You might remember the scene in the film Shirley Valentine in which Shirley recounts the discovery of her clitoris. I do because I was watching it with my mother. I didn’t exactly squirm with embarrassment but it did generate a moment of discomfort probably, I sensed, for both of us. It’s a subject we would not generally discuss over salmon sandwiches at Sunday tea. But that was at least 20 years ago and now the world is very different. Nowadays, female genitals can be the subject of family viewing on six o’clock news reports, not of course in a puerile sense, but for the very real and important discussion about their criminal mutilation. Female genital mutilation (FGM) is illegal in this country, but it is estimated that some 66,000 women in the UK are affected by FGM. Awareness of FGM is rising and women who have been subjected to mutilation are seeking help about how to become, in their words “normal” or, if this is not possible, how to live with it.
It was fascinating to spend the afternoon with Juliet, Melanie and Deqa (and briefly to meet Claire) at the African Women’s Clinic at Queen Charlotte’s Hospital in west London. This cohesive and passionate team see large numbers of women (not just from London) who are seeking advice about their FGM. Their recent success at seeing so many women is because of their advert on Somali satellite television. But it was not always so. Juliet, a midwife, and Melanie, a counsellor, were in at the very difficult birth of the clinic. Initially, the whole concept was met with resistance from doctors and managers but in 2006 the director of midwifery and a local commissioning nurse were so inspired by Juliet’s proposal that doors began to open and the clinic was established. Although it’s not all plain sailing even now. The clinic lurches year after year to ensure it is funded from a combination of NHS and local authority public health resources.
A health advocate was also a member of the team from the beginning. Deqa is the latest health advocate to work with the team. She is Somalian herself and is not only invaluable at interpreting but is a real advocate for the women. She helps them to make their own choices, to understand their options and she also makes clear the law in this country – which includes outlining the consequences for the women themselves, their husbands (they are commonly married) and their daughters.
Of all the people I was able to spend time with it was my greatest privilege to meet Aziza (not her real name). She was referred to the clinic because she was half-way through her fifth pregnancy. Having had FGM at the age of 10, her midwife thought she should be able to discuss her circumstances with the specialists and be clear about how her FGM might affect her options for giving birth. Now in her early 30s, Aziza told us she was married at 19 and had her two boys and two girls in quick succession. All were born before she came to the UK 8 years ago. Having no maternity history in this country meant her consultation with Juliet ranged from her previous birth experiences to understanding her type of FGM.
Aziza said she had what Somalians call “sunna” type mutilation. Of the four classifications used in this country, sunna is the term generally associated with the simple type 4 in which there is minimal cutting of the clitoris itself, with type 3 resulting in an almost completely closed vaginal opening (type 1 is a clitoridectomy: partial or total removal of the clitoris and type 2 is excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora).
“It’s just a cut” Aziza told us. Juliet and Deqa nodded knowingly. She explained that her mother was very religious and it was done for that reason. Her mother arranged for a traditional woman to perform the procedure at home and that she and her younger sister were mutilated at the same time. Since her mother had bought new and clean equipment she did not get an infection, neither did she bleed a great deal. Unusually, she was given local anaesthetic so the procedure was not painful and she does not suffer any consequent traumatic flashbacks. The only physical complication she experienced immediately afterwards was pain passing urine for the first time. Her periods have flowed normally since.
This was an easy conversation, partly in English, partly in Somali, and Aziza was very generous with her information. But I sensed something was not what it seemed. Deqa took an appropriate moment to make the point to Aziza that there is no requirement in any religion to perform FGM. Aziza smiled and understood. Was she perhaps recognising that her mother had used religion to justify complying with the cultural need to perform FGM on her daughters? Whatever she thought she didn’t seem to blame her mother and now, as a mother of girls herself, she had no intention of having them mutilated. Anyway, she assured us, they are now too old and they would not be persuaded into it for any reason.
