Archives ofDisease in Childhood 1994; 70: 441-444 441

CONTROVERSY Arch Dis Child: first published as 10.1136/adc.70.5.441 on 1 May 1994. Downloaded from

Female genital mutilation: a dilemma in child protection

Elspeth Webb, Bryan Hartley

Demographic perspective need for excision. In others it is seen as The city of Cardiff in South Wales saw massive essential to ensure female purity. In almost expansion in the 19th century when it devel- every group in which it is practised it is a oped into a major port. Although the docks necessary prerequisite in order for the woman to now see little activity Cardiff has the legacy of be truly female. The psychological importance a highly heterogeneous population of minority of this should not be underestimated. ethnic groups. Among these are two groups in which the practice of female circumcision, or female genital mutilation as it is now known, is Moral perspectives - a tension between traditional: the Somalis and the Yemenis. In cultures addition to these well established communities It is hard to imagine reasons for the develop- there are members of other ethnic groups in ment of a custom which, as well as causing which it is practised. great pain, can often have devastating effects Female genital mutilation is an ancient on a woman's fertility, her childbearing practice found in the main across the African capacity, and indeed her survival (table). Sahel extending in East north into Egypt Female genital mutilation, and particularly and south into Tanzania.I It is also found in infibulation, presumably acted as an anatomi- parts of the Arabian and Malay peninsulas.2 It cal chastity belt to ensure paternity was not in is traditional across many different ethnic doubt. groups and faiths, including people of Nilotic, The practice of female genital mutilation is Cushitic or Bantu origin, Christians, Moslems, illegal in most countries, including Britain, and Jews (Falashas), and followers of indigenous the majority of the countries in which it http://adc.bmj.com/ religions. is traditional. The Prohibition of Female Circumcision Act 1985 makes it a criminal offence in this country: Forms offemale genital mutilation '(a) to excise, infibulate or otherwise muti- There are three variations of female genital late the whole or any part of the labia majora or mutilation of which the most severe, infibula- labia minora or clitoris of another person: or tion, involves the cutting out of all external (b) to , abet, counsel or procure the perfor- on September 27, 2021 by guest. Protected copyright. genitalia and sewing up of the wound leaving mance by another person of any of those acts only a pinhole meatus for the passage of urine on that other person's own body'. and menstrual fluid. This form has been Any person found guilty can face up to a described in pre-Christian Egyptian mummies. maximum of five years' imprisonment. Excision and Sunna, the less radical forms of As a practice which harms girls and impedes female genital mutilation, are practised by a health and normal development female genital minority in the Yemen. In Somalia it is mutilation is clearly a child protection issue. In virtually universal and takes the form of infibu- Cardiff, as elsewhere in the UK under the lation.' 3 It is perceived by many to be an Children Act 1989, the Area Child Protection integral part of their Islamic faith, but in fact the practice has no Koranic basis.2 A survey of Department of Child Complications offemale genital mutilation4 Health, University of obstetricians in Cardiff suggests that female Wales College of genital mutilation is universal in the local Acute Pain Medicine, Community Somali population and this community Haemorrhage Health Unit, Infection therefore causes most concern. Urethral damage Lansdowne Hospital, Anal sphincter damage CardiffCFl 8UL Psychological trauma Elspeth Webb Death Chronic Urinary obstruction Ethnic Minorities Rationales for female genital mutilation Renal failure Division, South Current beliefs of the role and function of Obstruction to menstrual flow Glamorgan Social Haemosalpinx female genital mutilation are highly diverse, Pyelosalpinx Services, South and include the prevention of prostitution, Keloid Glamorgan County Neuroma of dorsal clitoral nerve Council, Cardiff promotion of easier childbirth, and the preven- Vulval abscess Bryan Hartley tion of the growth of male-like genital organs.2 Dyspareunia In some areas Infertility Correspondence to: it is believed that an infant will Psychosexual problems Dr Webb. die if its head touches the clitoris, hence the 442 Webb, Hartley

