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Female Genital Mutilation (2017)

Topic titleFemale Genital Mutilation (2017)
Topic ownerHelene Denness, Public Health Consultant
Topic author(s)Grace Brough, Insight Specialist Public Health
Topic quality reviewedJuly 2017
Topic endorsed byFGM Board Steering Group
Topic approved byFGM Board Steering Group
Current versionAugust 2017
Replaces versionN/A
Linked JSNA topicsSafeguarding
Insight Document ID186956

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Executive summary

Introduction

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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

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  1. 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.
 
  1. 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.
 
  1. 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.
 
  1. 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.
 
  1. 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

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  • 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.

What do we know?

1. Who is at risk and why?

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What is FGM?

FGM is a form of child abuse and is illegal in the UK; the Serious Crime Act 2015 extends this illegality beyond the UK, prohibiting acts of FGM committed abroad by a UK national or someone who is resident in the UK. Female Genital Mutilation (FGM) is described by the World Health Organisation:

‘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 sometimes referred to as ‘female genital cutting’ or female circumcision’. However, it is preferred not to associate FGM with circumcision due to the severity of the procedure in comparison to male circumcision. Male circumcision involves removing the foreskin of the penis without causing damage to the penis, whereas FGM can cause significant health problems for the women and girls involved.

Whilst FGM is the preferred term, in communities where FGM takes place there are often local terms for this. Forward have identified various terms that may be used in communities in order that practitioners can discuss the procedure with survivors.

There are four types of FGM:

Type 1: Clitoridectomy- This is partial or total removal of the clitoris and or the clitoral hood.
Type 2: Excision- This is removal of the clitoris and the labia minora, sometimes this will also include removal of the labia majora.
Type 3: Infibulation- This is the tightening of the vaginal opening through creation of a ‘seal’.
Type 4: Other- This includes any other form of procedure on the female genitalia for non-health reasons, such as piercing, pricking, incising, scraping and cauterizing the female genitalia.

FGM is most often performed by someone with no medical training, often elders who play a central role in the community, and conducted in unsterile or unsanitary conditions. Girls are given no anesthetic, no antiseptic treatment and are often forcibly restrained. The cutting is made using instruments such as a knife, pair of scissors, scalpel, glass or razor blade, sometimes the same blade is used to cut several girls. In some countries FGM is performed by health professionals in a ‘medicalized’ setting, such as Egypt, Guinea, Kenya, Nigeria, Northern Sudan, Mali and Yemen (Serour, 2013). This is still harmful with many short and long term health impacts.
 

Worldwide prevalence

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%.
A more detailed map showing prevalence of FGM (Unicef (2), 2016)is shown in figure 1


Figure 1: Prevalence of FGM

Source: UNICEF global databases, 2016, based on DHS, MICS and other nationally representative surveys, 2004-2015.

The highest FGM prevalence rates, 90% or more, are found in Djibouti, Guinea, Sierra Leone, Somalia and Sudan. Eritrea, Egypt and Mali also have very high prevalence rates, more than 80%.

The type of FGM performed is often linked to ethnicity. For example, one in five daughters has undergone the most invasive form of FGM, type 3, in Somalia, Eritrea, Niger, Djibouti and Senegal (Unicef (1), 2016).
 
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 must be acknowledged that dual heritage girls may also be at risk of FGM, particularly if FGM has been carried out on their mothers, sisters or extended family (NSPCC, 2016).

Risk factors for FGM

FGM is mostly carried out on girls sometime between infancy and adolescence, however, FGM can happen at any age. In the UK young girls at risk of FGM between the ages of 7 and 10 years of age, although it is acknowledged FGM can happen at any age (Nottingham City and Nottinghamshire County Safeguarding Boards, 2016). Risk factors for FGM include:
  • A history of FGM in the family; especially if the mother has undergone FGM
  •  Being a woman/girl are from a community or ethnic group where FGM is highly prevalent and a part of the culture of that community (although this does not always mean FGM will take place).
Local intelligence suggests girls are also at higher risk of FGM in the run up to and during the school summer holidays, as they are able to have a longer time off to recover from FGM before returning to school.

FGM is sometimes considered as having a religious connection. This is not the case and in no holy book is FGM endorsed. Some people who are Christian, Muslim and Jewish carry out FGM, some people of these religions do not, it is not specific to a religious faith and not all people of that faith will conduct this practice.

