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- 1. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Raising awareness about Female Genital Mutilation
- 2. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Aims to raise awareness about FGM and to increase confidence in responding • Definitions • Causes / motivations • Communities at risk • Health impact • The law and child protection • Resources and support
- 3. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Ground rules: Confidentiality Respect differing beliefs Respect differing opinions It’s OK to ask questions
- 4. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Female Genital Mutilation (FGM) comprises 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.
- 5. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Type 1 – Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). Type 2 – Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina). Type 3 – Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. Sometimes referred to as Pharaonic circumcision. Type 4 – Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area. www.who.int/mediacentre/factsheets/fs241/en/
- 6. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk De-infibulation (sometimes known as or referred to as deinfibulation or defibulation or FGM reversal): The surgical procedure to open up the closed vagina of FGM type 3. Re-infibulation (sometimes known as or referred to as reinfibulation or re-suturing): The re-stitching of FGM type 3 to re-close the vagina again after childbirth Re-infibulation is illegal in the UK as it constitutes FGM. www.who.int/mediacentre/factsheets/fs241/en/
- 7. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Preferred terms: The legislation refers to Female Genital Mutilation, and strategic and policy work should use this term. FGM is also known as cutting, and sometimes referred to as female circumcision. These terms are likely to be more recognisable to women in communities and are often used whilst inquiring about this health issue.
- 8. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Why does FGM happen? What are the different causes or justifications you have heard for FGM?
- 9. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Justifications for FGM include: • Preservation of virginity and chastity • Religion, in the mistaken belief that it is a religious requirement • Fear of social exclusion • To ensure the girl is marriageable or to improve marriage prospect • Hygiene and cleanliness • Increasing sexual pleasure for the male • Enhancing fertility • Family honour • Social acceptance
- 10. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies. FGM predates both Christianity and Islam. Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.
- 11. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk FGM is mostly carried out on young girls sometime between birth and age 15, and occasionally on adult women. The age at which FGM happens is different in different communities and areas, and is linked to the reasons for carrying it out. The most common age is between four and ten, although reports suggest that the average age is falling in some areas.
- 12. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Where does FGM happen? In which African countries do you think FGM is practiced In which other countries, outside of Africa, does FGM happen?
- 13. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk
- 14. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk
- 15. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk The total number of people (men, women and children) born in one of the 29 FGM practicing countries identified by UNICEF and living in Great Britain in 2011 was 23,979. …..the data available to us was not broken down by age or gender, and is based on self-reported country of birth. This figure therefore does not include the children born in Great Britain of parents born in an FGM-practicing country.
- 16. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Health impact What are the potential immediate and long term Health consequences of FGM?
- 17. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk The short-term health impacts of FGM will vary depending on the type and the conditions in which it is carried out, but may include: • severe pain and shock • infection • injury to adjacent tissues • sprains, dislocations, broken bones or internal injuries from being restrained • immediate fatal haemorrhaging • Infection by blood borne virus
- 18. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Long-term health impacts differ depending on type, but can include: • urine retention and difficulties in menstruation • uterus, vaginal and pelvic infections • cysts and neuromas • complications in pregnancy and childbirth • increased risk of fistula • on-going impact of trauma / PTSD • sexual dysfunction Negative impacts can include additional psycho-sexual and psychological issues and also social consequences such as estrangement from parents / family, and relationship or marriage breakdown.
- 19. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk FGM has been an offence in the UK since 1985 and the law was strengthened in 2005 Offence of female genital mutilation (1)A person who performs an action mentioned in subsection (2) in relation to the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina of another person is guilty of an offence. (2) Those actions are— - excising it; - infibulating it; or - otherwise mutilating it.
- 20. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk (3) Aiding and abetting female genital mutilation A person who aids, abets, counsels, procures or incites— • a person to commit an offence under section 1; • another person to perform an action mentioned in section 1(2) in relation to the whole or any part of that other person's own labia majora, labia minora, prepuce of the clitoris, clitoris or vagina; or • a person who is not a United Kingdom national or permanent United Kingdom resident to do a relevant act of genital mutilation outside the United Kingdom, commits an offence.
- 21. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Concerns about a child at risk If you are concerned about a child at risk you should follow child protection procedures. Ensure that appropriate authorities are contacted. In an emergency, dial 999 and ask for the Police. In non-emergency situations, call 101, the national non-emergency police number, and ask to be put through to the Family Protection Unit for your area. NSPPC has a 24-hour helpline for anyone concerned about girls or women at risk of FGM. 0800 028 3550 or fgmhelp@nspcc.org.uk
- 22. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Protecting girls What are the indicators that a girl might be at risk of FGM?
