1. Listening to you, working for you www.bexley.gov.uk and HEALTH BME and HEALTH

2. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Objectives To bring to light the issue of Female Genital Mutilation - FGM To understand the implications of this act on the health of BME children. To explore how professionals can help safeguard these children

3. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk OUTLINE Introduction Definition of FGM Where it is performed Types of FGM Reasons for FGM How it is practiced When it is performed Health implications of FGM

4. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk INTRODUCTION An estimated 100 to 140 million girls and women in the world today have undergone some form of female genital mutilation, and 2 million girls are at risk from the practice each year. The great majority of affected women live in sub-Saharan Africa, but the practice is also known in parts of the Middle East and Asia. Today, women with FGM are

5. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk INTRODUCTION increasingly found in Europe, Australia, New Zealand, Canada and the United States of America, largely as a result of migration from countries where FGM is a cultural tradition.

6. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk DEFINITION Female genital mutilation (FGM) constitutes all procedures which involve the partial or total removal of the female external genitalia or other injury to the female genital organs, whether for cultural or any other non therapeutic reasons (WHO 1995). FGM can be defined as Female Central Cutting or Female circumcision

7. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk WHERE IT IS PERFORMED Over 28 countries in Africa among all faith groups practice Female genital mutilation (FGM). It is also prevalent in many countries all over the world. (See sheet on prevalence and distribution)

8. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk TYPES OF FGM Type 1 Excision: Excision of the prepuce with or without excision of part or the entire clitoris. Type 2 Excision: This refers to the partial or total excision of the labia minora with or without the excision of part or all of the clitoris.

9. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk TYPES OF FGM Type 3 Excision (Infibulation): It involves total or partial removal of the clitoris. Type 4 (Unclassified): This includes pricking, piercing and or incising / burning of the clitoris.

10. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk REASONS FOR THE PRACTICE Culture and tradition Social acceptance Initiation into womanhood Religion Prevention of rape and preservation of virginity Hygiene and aesthetic reasons Increasing sexual pleasure of husband Controlling womans sexuality

11. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk HOW IT IS PRACTICED OR DONE AND WHO PERFORMS IT It is performed traditionally by traditional birth attendants or traditional circumciser in very poor conditions. It is also performed medically by health professionals, doctors, nurses and mid-wives.

12. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk WHEN IS FGM PERFORMED? Age varies and depend on the country to the group and geographical location. Infancy (from a few days old) Childhood (from 4 till 10 years) Onset of puberty At marriage During first pregnancy or delivery

13. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk HEALTH CONSEQUENCES There are both short and long term consequences to the practice of FGM. For short-term, they are Haemorrhage Severe pain and shock Urine retention Infection including tetanus and HIV Injury to adjacent tissue Fracture or dislocation of limbs as a result of restraint.

14. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk HEALTH CONSEQUENCES For long-term, they are Difficulty with passing urine. Difficulty with menstruation Acute and chronic pelvic infections Infertility Neuromas, chronic scar formation and cyst

15. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk HEALTH CONSEQUENCES For long-term, they are Fracture or dislocation of limbs as a result of restraint Vesico-vaginal fistula (VVF), recto- vaginal fistula (RVF) Complications of pregnancy Neonatal death

16. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk ERADICATING FGM To eradicate FGM, there must be General education on FGM Awareness raising for practicing communities on the health impacts of FGM on girls and women Religious education for practising communities

17. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk ERADICATING FGM To eradicate FGM, there must be Engaging young people in the work of FGM More research on the reasons for practising FGM Use of FGM Prohibiting law Implementation of law in the countries where there is a law.

18. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk FGM – CHILD PROTECTION IMPLICATIONS Summary of the female circumcision act of 1985 which carries 5 years imprisonment penalty. However, the female circumcision act of 2003 carries 14 years imprisonment penalty This should be considered under section 47 Inform parents of the law.

19. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk FGM – IDENTIFYING GIRLS AT RISK This is difficult because FGM does not fall easily into the Eurocentric definition of FGM. It is a one-off event Parents do it because they really believe it is best for their daughters There are rarely reasons for routine examinations of girls genitalia The culture does not enable girls to discuss FGM openly.

20. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk FGM – IDENTIFYING GIRLS AT RISK But there is a risk only if………………… The mother had undergone FGM herself There are older girls / siblings who have undergone FGM in the family She is isolated Her mother-in-law has a great deal of influence in the household

21. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk FGM – IDENTIFYING GIRLS AT RISK But there is a risk only if………………… No-one has ever raised the issue of FGM with her or provided accessible information for her You fail to respond appropriately and the message that gets back to the communities is that FGM is not taken seriously.

22. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk SAMPLE QUESTIONS TO ASK CIRCUMCISED WOMEN I am aware that in some African countries, women are circumcised. Have you been circumcised or closed? Do you have any problem passing urine or does it take you a long time to pass urine? Do you have any pain with menstruation?

23. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk REPONSIBILITIES OF PROFESSIONALS Your responsibility as a professional is to Be alert to the possibility of FGM Be able to recognise and know how to act upon indicators / disclosures that a girl may be at risk of FGM or may already have undergone FGM Refer the case to Childrens Social Care once you are aware that a girl is at risk or has already undergone FGM.

24. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk ROLE OF HEALTH PROFESSIONALS Your role as a health professional is to Undertake preventative work via education to promote a better understanding of the health and human rights implications of FGM Provide as much information and support to women from practising communities to enable them to protect their daughters Ensure that the message that is given out in respect of FGM is consistent across all the health services.

25. www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk Listening to you, working for you www.bexley.gov.uk References 1.Female genital mutilation (FGM) by World Health Organisation (http://www.who.int/gender/other_hea lth/teachersguide.pdf)http://www.who.int/gender/other_hea lth/teachersguide.pdf 2.Extracts from the lecture given by Dr Faduma Hussein at the Safeguarding Black African Children and Families training