Committee (ACPC) has a statutory duty to debate to them because they know how best to protect children from harm. In the context of handle it. the cultures in which it is traditional it is per- ceived as a responsible act by parents ensuring Arch Dis Child: first published as 10.1136/adc.70.5.441 on 1 May 1994. Downloaded from their daughter a place in society. For example A strategy for action most Somalis in Cardiff believe that a girl We believe that female genital mutilation will who has not experienced female genital mutila- only be eradicated by the communities them- tion has her prospects of marriage greatly selves, whether resident in Africa or elsewhere. diminished. Any suggestion that the practice is Educating the community at large both on the harmful or abusive is highly offensive. legal position in the UK, and the health The Somali population of the UK has been hazards faced by the female population is on- much increased by the arrival of refugees going. This takes the form of a leaflet available fleeing the civil war. Around 3000 have come in English, Somali or , backed up by an to South Wales. Most have experienced active discussion of the issue between social bereavement, fear, and great suffering before service/health link workers and members ofthe their arrival here. Many find the adjustment to community, and between education staff and a new country, and peace, difficult. Their selected school students as part of a wider plight is exacerbated by inadequate housing, health education programme on women's poverty, and racism in this country. In such health. Already young Somalis locally, men situations familiar customs and traditions are a and women, are questioning the need for vital source of security. female genital mutilation. This tension between the desire to eradicate Any health education initiative which at best female genital mutilation and to enforce the could be conceived as culturally hostile is law, but still to deliver services which respect doomed unless it occurs in the context of an peoples' race, culture and values, causes a overall strategy to improve the health and whole series of dilemmas for workers in health, social welfare of the population as a whole. social services, and education. Some of these There are several other initiatives aimed at are particular to the newly arrived refugees, improving the welfare of the community. A some to the whole Somali community. Somali Health Forum has been established to We believe that a campaigning style of develop response strategies specifically to meet approach to eradicate female genital mutilation the special needs of the refugee and host by British professionals involved in the delivery Somali populations. A catch-up surveillance of services to the Somali community, however programme for the child population is in horrific they personally find the practice, progress. Schools are being approached by would have negative outcomes. We are con- the local child psychiatry service to provide cerned, for example, that any perception by the support to teachers coping with the refugee community that the main focus of our behavioural problems inevitable in such a interest in the health care needs of girls and traumatised group. A 'well woman' clinic in http://adc.bmj.com/ women was female genital mutilation would the docks area has adopted an open door lead to a marked reduction in their trust, and policy to allow newly married women a fast take-up, of services, access to which is already track referral to a female gynaecologist to per- less than good. Furthermore we do not believe form defibulation. This is opening of the scar such an approach would work. Banning of the to allow consummation (not to be confused practice in Africa has merely driven it under- with disinfibulation, or reversal). Two local ground.2 Any action that drives it underground family doctors have set up clinics for their on September 27, 2021 by guest. Protected copyright. here is likely to increase the risk faced by the Somali patients. Four health advocates have children, and jeopardise any health education been employed to support these initiatives initiatives that we hope will contribute to the including one male employed mainly in the demise of the custom in the longer term. mental health services. In tandem with these A campaigning style could also place in initiatives a subgroup of the local ACPC has jeopardy the dialogue which is currently taking developed a policy to attempt to protect girls place between health and social services staff perceived as at risk in all groups practising and key members of the Somali community female genital mutilation. about female genital mutilation. Their message It has become impossible for children to be to us is simple: the eradication of female sent to Somalia for female genital mutilation genital mutilation cannot be achieved within since the outbreak of the civil war there, a the context of public meetings or exposure in practice we know to have occurred in the the media. It can only be achieved within the past. It is possible to arrange for girls to be context of individual families. It is clear from circumcised in other places, notably some of these dialogues that there are a wide range of the Arab Emirates and Addis Ababa. This attitudes toward the issue within the Somali remains a danger. We are aware that there community. At one extreme are those may be traditional circumcisors among the demanding the repeal of the 1985 act, together refugees, but have no evidence for this. with requests to social services to ignore If a girl is referred to social services because referrals of female genital mutilation. At the she may be at risk ofbeing mutilated the family other are people wanting to know more about are visited and informed clearly and firmly as the health risks and law in relation to the to the law and the options open to the courts. practice so that they can argue against it - their After such a referral it is our experience that it preference is for the professionals to provide is extremely difficult to gather enough evidence them with that information and leave the to proceed, within the powers available under Female genital mutilation: a dilemma in child protection 443

