Female genital mutilation (FGM) is any process that injures the female genital organs or the partial or complete removal of the external genitalia of a woman or girl for non-medical reasons, and is a violation of women's human rights (World Health Organization (WHO), 2017). Up to 200 million girls worldwide have endured FGM; 137 000 affected women and girls are living in England and Wales (Macfarlane and Dorkenoo, 2015). Because of increasing migration from countries where it is practised, FGM is an growing public health issue in the UK. The care of these women must be looked at closely by the nursing profession to enable improvement.
A study of more than 28 000 women in six African countries found FGM caused adverse obstetric outcomes including disease and death (Banks et al, 2006). Andro et al (2014) emphasise that FGM is also a growing health issue across Europe, although the practice is illegal in most European countries (United Nations Population Fund, 2018). The Royal College of Obstetricians and Gynaecologists (2015) reports that there are 137 000 women who have undergone FGM living in England and Wales. The number of women living in England who were born in countries where FGM is still practised is increasing, according to research from City University London (Macfarlane and Dorkenoo, 2015)). The NHS (NHS Digital, 2017) reported 9179 new cases of FGM in England in 2016 alone.
Responsibility for identification of FGM
Lundberg and Gerezgiher (2008) believe FGM is a midwifery matter. Nevertheless, NHS Digital (2017) reports that, while 54% of the new cases were discovered in midwifery services, 46% were discovered in other medical settings. The Royal College of Nursing (RCN) (2016) identified that health visitors and school, community, travel, practice, sexual health, neonatal, accident and emergency and gynaecology nurses work in sectors of nursing where FGM is most likely to be discovered; however, FGM can be discovered in any area of nursing. Additionally, Momoh (2014) argues that a nurse can be the first health professional a woman with FGM encounters.
The RCN (2016) advises that nurses need to be aware of best practice when dealing with FGM; this includes knowing what FGM is, where it is carried out, how to prevent it and how women who have undergone it can be supported physically and emotionally.
Andro et al (2014) found that health professionals need better education on FGM. This is supported by Relph et al (2012), who found that fewer than 25% of practitioners had had formal training on FGM, even in areas of high prevalence in London. Additionally, a large study by Zaidi et al (2009) found health professionals had substantial gaps in their knowledge regarding how to deal with FGM, and emphasised the need for appropriate FGM training.
The author has noted that some of her colleagues do not even know what FGM is. If nurses are working in frontline services with the potential to expose and reduce FGM, training needs to be included in university nursing programmes and continued throughout employment.
McCrae and Mayer (2014) state there are guidelines that give nurses advice on detecting and reporting FGM but these are recommended only for nurses who are in contact with practising FGM communities. However, Rymer and Momoh (2005) suggest that nurses working in low-prevalence areas are often the professionals who need the most guidance on FGM because they do not feel comfortable with discussing the practice as it does not arise frequently. All nurses should be aware of the Department of Health and NHS England (2014) ‘requirements for NHS staff’ as a case of FGM could be discovered in any setting, which could ultimately lead to the safeguarding of that person's daughter, sister or cousin.
Momoh (2014) believes it is an important role of a healthcare professional to report any actual cases or suspicion of FGM; in particular, a nurse has a duty to report any cases where a child is believed to be at risk to social services. Therefore, it is imperative that nurses are knowledgeable about the laws regarding FGM. To ensure this, courses on FGM need to be provided.
Cultural factors
According to Onuh et al (2006), discouraging the ritual of FGM will require culturally sensitive education for nurses. This includes understanding the history and culture of the practice, which Nour (2008) explains is not fully understood; nevertheless, it is believed to have existed for over 2000 years. According to Nyangweso (2014), FGM is a profound tradition reinforced by centuries of culture and beliefs. Momoh (2005) explains the practice of FGM has been performed by almost every civilisation throughout history, with the practice observed in the UK from the 1950s. However, the tradition is now mainly concentrated in certain African, Middle Eastern and Asian countries. According to Nyangweso (2014), FGM is considered to be an Islamic religious obligation. However, Momoh (2005), an expert in FGM, argues it is not a requirement of Islam, but a false belief. Furthermore, Broussard (2010) states there is no mention of FGM in the Quran. Mendes (2015) explains cultural arguments such as these need to be understood by nurses to effectively treat a patient individually and avoid stereotypes.
Other literature, such as Braddy and Files (2007), examines the need to treat women affected by FGM holistically and how a trusting relationship must be built, with an understanding of why FGM is undertaken. FGM is believed to be a rite of passage from childhood to adulthood and a necessity for marriage, as well as having many other explanations (Nour, 2008; Broussard, 2010; WHO, 2017). To prevent a girl from undergoing this procedure could cause her cultural identity to diminish. In health care, FGM gives rise to a situation in which issues of culture and safeguarding collide. This was highlighted by Leye and Deblonde (2004), who suggested that health professionals may feel unable to act on the law for fear of appearing racist.
Legality
It is common for FGM to be looked at from a Western perspective and it is usually agreed that the practice is abusive and should be illegal. This view arises mainly from the argument that FGM is customarily carried out on a child unable to give consent (Unicef, 2016). Yet, for some practising Muslim communities within the UK, FGM is a way to hold on to their important customs and traditions (Nyangweso, 2014). Momoh (2005) considers the proposed eradication of the practice involves a complicated argument, with supporters of FGM being offended by the allegation they are child abusers and believing that FGM is a gift.