- 23. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk The key indicators that a girl or young woman is potentially at risk of FGM are: • One or both parents come from an ethnic group that traditionally practices FGM • Her mother has had FGM The girl should be viewed as at increased risk if: • an older sister has had FGM • cousins of similar age have undergone FGM • the mother (and / or father) has requested re-infibulation following delivery • the parents express views which show that they value the practice
- 24. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk A free online eLearning module on FGM, developed by the Home Office in conjunction with Virtual College N.B. Information on legislation and child protection applies to England and Wales www.fgmelearning.co.uk
- 25. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk The FGM National Clinical Group www.fgmnationalgroup.org/contact_us.htm Includes a useful 16 minute film on FGM for non- health professionals (NB contains graphic images) www.vimeo.com/15703287#at=0
- 26. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Accessing support from Health Services Health services can provide support and treatment. Women can access the help they need by speaking to their doctor, health visitor or midwife or can attend a sexual health clinic. Support should be offered in relation to trauma / emotional impact, as well as in relation to any physical treatment.
- 27. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Saheliya Specialist mental health services, well-being support and advocacy for BME women and girls (12+) 0131 556 9302 / 0141 552 6540 www.saheliya.co.uk Amina: Muslim Women Resource Centre Services, campaigning and confidential free helpline Tel: 0808 801 0301 www.mwrc.org.uk
- 28. Skills Edge Training The Union Building, Rose Lane, Norwich, NR1 1BY | 03333 583559 | info@skillsedge.co.uk Women’s Support Project Resources to support training and public education on FGM. Supports the FGM Aware Network and maintains the FGM Aware website. 0141 418 0748 Enquiries@womenssupportproject.org.uk or can email via www.fgmaware.org
Editor's Notes
- Welcome ‘Housekeeping’ Introductions
- Be sensitive to the possibility of FGM survivors being present. Traditionally FGM is rarely if ever discussed in practicing communities, even amongst adult women. Not all women who have experienced FGM know exactly what has happened to them. You may wish to make copies of a line drawing illustrating the different types of FGM available at a side table for participants to refer to should they wish. Models illustrating different types and possible health impacts can be purchased from Maasai Aid – www.e-solidarity.org/activites-2014/FLYER-model-FGM-EN.pdf Again these can be made available at a side table so that participants have a choice as to whether to view.
- Information for participants: ‘It is ok to ask questions’ is included since FGM is a difficult and complex issue and people sometimes hesitate to ask when they are unsure or if they feel the question might be too basic. Let participants know that they are welcome to ask in the group as well as whether they can also speak privately to (the facilitator or other person) at the break or the end of the session.
- Information for participants: Can you think of any other situations that have parallels with FGM? Trainer: Possible parallels include surgery on intersex babies, and genital cosmetic surgery (sometimes referred to as ‘designer vaginas’). See FGM Aware Training Notes for more information. Participants may ask about male circumcision or you may choose to raise it here. There are valid concerns about routine circumcision of boys for non-medical reasons. Nevertheless female and male circumcision are not comparable practices: Firstly the motivation for male circumcision does not include limiting or controlling male sexuality or sexual desire. Secondly the procedures and health impacts are not comparable. For example type 1 FGM would be the equivalent of cutting off the entire glans (head) of the penis and type 3 would involve removing all the external male genitalia and closing the wound, leaving only a small hole for urination. This is why many FGM campaigners prefer not to use the term female circumcision – because it minimises what actually happens.
- Information for participants: The World Health Organisation classifies FGM into four types – 3 main types, and type 4 which involves a range of practices, as shown, and others such as stretching the clitoris or labia. There is not always a clear distinction between types -, for example in type 2 the vagina is not deliberately closed but may become partially sealed by scar tissue. Trainer: Illustrations of the different types can found at www.dofeve.org/types-of-fgm.html and also from the Royal College of Nursing educational resource www.rcn.org.uk/__data/assets/pdf_file/0012/78699/003037.pdf In relation to type 4 ‘piercing’ included in the World Health Organisation definition of FGM it is unclear whether this was intended to include cosmetic genital piercings which adult women may choose to arrange themselves.. However it is arguable that someone carrying out cosmetic genital piercings could risk prosecution, were a complaint to be made. 2015 - 2016 figures for FGM reported in under 18’s in England and Wale s included 10 girls born in the UK who were recorded as Type 4- piercings. http://content.digital.nhs.uk/catalogue/PUB21206 See page 24 of the Home Office Multi Agency Statutory Guidance for more information on Type 4 – piercings.
- Information for participants: De-infibulation, or FGM reversal, is perhaps most likely to come up in maternity or sexual health clinics but may also be raised in support work elsewhere. Some practitioners recommend not using the term ‘reversal’, since it is usually not possible to ‘reverse’ or restore all that has been removed. Note that re-infibulation is illegal in the UK since it constitutes FGM The first UK prosecution under FGM legislation went to trial in early 2015, and involved a doctor who allegedly re-infibulated a woman following childbirth. The doctor was acquitted. The case highlighted the need for FGM training for medical professionals.