the Children Act, if the girl and her parents Rights Group Report No 47. London: Minority Rights Group, 1983 (revised edition). deny that she is to undergo female genital 3 Warsame A. Social and cultural implications of infibulation mutilation. Can we go to court to seek care in Somali. Proceedings ofthe International Seminar on Female Circumcision. Mogadishu: Somali Women's Democratic Arch Dis Child: first published as 10.1136/adc.70.5.441 on 1 May 1994. Downloaded from proceedings solely on comments made to a Organisation and Italian Association for Women in teacher in school, or on the basis ofplayground Development, 1988: 88-93. 4 Armstrong S. Female circumcision: fighting a cruel tradition. conversations? Should we put all Somali girls New Scientist 1991; 2 Feb: 42-7. on the 'at risk' register? If they were registered 5 Ladjali M, Rattray TW, Walder RJW. Female genital mutilation. BMJ 1993; 307: 460. how could we ensure that they have not been mutilated, given the rights parents and children have under the Children Act to refuse Commentary consent to medical examination? Female genital mutilation has been illegal in Even when we have evidence that a girl has the UK since 1985.1 No prosecutions have been mutilated what kind of response is been brought in the UK (Guardian 22 Nov 93) appropriate? Do we want to remove a child but in November of 1993 a medical practi- from the care of parents who believe that they tioner was brought before the General Medical have acted in her best interests and indeed may Council charged with performing multiple be model parents in all other aspects of her female circumcisions, knowing the operation care? In such cases we believe the best to be against the law. He was struck off. approach is to request a police investigation to It is estimated that in the UK 10 000 girls see if there are grounds for prosecution of the are currently at risk of genital mutilation, a parents and/or others under the Prohibition of traditional practice that is not based in religion Circumcision Act, rather than set in motion but rather concepts of fertility, female sexu- child protection procedures after the event. ality, and marriageability.2 Genital mutilation There have been several referrals made in is widely practised by many ethnic groups from the last two years but in no case was there west, east, and north eastern parts of Africa. enough evidence to proceed with the powers Hosken provided an estimate of the prevalence available under the Children Act 1989. One of of genital mutilation from over 90% in Somalia these referrals involved a family with three girls to 50% in Egypt to 20% in Ghana.3 Over half who subsequently were taken to and the African nations do not practise female may have been circumcised. This case has genital mutilation.4 The African Charter on been referred by the police to the Criminal the Rights and Welfare of the Child stresses Prosecution Service. that positive traditional values and cultures be Naive approaches such as 'sensitive coun- preserved and strengthened, but requests in its selling in the child health clinics' are unlikely to Article 21, that, 'appropriate measures be have any impact upon a custom thousands of taken in order to eradicate traditional practices years old. Such an approach, involving flagging and customs which are prejudicial to the health up of female genital mutilation at health con- of the child'. Currently 26 African countries sultations for unrelated issues would only have committees established after an initiative http://adc.bmj.com/ alienate clients and could amount to harass- in 1984 to work towards eliminating female ment. Female genital mutilation is only dis- genital mutilation and other damaging cussed during client/professional contact ifthat customs (the Inter-African Committee Against contact arises out of a formal referral regarding Harmful Traditional Practices Affecting the practice or if the presenting complaint Women and Children). could result from, or interact adversely with, The current debate extends from the United female genital mutilation. Nations, the Convention on the Rights of the on September 27, 2021 by guest. Protected copyright. Child advocates eradication of genital mutila- tion, to governments, but most important is Conclusion the impact of women working at a local level. A recent editorial recommended that 'by The description of female mutilation working together local women and inter- and the possible physical and psychological national organisations will be most effective in sequelae are well known for the girl or woman5 eliminating ... female genital mutilation'.5 We but less well documented is the effect upon her would add that local statutory and voluntary partner and the consequences for their sexual agencies and all members of the community, relationship. not just women, should be included in any The way forward is difficult but much has initiative. However upsetting, we are mindful already been achieved. There is legislation that despite our best endeavours some children available in the UK, the 1985 Act, the in this area may suffer this mutilation. We Children Act 1989,6 and there is advice in believe that our approach, that is, one based on Working Together 1991 as to how children empowerment, will in the long term be the one might be protected.7 However, it is 'through that protects most children and helps the sensitive community education and social communities themselves to reject the practice. work intervention' that progress is likely to be With thanks to Maria Michael and Mina McElwain (South made.4 As a last resort a prohibitive steps order Glamorgan Social Services), Graham Anthony (South Wales or a care order may be needed to ensure the Police), Dr Heather Payne (South Glamorgan Health Authority), and John Clark. girl's protection (Children Act 1989). From the 1989 First National Conference

1 Hosken F. The Hosken report - genital and sexual mutilation of on Female Genital Mutilation in the UK females. Lexington, Mass: Women's International Network guidelines as to management were agreed8: News, 1982 (revised edition). 2 Minority Rights Group. Female circumcision, excision and 0 Female genital mutilation is the preferred infibulation: the facts and proposals for change. Minority terminology