Worldwide economic pressures can play a part in perpetuating the practice of FGM. Some practising communities believe their daughter will not marry unless she has undergone FGM. This belief alongside the reliance on dowry for family income perpetuates the practice of FGM, particularly in rural communities. In most countries, FGM prevalence is lower among girls in the wealthiest households (Unicef (1), 2016).

In addition, community elders often play the role of cutter for the whole community, earning a living conducting FGM for a fee, so it is in their interest to perpetuate this practice. There are various ‘given reasons’ for practicing FGM, for example women and girls are told they will gain respect and honour for themselves and their families. These ‘given reasons’ pressure women and girls to undergo FGM. ‘Given reasons’ for FGM include:
  • The procedure will increase marriageability of the woman/girl
  • To protect a girl’s virginity, ensure premarital virginity and marital fidelity
  • Perceived cleanliness: girls are told that female genitalia is dirty and this procedure will make the them more hygienic (World Health Organisation (1), 2016)
  • To maintain the family’s honour
  • The community will disown the woman/girl if she does not have the procedure
  • It is tradition and ‘a rite of passage’, or part of ‘coming of age’ (Guardian, 2011)
  • If the clitoris is not cut it will harm the woman’s husband/ keep growing/ harm the baby during delivery. (Forward, 2014)

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.Health implications.

FGM has no health benefits and is harmful to girls and women. It involves removing and damaging healthy and normal female genital tissue and interferes with the natural functions of girls' and women's bodies. Generally speaking, risks increase proportionately with the severity of the procedure.
There are health implications for all women and girls who undergo FGM. Health impacts caused by FGM can include (but not exhaustively), in the short term:
  • severe pain
  • excessive bleeding (haemorrhage)
  • genital tissue swelling
  • fever due to wound infection
  • urinary problems (difficulty and pain passing urine)
  • injury to the surrounding genital tissue
  • shock
  • death.
Health impacts in the longer term can include:
  • psychological problems including post-traumatic stress disorder, anxiety and mood disorders and low self-esteem
  • problems with childbirth which can put both mother and baby at risk including difficult deliveries, the need to resuscitate baby and haemorrhage
  • difficulty passing urine and urinary tract infections
  • difficulties in controlling menstruation
  • increased risk of infection
  • pain and/or difficulty having sex and reduced sexual satisfaction
  • vaginal problems including discharge, itching, bacterial vaginosis and other infections), keloid scar tissue and keloid
  • renal problems and renal failure.
 
Dependent on the type of FGM performed there can also be the need for later surgeries such as de-infibulation, which may be required to enable sex or childbirth. De-infibulation is the surgical procedure of opening the closed vagina following type 3 FGM. In some affected communities de-infibulation can be followed by re-infibulation and this cycle may be carried out multiple times, for example on the wedding night or prior to childbirth.
 
The resulting serious physical, psychological and social effects are devastating to all women involved. Many of these women do not access services or treatment until it becomes absolutely necessary; normally during pregnancy or where there has been recurrent pain, infections, etc (McNiven, 2015).

2. Size of the issue locally

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It is estimated that within the UK there are 137,000 women aged 15+ living with the consequences of FGM (McFarlane, 2015).In 2015-16 the FGM prevalence dataset HSCIC identified 1,015 newly identified individuals living with FGM in the Midlands and East Area (Health and Social Care Information Centre, 2016). 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. The most common type of FGM was type 2, accounting for 79% of all cases where type of FGM was captured. For the majority of cases recorded, FGM was undertaken between 0-9 years of age (92%), no cases were recorded where FGM happened after age 14 and all of these happened outside of the UK (Health and Social Care Information Centre, 2016).
The age at which FGM cases presented to healthcare varies with the majority of cases presenting between the ages of 18 and 44 years. This age range may be linked to the fact that all reported attendances related to pregnancy (midwifery service). Eastern, Northern and Western Africa were the most frequent country of birth; the majority of FGM was undertaken in these countries.
 
While the majority of cases presenting in maternity had no daughters, 40% did have daughters under the age of 18 and who may also be at risk of FGM.
 
Nottingham reported 53% of all recorded FGM cases in NHS England North Midlands group, we cannot be sure if this is because Nottingham’s staff are better at reporting FGM or if there is truly a higher prevalence. Comparison at a LA level is challenging due to levels of data suppression and inconsistencies in data reporting; however, NHS digital do not highlight Nottingham as a LA of ‘high volume’ in their Midlands and East of England region profile.
Since the Serious Crime Act came into force in 2015, less than 5 FGM Protection Orders[1] have been put in place for children in Nottingham City.


[1] The actual number of FGM Protection Orders issued has been redacted

3. Targets and performance

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Nationally, the Home Office have set a target to reduce prevalence of FGM in their Strategy to End Violence Against Women and Girls (EVAWG), stating an outcome of the strategy by 2020 is to see ‘reductions in the prevalence of FGM in line with our aim to end FGM within a generation’ (HM Government Home Office (1), 2016).

The United Nations have set a global goal to achieve gender equality and empower all women and girls, a target to eliminate FGM sits underneath this goal; ‘By 2030, eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation’ (The Global Goals for Sustainable Development, 2016).

There are currently no measures of performance against the Violence Against Women and Girls strategy targets and UN Global Goals targets as targets were set in 2016 and 2016 respectively, as such progress has not been yet measured.

Nottingham City has become a ‘Zero Tolerance’ city in respect of FGM. This is a recent development and the motion was signed off at Full Council in September 2016. More information can be found in appendix 1. There is currently no numerical target attached to this n recognition of the fact that a baseline of FGM would be difficult to set as many women who have undergone FGM won’t come forward for services.

Recording of FGM by healthcare staff became mandatory in October 2015, this requires all NHS acute trusts, mental health trusts and general practices to record data about women and girls with FGM who are being care for by the NHS in England. This data contributes to the FGM enhanced dataset which aims to present a national picture of prevalence of FGM within the NHS.  As data collection improves this will enable more effective monitoring of progress in tackling FGM.

4. Current activity, service provision and assets

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The Local Authority is driven by national changes in law, in line with this there are various local and national assets working to reduce and eliminate FGM in the city, such as legislation, training and partnerships.

Primary prevention & Early Intervention

The Serious Crime Act and the Law around FGM- Girls are protected against FGM by law, it is illegal and a criminal act, anyone found to have committed FGM could face up to 14 years in jail, a fine or both. It is illegal to carry out FGM in the UK, to perform FGM abroad on a UK national (even if the practice is legal in that country), or to assist someone (either UK or non-UK national) to perform FGM on a UK national, both in the UK and abroad. It is also an offence to fail to protect a girl from undergoing FGM, whether the procedure takes place in the UK or abroad, to aid or procure a person to commit FGM, to attempt or conspire to commit FGM and to encourage or assist a person to commit FGM. To date there have been no prosecutions in the UK for FGM. As part of the Act,  a new duty was introduced that requires health and social care professionals and teachers to report ‘known’ cases of FGM in girls aged under 18 to the police as part of the FGM mandatory reporting duty (HM Government, Home Office (3), 2016).The Serious Crime Act also introduced Lifelong Anonymity for survivors of FGM.
 
FGM protection order- This is a civil measure which can be applied for through a family court, this offers the means to protect actual or potential victims from FGM under the civil law. They are unique to each case and contain legally binding conditions, these can include confiscating passports or travel documents of the girl at risk and /or family members to prevent girls from being taken abroad; ordering that family members or other individuals should not aid another person in any way to commit or attempt to commit an FGM offence, for example bringing a ‘cutter’ into the UK for the purpose of committing FGM.

FGM Prevention Programme- This is a Department of Health programme with the aim of improving the response of health to FGM, through improved data collection and training for healthcare staff. As part of this the DoH published the FGM safeguarding pathway for healthcare staff.

FGM Risk Indication System- The FGM Risk Indication System (FGM RIS) is a new national IT system for health that allows clinicians across England to note on a girl's health record that they are potentially at risk of FGM. The FGM RIS allows the potential risk of FGM to be shared confidentially with health professionals across all care settings until a girl is 18 years old- something which current systems do not cater for.

UK Border Force- The UK Border Force works closely with the police and airlines on joint FGM operations to target high risk flights and raise awareness, especially during the school holidays when girls may be most at risk. Border Force Officers, both in the UK and abroad, provide crucial extra intelligence and carry out additional checks on passengers in support of these operations. In addition, Border Force’s Safeguarding and Trafficking Teams have been given advanced training on FGM and forced marriage, including on what to look out for on the equipment which may be used to carry out FGM, so they have the right skills to spot potential perpetrators and deal sensitively with potential victims of FGM (HM Government Home Office (1), 2016).
 
Nottingham City and Nottinghamshire County Female Genital Mutilation Board- The cross Nottingham City and Nottinghamshire County FGM board had been meeting every 6 weeks since May 2015 with representation from Police, Health, Education, social care and the VCS. Recently the board has agreed to meeting quarterly as this was felt more appropriate. The purpose of the board is to develop and deliver a strategy to prevent children and girls undergoing FGM and identify and support women affected. The purpose is also to co-ordinate and collate evidence of activity to prevent, identify and provide adequate support for those at risk, or victims of FGM within individual agencies.

FGM Zero tolerance City- As referred to previously, Nottingham City Council has passed a motion to become a ‘zero-tolerance’ city of FGM. As such there are commitments associated with this that have council buy-in to work towards ending FGM in a generation in Nottingham.

Mojatu Community FGM Steering Group- The Mojatu Community FGM Steering Group is comprised of survivors, community leaders, religious leaders and volunteers. There are more than 70 members, the aim of the steering group is to disseminate information to the community and best identify how to tackle FGM in the community. Members are trained by Mojatu in FGM and the facts around FGM, as well as how to deliver messages and FGM and materials. This way affected communities have members who can talk to them about FGM, the harms and illegality of FGM, with an understanding of the local community and delivered in the language of that community. The steering group also directs how to take the campaign work of Mojatu forward, and often carries out much of the campaign work.

Midwifery and health visiting service identifying risk to the child- The FGM board has worked in partnership with midwifery and health visiting services to ensure all female babies born to women who have undergone FGM have the female symbol added into their red book, which highlights the potential risk to the child.

Training for schools- The FGM Board has developed training for schools which is being delivered through the PSHE Advisory Service, CityCare Health improvement Co-Ordinator and Advanced Safeguarding Leads in partnership with Mojatu for schools across the city. This is delivered through the Emerging Threats to Children Team in the county. Train the trainer events have trained 50 multi-agency professionals involved in developing an effective response to FGM in schools in the city and county. All school safeguarding leads have been briefed or received training regarding FGM and mandatory reporting[1]. The Schools Safeguarding Policy for the city has also been updated to reflect the mandatory reporting requirements re FGM. 

Training for healthcare professionals- Nationally the FGM Prevention Programme launched FGM e-learning for healthcare, so that all healthcare professionals can have an understanding of FGM and the risks and health harms associated with FGM. Nottingham CityCare has recently released guidance and a pathway for their staff members to refer to so that they have the knowledge to protect girls from FGM and respond to FGM appropriately. Nottingham University Hospitals (NUH) also include information on FGM as part of their mandatory safeguarding training for staff.

Training for school nurses and health visitors- School nurses and  health visitors are required to complete online Home Office training re FGM, however we do not have numbers on how many have completed this at present.

Wider training on FGM- The Home Office have launched an e-learning package to help appropriate professionals recognise and assist girls who are at risk of FGM.

Raising awareness in Schools- As of 2015, Nottingham City Council and the FGM Board send letters to all schools to inform them of the dangers posed to girls of FGM and the ‘cutting season’. The ‘cutting season’ is normally the school summer holidays as this will enable time for girls to recover from the procedure without missing school in the hope the procedure will not get noticed by the authorities. The letter raises awareness amongst teaching staff of the signs they are looking for, as well as what they can do if they suspect a girl is at risk of FGM. This is something that is planned to continue every year.

Local FGM action plan- The FGM Board devised an action plan to which it is working in order to reduce and eliminate FGM in the city.

Local support

 
Mojatu- Mojatu is a local voluntary sector organisation which campaigns to end FGM at a local, national and international level. Mojatu runs a community FGM steering group as well as offering peer to peer support for survivors in both a group setting and on a one to one basis. Mojatu are also a key partner on the FGM Board, informing and contributing to the work of the board. 

FGM clinics- These are specialist FGM clinics provided as part of maternity services where women can attend to access specialist healthcare for health issues relating to the FGM they have experienced and associated procedures such as de-infibulation. There are around 14 of these operating nationwide, including one in Nottingham.

