Female Genital Mutilation (FGM) is a centuries- old cultural practice that involves the removal or cutting of healthy female genitalia. The physical and psychological impact on women and girls from this practice continues long after the cutting. Many of those affected suffer in silence. Though it seems completely incongruent with contemporary life, traditional communities continue the practice because it is deemed to have social and cultural benefits.
FGM was outlawed in the UK in 1985 and the Female Genital Mutilation Act 2003 further delineates prosecutable offenses. In the last year, the UK government along with the European Union started working toward the prevention of FGM in European communities. Large funds have been raised to raise awareness, provide advocacy, collect data in hospital settings and provide support to girls and women at risk. Government agencies are working with schools, community groups and local authorities. In the midst of enthusiasm, dialog regarding FGM must be handled delicately as there is danger of alienating communities which continue this practice.
Recently a prosecution case took center stage in the UK. A young doctor, Dhanuson Dharmasena, was accused of re-infibulating (re-doing the FGM) on a young postpartum woman. The patient had undergone type 3 FGM – in which part of the labia are sewn together – as a child in Africa. In order for delivery to progress safely, the doctor made two cuts to her vaginal opening. Dr Dharmasena stated categorically that he did not carry out re-infibulation at the request of the patient’s partner. Throughout the trial, Dr Dharmasena made clear that at no point during the procedure was it his intention to knowingly cause harm to the patient. Indeed it was his aim to stem the bleeding that occurred from the FGM site following delivery of the baby. Pregnant with her first child, the woman had been seen in antenatal appointments by midwives at the hospital. The patient herself declined to give medical history which may have prevented the incident. When asked during those appointments, she denied that her vaginal opening was narrowed from FGM. Midwives may have been able to organize a birth plan involving a controlled reopening of the vagina prior to labor. Instead, her severely narrowed vaginal opening was discovered at the time of delivery.
This case highlights the complex issues around the care of women with FGM. The implications for all health service providers, including early identification, better record-keeping, information-dissemination between healthcare professionals, surgical skills in repairing complex genital tract injuries in post-partum women with FGM and clarity about due process and care for the woman are illustrated in this landmark trial. The recent legal case demonstrates the difficulties encountered not only by trainee doctors, but also by midwives and consultants when they face such situations in a busy labour ward.
In essence, doctors and midwives must refuse all requests for re-infibulation and advise their patients, and their families, that the practice is illegal in the UK. If questions arises repairing trauma in a woman with FGM following childbirth, a senior colleague must be consulted before intervention. In difficult situations where the patient needs specialised surgery, a consensus opinion should be sought from a team of consultants, trainee doctors and midwives to ensure no harm is done to the woman.
A downstream effect of this case may be for doctors to practice defensive medicine under the threat of prosecution. Authorities should provide supportive guidance and reassurance that doctors and other health professionals will not be persecuted. It must be clarified that FGM re-infibulation procedures differ from surgery for perineal trauma that affects a wide ranging group of women following delivery. The latter are a medically-indicated group of surgical procedures used to correct traumatic injury to the pelvic floor following childbirth.
Prosecution is important but prevention is necessary. Currently there is no policy guidance on engaging communities affected by FGM, and many remain marginalised. Thus, it is our duty as a community of professionals to provide support and understanding, as well as medical care to affected women in order to bring about sustainable change. Globally many non-governmental agencies, such as FORWARD in the UK, are working closely with the Department of Health and the Home Office to bring about this much needed transformation for those affected by FGM.
Article by Sohier Elneil on behalf of the Fistula Committee.