Whichever view one takes, it is important to appreciate that both sides come from a belief that they are doing what is best for the child. Breitung (1996), while not supporting the practice, argues that a person's cultural identity should be respected; however, this is strongly disputed by Naughton (2013), who states that FGM is a barbaric practice and should be viewed as child abuse.
Nurses dealing with the subject of FGM must be sensitive to the issue that FGM is related to identity and a ritual acceptance of a woman into the community. Not enduring FGM could cause a woman to be rejected by family and peers (Nyangweso, 2014).
Nevertheless, whichever way nurses look at the reasoning behind FGM, they must remember that FGM is illegal in the UK under the Female Genital Mutilation Act 2003 (Gov.UK, 2019) and the practice of FGM must not be encouraged under the Nursing and Midwifery Council's (2018) Code, which states a nurse is required to sustain the laws of the UK.
FGM health issues
The findings of Andro et al (2014) highlight the long-term health problems to which FGM exposes women. This impacts on nursing practice as it informs nurses how the act of FGM can affect women through gynaecological and urinary problems, severe pain and psychological health complications (Andro et al, 2014). They also highlight the need for worldwide awareness of the consequences of FGM, as it may be possible to educate, treat and therefore alleviate symptoms.
Clarke (2016) found that the consequences of FGM vary, depending on factors such as type performed, age when it was executed and how it was carried out, for example, whether the perpetrator was trained or untrained and whether it was done in a hospital. Clarke (2016) believes this information will impact on the needs of the woman affected by FGM, and on the health professionals who will need the skills and knowledge to assess this, again demonstrating the need for education of nurses on FGM.
The NHS England (2016) commissioning for quality and innovation (CQUIN) document states that one of the 2017–2019 goals is to personalise care and support planning by identifying groups of individuals who would benefit most from personalised care. From the literature, it is clear that women affected by FGM would be a desired group for CQUIN. Modifying the CQUIN to involve the personalised care of women with FGM and its long-term consequences could be a beneficial step in the support and treatment of women harmed by FGM.
Preventive measures
FGM should be eradicated to prevent its damaging health consequences, suggest Cottingham and Kismodi (2009). It may be thought that informing women about the dangerous effects of FGM would prevent them from enduring or encouraging the practice. However, Shell-Duncan (2008) found that, when the health consequences of FGM were explained, practising communities believed this was a ‘scaremongering’ tactic and continued to endure FGM. Shell-Duncan (2008) alternatively suggests proposing FGM as a human rights issue in the practising communities as a better method to invalidate the tradition. Similar recommendations were made in the UK by Bagness (2015), who states FGM must be seen as a violation of human rights if it is to be eradicated. Furthermore, Anim (2014) agrees, adding that close work with communities is needed to help them understand that FGM is an act of violence with potential long-term negative consequences.
The NHS England (2014)Five-Year Forward View involves ‘getting serious about prevention’ and FGM fits into that category. If FGM can be prevented, then the health complications associated with it will cease to exist. This will save the NHS money on curative interventions, which were found by Simoens (2011) to be more costly than preventive measures. Bagness (2015) believes nurses are at the forefront of the eradication of FGM and it is their duty to dynamically participate in challenging this abuse sensitively.
However, for nurses to be able to do this, proper training is fundamental (Anim, 2014). An FGM prevention programme that aims to eradicate the practice was launched in the UK in 2014 (Department of Health and NHS England, 2014; NHS Digital, 2017). The programme has made it mandatory to document FGM status in a patient's medical records and set out a specific procedure for referring FGM cases or suspicions. It also recognises the significant role health professionals play in the pursuit of the eradication of FGM.
Conclusion
The research referenced in this article demonstrates the serious health consequences of FGM. Along with further evidence, it highlights the lack of knowledge of FGM among nurses and other health professionals. Therefore, training specifically on FGM should be included in university and employment programmes to ensure nurses are aware of the complications of FGM and are able to provide up-to-date, evidence-based care. Additionally, it is vital that nurses are educated in the potential psychological impacts of FGM so they can make appropriate referrals.
Early identification of women and girls who have had FGM is essential for the nurse to be able to discuss the risks and complications of FGM, treat any health problems that have arisen or may occur in the future and improve the quality of life for those affected. The issue of FGM must be dealt with sensitively and the nurse must appreciate the cultural origins involved.
Education for nurses regarding differing cultures, beliefs and values is essential in providing culturally competent care and this reduces the risk of considering FGM solely from a western perspective. This should encourage individualised, patient-centred care and increase the nurse's confidence in discussing cultural practices.
Reflective practice should be encouraged as this can aid nurses' understanding of how their own values and those of the woman can impact on each other.
Furthermore, the nurse should be knowledgeable about the law and policies regarding FGM, should act lawfully and be culturally sensitive in practice. The nurse must ensure that all suspected and actual cases are reported and child protection referrals are made where appropriate, or the right agencies contacted.
As a practising nurse, the author will ensure that although she believes FGM to be wrong, she will not belittle or disregard the practice of FGM as something unimportant or sordid. Instead, she will use the best available research and literature to enable herself to have an informed and culturally sensitive discussion with women affected by FGM. She will keep her knowledge up to date and inform colleagues of the practice if they are unaware. She will also be attentive to women in her care who originate from FGM-practising communities and use awareness to sensitively approach the subject, while being conscious of the laws around it.