1. Sexual and reproductive health to include Female Genital Mutilation Dr Hilary Cooling Dr Susanna Hall Bristol Sexual Health Services www.bristolsexualhealth.nhs.uk

2. Global issues of womens’ reproductive health and rights UK scene setting Sexual and reproductive health services and migrant populations Case study about Female Genital Mutilation/Cutting (FGM) and the issues this raises

3. Global Perspective WHO: Reproductive Health and Rights Core issues worldwide: – Choice of number and spacing of children – Choice of safe methods – Supported by education – Free from coercion

4. United Kingdom Perspective Background to sexual health services – NHS Regulations (1974)- enhanced confidentiality – Self referral to any clinic – Free treatment – Integration of sexual health services – Support to use service – Clinics in localities around Bristol – Interpreters – face to face, telephone

5. Contraception and Family Planning Services All contraception is free in the UK Wide range of methods available Long acting reversible contraception (LARC) provision is encouraged and supported by national guidance

6. Unplanned Pregnancy and Abortion Abortion legal in the UK Requires 2 doctors’ signatures to agree the grounds of the abortion Majority of abortions are funded by the NHS Bristol increasing ease of access Migrant issues including payment

7. Reproductive Health NHS Cervical Screening Programme to prevent cancer of cervix (“PAP smears”) Initially introduced in1964 Improved in 1988 by a computerised recall system HPV screening and immunisation Access through primary care or sexual health

8. Sexually transmitted infection including HIV National screening initiatives – Chlamydia Screening Programme National drive to increase numbers of women screened for HIV – Antenatal screening: chlamydia, HIV, syphilis, Hepatitis B – Primary care

9. Psychosexual counselling Specialist counsellors: counselling for sexual problems couple counselling

10. Sexual Assault Affects 1 in 4 women in their lifetime ~ 95% do not report the assault Sexual assault referral centres (SARCs) developed nationally Bristol- “The Bridge”

11. Female Genital Mutilation (FGM) Female genital cutting “female circumcision” partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

12. FGM and UK law Female Circumcision Prohibition Act (1985) Female Genital Mutilation Act (2004): FGM is illegal in England, Scotland and Wales whether it is committed against a United Kingdom national or permanent United Kingdom resident in the UK or abroad maximum penalty of 14 years in prison

13. Estimated figures for those at risk of FGM UK: up to 100,000 women 10,000 to 20,000 girls Bristol Black African population 7600 estimate (2011) More than 1600 girls 3-15 yrs in Bristol schools

14. Specialist advice for FGM Minority ethnic woman and girls clinic Sexual health services – staff with specialist skills Community education/awareness raising (with women and men) Multi-agency network – services for women, protection of children, schools, police

16. “Sahra” aged 28 She attends a sexual health clinic with her husband, both from Somalia, married for 2 years. She complains of pain and discomfort with attempts at sexual intercourse, and problems passing urine Examination shows vagina almost completely closed

17. FGM “opening” surgery – referral pathway to gynaecology for general or local anaesthetic procedure referral to midwife if already pregnant, for “opening” before labour protection of children (safeguarding) – daughters (not yet born), sisters, etc

18. Sexual and reproductive health pregnancy planning/unplanned pregnancy Contraception Sexually transmitted infections (STIs) HIV psychosexual counselling

19. Thank you Any questions?

20. Further information FORWARD (UK) http://www.forwarduk.org.uk/key-issues/fgm World Health Organisation http://www.who.int/topics/female_genital_muti lation/en/ United Nations Population Fund (UNFPA) http://unfpa.org/gender/practices1.htm Integrate Bristol http://integratebristol.org.uk/documentary/

21. South West Safeguarding and Child Protection Procedures http://www.online- procedures.co.uk/swcpp/contents/guidance- child-protection/female-genital-mutilation/ The Bridge www.turntothebridge.org Faculty of Sexual and Reproductive Healthcare www.fsrh.org Royal College of Obstetricians and Gynecologists www.rcog.org.uk

22. National Institute for Health and Clinical Excellencewww.nice.org.ukwww.nice.org.uk NHS Cancer Screening Programmes www.cancerscreening.nhs.uk National Chlamydia Screening Programme IPPF www.ippf.org/enwww.ippf.org/en fpa www.fpa.org.ukwww.fpa.org.uk Medical Foundation for AIDS & Sexual Health www.medfash.org.uk