- Information for participants: The key learning point is the need to KNOW YOUR LOCAL COMMUNITY. If there is a community in your area which practices FGM you can find information online, or simply ask in an appropriate context about what terms are used and what benefits the community believe it brings. Trainer: FGM is also referred to as ‘sunna’ in some regions but be clear that FGM is not approved by Islam or any other religion. “Sunna is the traditional name for a form of FGM that involves the removal of the prepuce of the clitoris only. The word 'sunna' refers to the 'ways or customs' of the prophet Muhammad considered (wrongly in the case of FGM) to be religious obligations. Studies show however, that the term 'sunna' is often used in FGM practicing communities to refer to all forms of FGM, not just FGM that involves only the removal of the hood of the clitoris.” (www.forwarduk.org.uk)
- Information for participants: In small groups take 5 - 10 minutes to list the different reasons you have heard for FGM being carried out. Make a note of main points and also of any questions you may have as a group. Trainer: It is helpful to spend a few minutes with each group to encourage people to ask questions in the smaller group After the groups have had about 10 minutes to discuss, ask for feedback and any remaining questions. Ask the group ‘Is there one overarching reason why FGM is carried out?’
- Information for participants: The roots of FGM are complex and numerous and there is no conclusive answer as to where or why it originated. The justifications given for the practice are multiple and reflect the ideological and historical situation of the societies in which it has developed. See FGM Aware Training Notes for more information. In the Horn of Africa it is referred to as Pharonic circumcision. It also occurred among the early Romans and Arabs. As recent as the 1950s, clitoridectomy was practiced in Western Europe and the United States to treat 'ailments' in women as diverse as hysteria, epilepsy, mental disorders, masturbation, nymphomania, melancholia and lesbianism.” www.unfpa.org/resources/promoting-gender-equality It is important to understand the possible negative impact that not undergoing FGM can have. In some areas a woman cannot be considered an adult unless she has undergone FGM, or a woman’s survival may depend on it. See FGM Aware Training Notes for more information. Trainer: The important learning point here is the need to get to know your local community and to discuss the motivations for FGM where appropriate.
- Information for participants: FGM is practiced by people of Christian, Muslim and Jewish faiths, and by Animists and groups with no particular religion or faith. The overarching effect of FGM is to control women’s bodies and to limit sexual options and pleasure.
- Information for participants: A Peer Research report published by Rosa in 2012 recommends that the age of risk be raised until at least 21 years. FGM/FGC is usually carried out by elderly people in the community (usually, but not exclusively, women) who have been specially designated for this task, or by traditional birth attendants. These people receive a fee from the girls' family members, in money or in kind. In some cases, medical personnel perform the operation as well, for a fee. Among certain populations, FGM may be carried out by traditional health practitioners, (male) barbers, members of secret societies, herbalists, and sometimes by a female relative. - See more at: www.unfpa.org/resources/promoting-gender-equality#sthash.s5yYDyVJ.dpuf In some countries a considerable percentage of FGM is performed by health care providers, even although FGM is against the law, for example in Egypt it is estimated at 50 – 70%. The trend towards medicalisation is increasing. Whilst there may be less pain and less risk of excessive bleeding or infection when performed under clinic conditions, there is also evidence that girls and women are cut more deeply and more flesh is removed in this context.
- Information for participants: Take 10 minutes to discuss in which countries FGM is practiced. It is helpful to spend a few minutes with each group to check on progress and encourage questions. After about 8 - 10 minutes ask groups to consider which four countries have the highest prevalence rate (In which four countries do you think FGM is most common?) You can then either distribute copies of the UNICEF map, or show the next slide. The four countries with the highest prevalence rates are: Somalia (98%), Guinea (96%), Djbouti (93%), and Egypt (91%). However it should be pointed out that Eritrea, Mali, Sierra Leone and Sudan are close behind at 88 – 89% whilst in Gambia, Burkina Faso, and Ethopia more than 70% of women have experienced FGM. Once participants have seen the map and prevalence rates ask “Was there anything that particularly surprised you?”
- Information for participants: The map gives a useful indication of communities at risk, based on nationality, but it is more accurate to view FGM as being practiced by specific ethnic groups, rather than by a whole country. (www.forwarduk.org.uk) It is important not to ignore countries where average prevalence is low – there may be one area of that country in which prevalence is high. For example: “The most recent Demographic and Health Study (DHS) for Nigeria (NPC Nigeria 2009) suggests that the prevalence of FGM differs by region, ranging from 53.4% in the south west, to 2.7% in the north east. UNICEF gives a 27% national rate for Nigeria.” Trainer: Highlight that not every woman from an FGM practicing community will have had FGM and not every woman who has been cut will support the practice The figures on the UNICEF map are widely accepted as the best available but be aware that: FGM is not always documented; the figures are not necessarily accurate - depending on how the information has been gathered some rates may be underestimated; many studies date to the 1990’s. Statistical profiles for 30 countries are available on the UNICEF website.
