Female genital mutilation: making the case for good practice.

I asked a 13-year-old girl whether she had been cut. She replied, “That’s horrible isn’t it”, a rhetorical question to which I nodded assent. She felt that it was an appropriate question to ask, given the clinical context. The next morning I read, “Cameron in crackdown on summer surge of FGM cases” (from The Observer, Sunday 14 June 2015). New laws aimed at preventing young girls being taken abroad to undergo what the prime minister described as the “cruel and barbaric practice” of female genital mutilation (FGM) were to be “fast-tracked within weeks, amid fears that the number of cases could soar during the summer holidays”. The headline and story is revealing in a number of respects: it is one of a number of articles, particularly in the lead up to the historic Girl Summit in London in July 2014, that reflect increasing community, professional and political concern over the practice of ‘FGM/cutting’. It signals government determination to eradicate this practice yet does so in a tone and language that might be construed as hostile to the very communities and their activists who put FGM onto the front pages in the first place. Later that week, I was sent a link to the West Midlands Police and Crime Panel press release, which announced that, between January and November 2014, 118 cases of FGM had been referred to the West Midlands Police, and that, while there had been “no reports to West Midlands Police of mutilation in the area”, there had been some intelligence to suggest girls “are brought to Birmingham to be cut”. Is there a ‘summer surge’ when at-risk children and young people from practising communities are more vulnerable? Is there a risk that some of those children will be sent to Birmingham to be cut? Are these evidence-based assertions or the result of careful police intelligence? How can one distinguish truth from rhetoric? What is the situation for at-risk children in the UK? This can only be answered through continuing community action and the careful accumulation of accurate data. The paper by Hodes et al is a fine example of the latter and does as the authors attest, provide a snapshot of FGM within the UK. In order to provide some context for this study, I will briefly trace the relatively recent upsurge in community activism that has prompted a professional, organisational and political response to FGM. I will be selective and will not cover the classification of FGM, its adverse physical and emotional consequences and clinical management as these and other areas have been the subject of a burgeoning literature, a series of excellent recent reports, particularly from UNICEF and WHO and the review by Creighton and Hodes. FGM, the removal or damage of external female genitalia for no medical reason, is proscribed in the majority of countries in which it is practised. It has been illegal in the UK since 1985. Since 2003, it has been illegal for a child to be taken out of the country for the purpose of FGM. It is a violation of human rights and the UN Convention on the Rights of the Child (Article 19). It is defined as child abuse within the UK. Yet it represents a dilemma in child protection in that, despite the potential grave physical and emotional risks to the child, the practice is perceived as a responsible act by practitioners to ensure the child’s rite of passage within their culture. As such, FGM is a locus for contested views on ‘culture’. Korbin argues that failure to allow for a cultural perspective in defining abuse promotes an ethnocentric position, whereas adopting a stance of false cultural relativism in which all judgements are suspended in the name of cultural rights could expose children to risk. It is important to recognise this with FGM, not as an excuse or justification for the practice but to understand why it has persisted from antiquity in order to build preventative strategies for change. It is salutary to trace the emergence of the movement against the practice of FGM. This was deeply rooted in wider issues surrounding community activism and control and supported by organisations such as the Foundation for Women’s Health Research and Development, Africans Unite Against Child Abuse and The Minority Rights Group, groups that remain very active in the UK. African women broke the widespread silence surrounding FGM in the 1950s and 1960s, a period corresponding to the emerging postcolonial discourse when the practice may have been linked with preservation of cultural identity, particularly within impoverished groups in Africa where there was the threat from the dominant culture. There is an association between FGM prevalence and household wealth in African communities, and this is likely to be more so with the additional hardships associated with immigrant status. This theme was picked up in the UK by Webb and Hartley, who argued that any health education initiative targeted towards FGM within practising communities must occur in the context of an overall strategy to improve their health and social welfare. This was true then as it is today. The early efforts to prevent FGM focused on the risks to health, but in the 1980s and early 1990s, the emphasis shifted to encompass FGM as a human rights violation. 6 With this shift in emphasis came new language, with ‘female genital mutilation’ replacing the term ‘female circumcision’. International reports such as the Minority Rights Group Report No. 47 and treaties such as the Convention to Eliminate All Forms of Discrimination Against Women and the UN Convention on the Rights of the Child followed, with reviews in the medical literature, 8 10 11 guidance from the British Medical Association and policy statements from the American Academy of Pediatrics. In the years leading up to the London Girl Summit in London in 2014, there were campaigns on both sides of the Atlantic, backed by The Guardian, and spearheaded by individual activists, survivors of FGM and organisations such as the Orchid Project and Integrate Bristol in the UK and Equality Now in the US, that ‘woke up the world and forced politicians to act’, through petitions and effective lobbying. In the UK, the House of Commons Home Affairs Committee laid out a compelling case for a national action plan. A mandatory duty for regulated health and social care professionals and teachers to report known cases of FGM in girls under 18 years of age to the police came into effect in England and Wales in October 2015. The Health and Social Care Information Centre established an FGM Prevalence Data Set that started in September 2014. This consists of aggregated data from monthly returns from acute hospital providers in England on all Correspondence to Dr Geoff D Debelle, General Paediatrics, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; geoff.debelle@bch. nhs.uk