This chapter considers women and girls resident in Nottingham City who are at risk of or who have undergone Female Genital Mutilation (FGM), either in the UK or abroad. Female Genital mutilation can affect women of all ages, however FGM is mostly carried out on girls sometime between infancy and adolescence.
FGM is a form of child abuse and is illegal in the UK and is described by the World Health Organisation as:
‘all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non‑-medical reasons’.
This procedure has no health benefits for women and girls, can cause severe short and long term health problems and is recognised internationally as being a violation of the human rights of women and girls.
FGM is a worldwide issue with an estimated 200 million women living with FGM in the world (World Health Organisation (2), 2016). However, women and girls from some communities are at increased risk. In some African countries, such as Somalia, the estimated prevalence of FGM is as high as 98%.
In Britain, FGM is seen in ethnic groups that have migrated from Egypt, Eritrea, Ethiopia, Gambia, Iraq, Kenya, Kurdistan, Liberia, Mali, Nigeria, Northern Sudan, Sierra Leone and Somalia.
Dispersal of asylum seekers across the UK makes increasing numbers of all education professionals likely to come into contact with girls and women who have undergone and girls who might be at greater risk (Nottingham City and Nottinghamshire County Safeguarding Boards, 2016).
It is estimated that within the UK there are 137,000 women aged 15+ living with the consequences of FGM (McFarlane, 2015). As FGM is a hidden issue, as such the figures we can get from the prevalence data are likely to be a huge under-representation of the true size of the issue, which often only comes to light when related health problems occur or the women is pregnant.
In Nottingham there were 80 cases of FGM recorded by healthcare staff in 2015-16.
Women and girls are at increased risk of FGM where there is a history of FGM in the family or if they are from a community or ethnic group where FGM is highly prevalent or part of the culture of that community (although this does not always mean FGM will take place).
There are various ‘given reasons’ to pressure women and girls to undergo FGM including economic reasons associated with marriageability and dowry, social and cultural reasons associated with honour and acceptance as well as perceived hygiene reasons.
Whatever the reasons advised for the practice, FGM is child abuse, it is illegal and it violates human rights, that women and children should be protected from cruelty and violence.
There is on-going work locally and nationally to prevent and respond to FGM, more information on local and national response to FGM can be found in section 4 of this document.
Unmet needs and gaps
- The FGM board members are currently working with NHS England to establish if FGM examination should be included within the service specification for the East Midlands Paediatric Sexual Assault Referral Centre (SARC), intended to be commissioned in the near future. There is some debate and uncertainty at present about which service should undertake FGM examination. Currently there is no commissioned service to examine children and this is undertaken by the Designated Paediatrician which is outside of the commissioned role. Due to a lack of specialist knowledge in this area and examinations falling outside of commissioned health roles, it is uncertain who will complete these in the future.
- Nottingham currently has an FGM clinic and an FGM specialist midwife, it is unclear as to the long term succession arrangements for the continuity of the service, which may result in a service gap for survivors of FGM. Due to a combination of funding and lack of specialist knowledge of FGM amongst the current workforce, two midwives have been seconded to the FGM clinic as succession of the previous specialist midwife, however it is not clear how the temporary nature of a secondment will affect the clinic in the longer term. This service could cease in the long term unless succession planning is implemented now. This is particularly important as acquiring FGM specialism involves much on the job training with specialists in the field, if this cannot happen before specialist knowledge exits the workforce in Nottingham, acquisition of specialist skills will be difficult for any long term successor.
- The current FGM clinic is not intended to provide services to non-pregnant women as it is midwifery led, however historically women have been seen here outside of these commissioned arrangements. Going forward it is not clear where these women would receive a service. There is no clear pathway for non-pregnant women to receive service and support as well as no associated trauma-based psychological support available for them. It may be appropriate for a service to be provided jointly with midwifery and clinical gynaecology specialists due to the wide health impacts FGM can have. A clear pathway needs to be developed for non-pregnant women, so that all professionals are clear on their roles and responsibilities in relation to this group and survivors themselves can access the support they need. To not provide this service may be a missed opportunity to engage with both women requiring healthcare but also their families and children who may be at risk of FGM.
- Local intelligence suggests there is concern around how effectively current mental health services are able to support FGM survivors. Local voluntary sector services report that due to a lack of understanding around FGM, the implications, the wider context and given reasons for FGM, this can make survivors feel that they are not understood and this can impair their experience of mental health support. Further to this, survivors have expressed that they sometimes feel judged when they have encountered mental health support, which has been a barrier to access and meant they ceased using services.
- Local intelligence suggests there are concerns regarding healthcare professionals awareness of support available for survivors of FGM, such as the Mojatu survivors group, and as such women are not being signposted and are not getting access to support available.
Recommendations for consideration by commissioners
Prioritisation should be given to finding a solution for effective longer term succession of the Nottingham FGM clinic and specialist midwife to ensure continuity of services for survivors. Multi-agency statutory guidance advises commissioners should ensure services are provided to meet the physical and mental needs of women and girls who have undergone FGM as appropriate.
- Focus should be given by commissioners to explore whether mental health support in the city is meeting the needs of survivors, if not the reasons for this, and consider whether further training is required or a specialist service.
- Prioritisation should be given by commissioners to work with the specialist midwife, police, NHSE and Nottingham CCG to ensure service continuity of examination of girls under 18 suspected of having undergone FGM whilst discussions are underway to decide where examination should sit, (potentially the paediatric sarc).
- Prioritisation should be given to creating a clear pathway for non-pregnant survivors of FGM, so that they receive a holistic service that meets their needs. CCG’s, NUH and the FGM board should focus on finding a solution to this gap in provision.
- To undertake a training audit may be useful to identify any service areas where lack of understanding of FGM could discourage disclosure or create barriers to access of services for survivors of FGM. This would also be useful in identifying how many frontline workers would be able to effectively respond to FGM.
- Further insight to be undertaken into what community work is being conducted in Nottingham, as this was cited as one of the key mechanisms for preventing FGM and changing attitudes towards FGM.
- Promotion of specialist FGM services such as survivors groups and specialist midwife may increase women coming forward for help and support. However, if this is promoted, work may be necessary to establish if services could cope with increased demand.