FGM specialist midwife- Nottingham has a specialist midwife who supports and trains other midwives to support women with FGM in the city during pregnancy and birth.

Mental health- Survivors of FGM can access primary care psychological (therapies) via self-referral, or for those with higher levels of mental health need, they may be referred to the Mandala Centre (who have expertise in trauma) via their GP. There is also counselling available from professionals who have received FGM training, from Women’s Aid Integrated Services and Rape Crisis.


[1] Local intelligence, Nottingham City Council PSHE Team November 2016.

5. Evidence of what works (what we should be doing)

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There is scarce academic literature detailing evidence based interventions to prevent FGM and support survivors effectively. There is, however, multi-agency statutory guidance and NICE guidance re FGM. There is also a body of grey literature that, whilst not academic or perhaps statistically significant, can still give insight into what works in the light of an evidence drought on the subject. This is particularly useful as some of this is the result of work collecting perceptions of survivors and affected communities.  What works in preventing FGM and what works in responding to survivors of FGM is explored in this section.
What works in preventing FGM in communities?
  • The Law- The law is viewed as a key instrument empowering and supporting women to oppose FGM (Options UK; Esmee Fairbairn Foundation (2), 2016). The impact of legal consequences gives parents and girls a tool to oppose wider social pressures due to the risk of imprisonment.  Even if we cannot change attitudes towards FGM, the law as a deterrent can change behaviour, however this must be in conjunction with other measures (Options UK; Forward, 2009).
  • Community Engagement- Community engagement is viewed as key to preventing FGM. Women believe increasing education in the community around FGM is most important in growing opposition to the practice, rather than focussing solely on health and other professionals. However this is not seen as sufficient to prevent FGM alone (Options UK; Forward, 2009), comprehensive responses are needed to shift attitudes towards FGM with multiple actors working together. However, there is widespread support for a grassroots approach, enabling community led change in local areas (Options UK; Esmee Fairbairn Foundation (2), 2016). Community led campaigns can combat the feeling of being demonised by others outside of the affected community; it is important to bring together religious and community leaders, there is evidence this can change perceptions (Options UK; Esmee Fairbairn Foundation (1), 2013). Multi-agency statutory guidance on FGM advises ‘organisations and professionals can help to end FGM by talking to all groups including men, boys and community leaders about FGM and its consequences’ (HM Government, Home Office (2), 2016). Where community based prevention work is taking place, rejection of FGM has increased (Options UK; Esmee Fairbairn Foundation (1), 2013). Of interest is that one paper highlighted the effectiveness of targeting work at specific age groups, stating working with younger women had been more effective than older women where values are entrenched (Options UK; Esmee Fairbairn Foundation (2), 2016).
  • Information- Women from affected communities feel there is a lack of information about FGM and specialist services available through health services. Some women felt efforts were focussed on professional healthcare rather than communities. They would like more information on health and services, as well as the law (Options UK; Forward, 2009), at various access points, available more widely than only midwifery services (Options UK; Esmee Fairbairn Foundation (2), 2016). Increased information would help women access support earlier and information around the law would contribute towards prevention.
  • Identification and referral- It is important all relevant organisations ensure their staff understand their role in protecting those who have undergone or are at risk of FGM.  Information sharing is very important to ensure the correct organisations can safeguard women and girls at risk (HM Government, Home Office (2), 2016).
What works in supporting women who have undergone FGM?
  • Understanding rather than punishment- Women have advised they feel that barriers are put up when professionals react to disclosure in a manner which lacks understanding, frontline workers should frame conversations following disclosure around the woman, not around punishment and suspicion (Options UK; Forward, 2009). Multi-agency statutory guidance advises a victim centred approach should be taken by workers (HM Government, Home Office (2), 2016).
  • Awareness and understanding of FGM- It is important for professionals working with practicing communities to have awareness of the social and economic context in which FGM occurs. This may enable them to develop greater empathy and sensitivity when communicating with individuals or families from practicing communities. As such this shows the importance of training for professionals (Options UK; Forward, 2009).
  • Outreach to encourage service uptake- ‘Options UK’ found in their programme evaluation that access to care had been increased in areas where women had been encouraged to do so through outreach (Options UK; Esmee Fairbairn Foundation (2), 2016).
  • Culturally appropriate Mental Health service- In a similar vein to the first two points above, awareness and understanding of FGM is important to women for them to feel supported when accessing MH services (Options UK; Esmee Fairbairn Foundation (2), 2016). This is complimented by local intelligence from survivors reiterating the importance of being able to access MH support that is understanding and does not result in the survivor feeling judged or that lack of understanding is a barrier.

6. What is on the horizon?

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Future demand

Because FGM prevalence is difficult to establish due to the hidden nature of this, it is difficult to make projections of demand as there is no robust baseline for this.  

Nottingham has an increasing Black African community, rising from 0.5%- 3.2% of the population between 2001 and 2011 (Nottingham City Council, 2016). This may correlate with an increase of women and girls in Nottingham who have undergone or are at risk of FGM if these women come from a country with a high prevalence of FGM. It should be noted that country of origin is not a predictor of FGM, only that high prevalence is observed in some countries.

Increased prevalence and risk does not automatically result in higher demand for services. Work is underway in the city to prevent FGM, if these interventions and initiatives prove effective, we would expect there to be fewer instances of FGM occurring. However, as more work is undertaken to talk about FGM and the associated health risks and services available, women may feel more empowered to come forward for services, as such, even if the incidence or prevalence of FGM does not increase, we may see an increase in the existing population presenting for services. The picture for demand is complex with many factors at play.

As prevalence data has only become mandatory for NHS trusts in October 2015, and only became available for some authorities in September 2014, there is currently insufficient data to be able to map trends of FGM locally.

Future service and policy developments

Public health and Nottingham City Clinical Commissioning Group (CCGs) are working alongside Mojatu to identify appropriate mental health pathways and support for children and women who have undergone FGM.

The FGM board has agreed that every year a letter will be sent out to schools to highlight the danger of children being taken abroad or having FGM undertaken within the UK. This may potentially be extended to GP’s, health visitors and nursing also.

Nottingham City Children’s Safeguarding Board will be recommending to schools that all school governors access e-learning regarding FGM.

Nottingham’s PSHE Advisory service in partnership with Mojatu are planning to run yearly train the trainer events so that schools can have an FGM trained staff member within their School/ Academy Trust. This will be run every year to try to combat staff turnover.

7. Local views

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Local intelligence suggests survivors feel that they need services to be understanding and non-judgemental for them to access these. Survivors feel that it is important for services to have understanding of cultural nuances, community and family pressures on survivors and the context around FGM.  If someone from an affected community has had a positive experience this gives others more confidence to come forward and use services themselves, with much knowledge of services available being communicated via word of mouth This highlights the importance of ensuring staff are aware of FGM and deliver services in an accessible and non-judgemental manner.
 
Concerns have been expressed from survivors locally re some negative experiences of mental health services; judgement and lack of understanding were cited as barriers to accessing these. Concerns have also been expressed regarding where women can go for services (specifically non-pregnant women) and the importance of having a named contact at services whom survivors can trust. This indicates that building trust through positive experience, continuity of provision and staffing are key to encouraging survivors to access healthcare and other services locally.

What does this tell us?

8. Unmet needs and service gaps

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  1. 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.
 
  1. 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.
 
  1. 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.
 
  1. 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.
 
  1. 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.

9. Knowledge gaps

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  1. Current local data is insufficient to give a robust baseline of FGM prevalence in the city. Over time this should improve as mandatory reporting of FGM in health care has been rolled out in October 2015, as more providers become familiar with reporting this data will become more robust, we will also have data for a full year in the future as present data sets do not have complete time periods for all providers completing them.
  2. There is very little literature on evidence based interventions to prevent FGM and support women who have undergone FGM. There is a particular gap around interventions to support mental health of survivors.
  3. It is difficult to project increases or decreases in communities at risk of FGM in the city, as there is no data detailing trends and numbers of citizens by country of origin, this would give an indication if populations from countries with high FGM prevalence were increasing or decreasing in the city.
  4. Evaluation of existing efforts to prevent FGM in the city cannot be undertaken as data is not robust enough as yet to offer a baseline to measure against, due to the hidden nature of FGM.
  5. There is a lack of knowledge of how many frontline workers in the city have received training around FGM; however it may be that with further time and resource we may be able to ascertain a better picture of this.

What should we do next?

10. Recommendations for consideration by commissioners

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  • 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.

Key contacts

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Grace Brough- Insight Specialist Public Health
Sarah Quilty- Children’s Commissioning Lead Public Health
Helene Denness- Consultant Public Health

References

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Forward, 2014. Female Genital Mutilation: Frequently Asked Questions: A Campaigners Guide for Young People, s.l.: Forward.
Guardian, T., 2011. 'I will never be cut': Kenyan girls fight back against female genital mutilation-video. [Online]
Available at: https://www.theguardian.com/global-development/video/2011/apr/18/female-genital-mutilation-video
[Accessed 4 11 2016].
Health and Social Care Information Centre, 2016. FGM Local Authority Report, s.l.: HSCIC.
HM Government Home Office (1), 2016. Ending Violence Against Women and Girls, Strategy 2016-2020, London: Home Office.
HM Government, Home Office (2), 2016. Multi-Agency Statutory Guidance on Female Genital Mutilation, s.l.: HM Government, Home Office.
HM Government, Home Office (3), 2016. New duty for health and social care professionals and teachers to report female genital mutilation (FGM) to the police, London: Home Office.
McFarlane, A. E., 2015. Prevalence of Female Genital Mutilation in England and Wales: National and Local estimates, London: City University London and Equality Now.
McNiven, L., 2015. Report from the Nottingham City and Nottinghamshire County Female Genital Mutilation Board highlighting important developments in mandatory FGM data collection and details of the serious crime act 2015., s.l.: Nottingham City Council.
Nottingham City and Nottinghamshire County Safeguarding Boards, 2016. Female Genital Mutilation: Letter to Schools, s.l.: Nottingham City and County Safeguarding Boards.
Nottingham City Council, 2016. Nottingham City Demography JSNA 2016, s.l.: Nottingham City Council.
NSPCC, 2016. Who is affected by FGM?. [Online]
Available at: https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/female-genital-mutilation-fgm/who-is-affected/
[Accessed 31 January 2017].
Options UK; Esmee Fairbairn Foundation (1), 2013. Tackling Female Genital Mutilation in the UK: What works in community-based prevention work, s.l.: Options UK; Esmee Fairbairn Foundation.
Options UK; Esmee Fairbairn Foundation (2), 2016. Tackilng FGM in the UK: Views of people from communities affected by FGM, s.l.: Options UK.
Options UK; Forward, 2009. FGM is always with us: Experiencesm perceptions, beliefs of women affected by FGM in London: Results from a PEER study, s.l.: Options UK; Forward.
Serour, G., 2013. Medicalization of Female Genital Mutilation/Cutting. African Journal of Urology, 19(3), pp. 145-149.
The Global Goals for Sustainable Development, 2016. Gender Equality: Achieving Gender Equality and Empower All Women and Girls. [Online]
Available at: http://www.globalgoals.org/global-goals/gender-equality/
[Accessed 09 November 2016].
Unicef (1), 2016. Female Genital Mutilation/ Cutting: A statistical overviewand exploration of the dynamics of change, s.l.: Unicef.
Unicef (2), 2016. FGM Current Status and Progress: Prevalence. [Online]
Available at: http://data.unicef.org/topic/child-protection/female-genital-mutilation-and-cutting/
[Accessed 31 January 2017].
World Health Organisation (1), 2016. Female Genital Mutilation: Fact Sheet. [Online]
Available at: http://www.who.int/mediacentre/factsheets/fs241/en/
[Accessed 4 November 2016].
World Health Organisation (2), 2016. Prevalence of FGM. [Online]
Available at: http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/
[Accessed 4 November 2016].
 

Glossary

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The City Council stands against FGM and resolves to:
  • Make Nottingham a “Zero Tolerance” City in respect to Female Genital Mutilation.
  • Work to end the procedure within the city by working closely with survivors, affected communities and other agencies with a responsibility to safeguard and protect.
  • Provide training for staff to help spot the signs associated with Female Genital Mutilation.
  • Work closely with grassroots organisations, survivors and communities to prevent children being removed from the city to experience Female Genital Mutilation.
  • Help support potential survivors of Female Genital Mutilation to say no and raise awareness amongst their peers and communities.
  • Help with raising awareness and keep the subject on the agenda while showcasing the successes of Nottingham.
  • Support the establishment of a referral pathway for the City