- Information for participants: FGM is most prevalent in 29 countries in Africa and the Middle East, but as global awareness around the issue has grown over the past decade, FGM has increasingly been reported throughout the world, and it is now known to also be common in several Asian countries, such as Thailand, Malaysia and Indonesia. In 2015 it was reported that FGM is becoming more common in Malaysia. Since this map was published it has been reported that FGM is carried out by several ethnic groups in Colombia, South America. FGM also takes place in parts of the Middle East, e.g. in Yemen, Oman, Iraqi Kurdistan and is practiced among Bohra Muslim populations in parts of India and Pakistan. www.forwarduk.org.uk/ As a result of immigration and refugee movements, FGM is now potentially being practiced by ethnic minority populations across the world
- Information for participants: It Is not possible to give a reliable figure for the number of women in Britain living with FGM, nor for the number of girls at risk. Firstly available information, such as the most recent census in 2011, reports on NATIONALITY, rather than ETHNIC GROUP Secondly the census does not ask about experience of FGM and nor is this information collected elsewhere. Maternity throughout the UK should now ask about FGM, and baby girls born here who are potentially at risk of FGM should be identified and protected
- Information for participants: In small groups, discuss possible health impacts immediately following the procedure being carried out, then share information about possible longer term consequences. Trainer: If the group have little or no prior knowledge and where participants do not have any direct practice experience, it may be more helpful to have this discussion with the large group.
- Information for participants: Obviously not all girls will experience these issues, depending on the type and how it is carried out. The image of a girl being held down does not reflect all women’s experience. When it is done under clinic conditions the immediate risks are likely to be reduced, but on the other hand there is evidence that the cuts are likely to be deeper and more severe. All forms of FGM are unnecessary and harmful.
- Information for participants: These are possible impacts – not all women will experience all of these. Some women have no health issues associated with the FGM. Some women may not be aware of the extent of what has happened to them, or in the case of girls who were cut shortly after birth, they may not realise that anything has happened. Women who have experienced FGM, especially younger women, often express that they want appropriate services, but they do not want to be pitied - they want to be treated like everyone else. Whilst it is important that practitioners pro-actively raise FGM when appropriate, it is also important to address health needs in a holistic way.
- Information for participants: As noted earlier it is an offence in the UK to re-infibulate a woman following childbirth
- Information for participants: It is an offence to aid or abet FGM or to pay someone to carry it out, whether in the UK or elsewhere. There has been one unsuccessful prosecution in England, in 2015. In March 2016 a retired nurse, a mother of two girls and a Dawoodi Bohra community leader have each been sentenced to a maximum 15 months in prison after Australia’s first criminal prosecution for female genital mutilation.
- Information for participants: FGM is included in the national child protection guidelines. Trainer: Prior to the training it is helpful to find out about any local contacts and procedures in relation to FGM and child protection
- Trainer: If the group has limited knowledge or experience of FGM they might find it more helpful to have this discussion as a large group It will help to focus the discussion if you ask the group/s to list their ‘top five’ indicators of risk. Information on risk factors can be found at pages 44 and 45 of the Home Office Multi Agency Guidance on FGM (2016)
- Information for participants: Don’t assume that all women who have undergone FGM support the practice. The global campaign to end FGM is led by women from FGM communities. Girls may also be at risk if their father comes from a group affected by FGM, even if their mother does not. Don’t assume that all men support the practice. The level of integration is also significant. Girls are thought to be less at risk if the family is well integrated into UK / European society. The risk would also be lessened if the mother has sought asylum in order to protect her daughter. In some areas FGM is believed to be a community responsibility, rather than just a parental responsibility. It is therefore possible that FGM might be arranged without the parents consent, or even against their expressed wishes. Practitioners should aim to work with parents to help them resist any pressure from the wider family or community.
- Information for participants: This can be completed online, free of charge, and you can print a certificate of completion.
- Information for participants: The FGM National Clinical Group also offers a film aimed at health professions. You have to register with the site to view, whereas you can watch the film for non-health professionals without registering. (No charge for registering) These links can be found at www.fgmaware.org
- Information for participants: Interpreting services will be provided for people who need them. Family members should not be used as interpreters. Anyone having a clinical examination can ask for a male or female health worker. Trainer: Insert a slide here with information on any local contacts and services relevant to FGM
- Information for participants: