1. Dorcas O Akeju OBE Retired Midwife-Chair of Liverpool & National FGM Clinical Group

2. SILENT TRADITION: A VIOLATION OF HUMAN RIGHTS

4. To discuss the issues around FGM. Its violation against women and girls The Human Rights issue Health implication on women and girls The Law Actions for its elimination.

5.  FGM constitutes all procedures which involve the partial or total removal of the external genitalia organ or other injury to the female genital organs, whether for cultural or any other non-therapeutic reasons (WHO, 1995).  3 million girls in Africa undergo FGM every year.  100 to 140 million in Africa live with the consequences of FGM

6.  Dated back at least 2000 years  Believed that it was practised as a sign of distinction amongst the aristocracy-Egypt  Traces of infibulation can still be found on Egyptian mummies.

7. Classification Type 1-partial or total removal of the clitoris and rarely the prepuce.Type 1-partial or total removal of the clitoris and rarely the prepuce. Type 2-partial or total removal of clitoris and labial minora with or without removal of labial majora.Type 2-partial or total removal of clitoris and labial minora with or without removal of labial majora. Type 3- narrowing vaginal opening through creation of a covering by cutting and repositioning the inner and sometimes the outer labia with or without removal of the clitoris.Type 3- narrowing vaginal opening through creation of a covering by cutting and repositioning the inner and sometimes the outer labia with or without removal of the clitoris. Type 4all harmful procedures to the female genitalia for non medical purposes e.g pricking, piercing or incising, stretching, scraping,cauterisingType 4all harmful procedures to the female genitalia for non medical purposes e.g pricking, piercing or incising, stretching, scraping,cauterising

8. Type 11 Type 111

9. Violation of human rights principles Norms and Standards Equality and discrimination on the basis of sex. (Gender Inequality) The right to freedom from torture or cruel The right to life

11. Reasons to justify female genital mutilation Religion (Muslim faith) Tradition-Norms, Customs, Myths, Taboos Preserve virginity Avoid sexual immorality Initiation rite Aesthetic reasons improve fertility and prevent mortality Cleanliness/Purification

12. Female Genital Cutting Areas of Practice - TYPE II Type II involves the partial or entire removal of the clitoris, as well as the scraping off of the labia majora and labia minora. Return to Introduction

13. Prevalence of FGM Particularly prevalent in Africa Somalia Ethiopia Sudan Mali Nigeria Tanzania Sierra Leone Egypt Muslim Groups Australia Philippines Malaysia Pakistan Indonesia United Emirates South and North Yemen Bahrain Oman

14.  Depends on the migration of people from different affected countries to a city (1999- Immigration and Asylum Seekers Act)  66,000 women in UK have undergone FGM (2001 Census figure).  22,000 girls are at risk of FGM  Statistical study to estimate the Pervalence of FGM (FORWARD, 2007).  Highest-London, Small numbers Wales, Northwest and Midlands

15. UNICEF-FGM/C-A Statistical overview and Exploration of the dynamics of change (2013) Data Collection England from Sept 14 Current data-125 Acute Hospitals out of 160 eligible Trusts 1,279-Active cases 467-New cases

16. rit F.G.M. Rituals reinforcing woman- hood Superstitions based on patriarchal ideology Women’s lack of access to resources in the community Economic aspects: income +status for excisor -brideprice Sanctions against women Lack of health care Religious Propaganda Lack of government policy and action illiteracy Male Fears Lack of Choice Marriage partners reproductive rights FEAR How female genital mutilation is sustained at grassroots level

17. For many women FGM is a fact of life, a pain that must be borne because they must conform to social expectations in order to survive. It is a centuries-old tradition practice present with a number of physical, psychological and cultural challenges to midwifery care.

18. Immediate effects Shock Bleeding Accidental damage to surrounding organs Urinary complications Death

19. Long term effects Haematocolps Vulval Cysts / abscesses Rectal /Vaginal Fistula Pelvic inflammatory disease Problems childbirth General health Dysuria Infection Dyspareunia Infertility Keloid scars

20. Access/Setting up FGM Clinic Approachable Communication Counselling and advice Flexibility Safe environment. Sensitivity

21. Counselling Non-judgmental and sympathetic. Language barrier-trained interpreter or link worker should be present. Do not rely on family members. Discuss potential consequences of FGM. Explain FGM with diagram.. Involving partner is very important as this is about changing attitude.

22. Reconciling strategies to the distinctive features of each culture. Integrating strategies with other health and developments. Forming alliances between modern and traditional healers. Exercising discretion and tact in referring to deeply held beliefs. Seeking solutions from within countries complemented by international solidarity.

