudan and Eritrea where the incidence is reported high and infibulation commonplace.

While the type women had undergone was rightly shared with them, not sharing it in the report misses an important opportunity to add to our collective knowledge.

Community mediators became lynchpins
A heightened suspicion of authorities like police and social services is common among immigrants and refugees. Families in particular worry about children being taken into care for even minor transgressions. That was an acknowledged problem for the pilot.

So they tried to overcome it by using community workers – people known to and trusted by families, to introduce and normalise social care involvement in family life. They soon became ‘the lynchpin of the model’ and were used as mediators to break down barriers and to normalise the involvement of representatives of statutory services like social workers.

Through community mediators, authorities elsewhere have gained a much desired foot-in-the-door. The work of the Avon & Somerset Police demonstrates this well. Following nomination by the charity Integrate Bristol, the South West regional lead for FGM received an award for her FGM community related work.

I wonder whether these traditionally ‘hard-to-reach’ families and communities feel as positive about this development?

Interestingly, representatives from one community organisation from which community advocates are drawn made a telling point: ‘If the kind of engagement driven by statutory services creates barriers rather than dismantling them, and government victimises communities or does not listen to grassroots organisation (we) will stop running FGM projects’ in conjunction with local services.

Safeguarding undermines intergenerational support
It was good to learn that some social workers accepted that women do not automatically intend having their daughters cut, so changed from focussing solely on safeguarding to helping them with actual concerns about housing, service and benefit entitlements.

But the safeguarding aspect took a worrying turn nevertheless. Social workers sowed suspicion among women about elders and communities as potential perpetrators of FGM. They encouraged them to consider how they could keep their daughters safe from those supposedly ready to pounce on an unsuspecting child, once the mothers’ backs were turned.

One social worker explained ‘often it might not be something women want to actively think about, so actually having those conversations sometimes might open up their thinking, just to consider “okay, there are things I might need to be wary of” as opposed to just “okay, you can have her while I go to the shops.’’

So valuable, intergenerational support is promoted as potentially dangerous and is being actively undermined by professionals who favour extending their services’ control over families instead. This can only undermine mothers’ relationships with their extended families and communities, and alienate them from these important support networks.

Nevertheless, two converts expressed interest in becoming FGM ‘awareness raisers’ among community elders.

Women are assumed to need therapy
Activists and professionals have long promoted that mental health is as big a problem as physical health in women who’ve undergone FGM. That’s because ‘FGM is strongly associated with trauma, and also that women who have undergone FGM are more likely, relative to the general population, to have experienced other forms of trauma.’ That may be true. On the other hand it may not be, being dependent on many factors and influences.

Nevertheless, pilot site therapists have found a way of securing their involvement with women and families also. This has resulted in a change to the way the service is offered. Instead of opting in, women now have to consciously opt out. So the pilot was able to report that 75% of women had opted to engage with the therapy service, thereby re-confirming the need for it. Catch 22?

The single case study provided may be unintentionally revealing in describing the effect that official involvement can have on a family’s mental health.

A mother described the consequence for her family of her daughter being subjected to an FGM Protection Order (FGM PO). We are not told why it was sought or granted. But she told staff she had no intention of committing FGM, understands how to safeguard her daughter, and is keen to cooperate with authorities. And her contact with the court had a worse impact on her mental health than FGM had.

She also believed that because of the FGM PO, her children were missing out on important life experiences like the family’s ability to take a holiday abroad. Being repeatedly asked the same questions by professionals left her feeling misunderstood and distrusted. Hardly a good example of a sensitive and caring approach. We weren’t told whether the social worker intervened to try to have the FGM PO lifted.

Breaking the FGM taboo with men
Work with men and boys from potentially affected communities is increasingly being promoted as key to preventing FGM. Engagement with men around this taboo subject also became a component of the pilot’s work. An additional £53,750 was made available to fund a male worker (or workers) to engage with 28 male family members of women who attended the FGM clinics in Tower Hamlets and Waltham Forest. This number exceeded expectations and the work was considered innovative.

Looking ahead
Contrary to the report’s confirmation of an ongoing need for this type of service, it appears to benefit professionals (and researchers) more than women and families. Its continuation therefore needs to be questioned.

It was also thought to have considerable promise as a model in other areas of high prevalence. I think the Mayor should seriously consider this before agreeing, or approving funding for it.

Women who’ve undergone FGM will continue to need sensitive and specialist health care without having to jump through hoops. There is a lot of expertise in the NHS, and professionals should be allowed to provide this, and in collaboration with patients, exercise their judgement regarding additional service referrals.

Update: The research referred to here underpinned the need for the eight new FGM ‘one stop shop’ clinics launched by the NHS 12 September 2019. The new clinic network in Birmingham, Bristol, London and Leeds aims to reach more than 1,300 over 18s before they are pregnant with a range of services, all under one roof.