Not all consultations need to include a physical examination and it seemed that Aziza would not need to be examined. But Juliet dextrously wove the possibility into the conversation. Aziza thought it would be a good idea because, although she hadn’t had problems giving birth previously, she wanted to be reassured that this time it would be the same. I then understood the significance of the knowing nods from Juliet and Deqa earlier. They suspected that Aziza’s mutilation was more extensive than the type she was describing. Did she even know what type she had? Did she realise that sunna is a generic term covering a range of types? I left the consulting room while Aziza was examined.
This gave me a chance to talk more with Melanie. She would normally have been part of the consultation but had sacrificed her chair to me so Aziza didn’t have too many people in the room. Clearly very skilled in her counselling role, I sensed she brought a helpful non-clinical tone to the consultations. She saw the women as holistically as possible often seeing them for ongoing counselling with their partners at which they could address wider issues such as contraception. In doing so she was able to cast the whole process as one of empowerment for the women. Visiting the clinic was their first step on a journey of making choices for themselves, being valued as individuals and challenging their cultural norms. Crucially, their education and empowerment was getting back to Somalia and the attitudes there to FGM she perceived were gradually changing. The challenge in this country is getting messages to schools so that youngsters, both boys and girls, could be clearer about FGM and its consequences.
By the time I returned to the consulting room Aziza had been examined and had gone, but left armed with a new understanding of her mutilation. As Juliet and Deqa suspected, she hadn’t just had a simple cut. She had had type 2 mutilation in which her labia had been stitched reducing the size of her vaginal opening. This threw into question Aziza’s history of having normal births. Had she been deinfibulated (the procedure to reverse the mutilation) to give birth and then re-sutured? Had she really understood the nature and consequences of her mutilation? It’s impossible to tell from what she said to us: the history diminished in importance, but what was crucial now was for her to be empowered to make appropriate choices about giving birth next time. And would she have more children after this one? “Yes” she said, “my husband wants more, he’s a man”. Aziza did say she would go back to the clinic after having the baby so she could have surgery to repair damage to her vaginal wall – damage she didn’t realise she had and which was probably caused by giving birth through a constricted vaginal opening.
I didn’t see Aziza leave but Deqa was keen to tell me that many of the women leave the clinic with extraordinarily happy faces. The ones who are deinfibulated in the clinic as a quick out-patient procedure leave feeling liberated. And recently, one 50 year old woman, about to enter her second marriage, punched the air at the success of her deinfibulation she was so thrilled.
It’s not always as straightforward as that. Some reversals are not possible, there could be too much scar tissue, there could be damage to the urethra and other structural reasons that, even with extensive surgery under general anaesthetic, would prevent a reversal. And to a certain extent, it is still unknown territory.
We are learning more about FGM. The government is improving the information held in the NHS about women and girls with, and at risk of, FGM. The first data were published in October 2014 by the Health and Social Care Information Centre. And by sharing anonymised data, the government is supporting the police and social services in their work. Data collection by NHS organisations is now a legal requirement. The Department of Health national FGM prevention programme is backed by £1.4 million so that healthcare professionals can be clear about their role in FGM which is to care, protect and prevent. To supplement this Health Education England will be producing six new e-learning training sessions which will be available free to the NHS. Updated information will also be available on NHS Choices to help professionals hold sensitive conversations and how best to support women with FGM and the actions to take to safeguard vulnerable girls. Health professionals are already required to inform the police or social services whenever they have concerns that a child is at risk of any form of abuse, including FGM and we should not underestimate how difficult some of these conversations are.
FGM is not a subject I will necessarily be bringing up with my mother, but I have seen impressive professionals promote women’s health and help manage this criminal practice. In doing so they support women who have experienced it to deal with their circumstances and their future in an empowered and informed way. My experience at the African Women’s Clinic was fantastic. I am grateful to Juliet, Melanie and Deqa for giving me so much time and the benefit of their valuable insights. But most of all I am grateful to Aziza and those like her from whom I have been able to learn first-hand what it means to have FGM.
You can find out more about this clinic on http://www.youtube.com/watch?v=b6chv-YRDBU
More information on FGM can be found at:
David Foster is the Deputy Director of Nursing and Midwifery Adviser at the Department of Health
Deputy Director of Nursing and Midwifery Advisor
Department of Health