23.  International  Regional  National  Community activists

24. Declaration of Human Rights-10 th Dec 1848 International Covenant on Civil and Political Rights 10 Dec 1966 into force 23 rd March 1975 Convection on the Rights of the Child 20 Nov 1989 Committee on the Elimination of all Forms of Discrimination against Women-1990

25. The Convention on the elimination of all forms of Discrimination against women(1979) The African Charter on Human and Peoples’ Rights (1981) United Nations General Assembly-Declaration on Elimination of Violence against Women (1993) The Convection on the rights of the Child(1989) The World Health Assembly resolution on the elimination of FGM (2008

26. European Convection for the protection of Human Rights and Fundamental Freedoms (Nov 1950.) American Convection on Human Rights (July 1978) African Charters on the Rights and Welfare of the child. (Nov 1999)

27. Economic and Social Council of the United Nations- NGO working group (ECOSOC Geneva 1977) Somali Women’s Democratic Organisation formed 1977 Symposium on “The Changing Status of Sudanese women” (1979) Inter-African Committee (IAC- 1984)

28. National Strategy Developing services Working with the communities especially the women in understanding the Law Raising awareness amongst the communities in general Educational programme for professionals Safeguarding issue

29. FGM and the Law 1985 Act Prohibition of Female Circumcision Children’s Act 1989- (Safeguarding) Child Assessment Orders Emergency Protection Removal and Accommodation Human Rights Act 1998 Who is involved? All professionals involved in the care of the child. Midwives, health visitors, School Nurses, GP’s, Teachers and Social Services. FGM BILL-2003 How is the law enforced? The Children Act 2004

30. Act 2003 brought into force 3/3/04 To close the “loophole” of FGM Act 1985 Section 1 states “it is criminal offence to excise, infibulate or otherwise. Act refers to “girls” also applies to women Also an offence if a person in UK advises his UK National brother to carry out FGM over the phone.

31. Section 5 of the FGM Act 2003- on Conviction or indictment to imprisonment for a term not exceeding 14 years or a fine or both

32. Use of Expert witness e. g. Medical professional Specialist in FGM. International Evidence-may be from passports or Flight records. Victim evidence which has become very difficult leading to non-charging. Use of video(but permission is needed Referral system/partnership working.. NO WITNESS-NO PROSECUTION!!!

33. Victims may see it as “conforming to the Norm” and may not report it. May not report it if it will not affect their “stay status” Need to recognise the diversity of the victims. It is a “silent thing” within the practising communities.

34. FORWARD-Charity-London/campaigner against FGM Nancy McKenna-Charity working in Africa to support girls and women-empowerment/DVD- The Cutting Tradition. Cathy Holland-works with girls at the village of Pokot-Kenya-DVD-”I will never be cut” IKWRO-Iranian and Kurdish Women’s Rights Organisation

35. Equality Now-charity org working with UK Government to collect data on FGM The Bristol community Development Programme. Kudistan report on FGM-Germany’. Communities in the Dutch responding to FGM. FGM work in the Middle Eastern Community Diaspora.

36. Partnership Working Liverpool FGM and Multi-Cultural Women Health Advisory Group-set up 1999 www.fgm- liverpool.orgwww.fgm- liverpool.org Forced Marriage/Honour Based Violence Group FORWARD-based in London www.liverpooluk.org.uk www.liverpooluk.org.uk FGM National Clinical Group- www.fgmnationalgroup.org FGM Forum-Home Office

37. THE DAY OF CIRCUMCISION HER WEDDING NIGHT THE DAY SHE WILL BE HAVING HER BABY

38. Conclusion To eliminate FGM is about partnership working between the women and professionals. Having empathy for the women who have been circumcised and understanding the issues around tradition and cultural.

39. This violation of women’s rights cannot be abolished without placing it firmly within the context of efforts to address the social and economic injustice of women. If women are to be considered as equal and responsible members of the society, no aspect of their PHYSICAL, PSYCHOLOGICAL OR SEXUAL INTEGRITY CAN BE COMPROMISED. Toubia,N 1995 THANK YOU FOR LISTENING/ANY QUESTIONS OR VIEWS!!!

40. Integrating the prevention and the Management of the Health complications into the curricula of Nursing and Midwifery-WHO/RHR/01 Female Genital Mutilation: an overview WHO (1998) Summary of International and regional human rights relevant to the prevention of violence against women-WHO/GCH/WHM/99.3 Geneva (1999) Female Genital Mutilation-WHO (2008) FGM Act-2003: HSMO

41. The Cutting Tradition-Safe Hands (Nancy McKenna-47mins FGM-National Clinical Group/resource and training-appx 40mins DH-FGM (2006)-30mins Not with my daughter –FGM in Europe (41mins) The Broken Silence film by esther heller Moolaade-a film by Ousmane Sembene-120mins