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FGM: When the marginal enters the mainstream

There is a disturbing familiarity to the back-story that describes how Dr Dhanuson Dharmasena (32), a junior registrar in obstetrics and gynaecology, ended up facing a career-threatening charge of perpetrating FGM. He was found not guilty at a London court last month.

Contributory factors to Dr Dharmasena’s situation included a pressurised maternity service, lack of clinician training on female genital mutilation (FGM) issues, poor identification of victims of FGM within healthcare, and insufficient information-sharing between healthcare professionals. All of these factors would speak to a stressed Irish health service.

In November 2012, Dr Dharmasena was working at the Whittington Hospital in London when he was tasked with an emergency delivery. The patient, subjected to FGM as a child, had been deinflibulated at another London hospital prior to becoming pregnant. However, the Whittington had failed to properly take note of this or of her prior history of FGM during appointments. This meant that she was not on the appropriate care pathway.

Following the verdict, the Royal College of Obstetricians and Gynaecologists (RCOG) reported on key facts that were established during the proceedings. It noted that Dr Dharmasena did not deinfibulate or reinfibulate his patient, known as AB; that AB had already been deinfibulated at Kingston Hospital before pregnancy; there were no difficulties with vaginal examination in labour; the urethra was obscured by a band of scar tissue, which Dr Dharmasena incised in order to insert a catheter, as there were signs that the baby was in distress; Dr Dharmasena repaired the bleeding edge of the scar tissue with a single figure-of-eight suture and the vagina was not closed by the single stitch; and AB had a further baby within the year without the need for deinfibulation.

The RCOG stated: “It is clear that Dr Dharmasena did not perform FGM on AB.”

The court had heard he made a stitch across the opening, as opposed to suturing each side. Under the UK’s Female Genital Mutilation Act 2003, a person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl’s labia majora, labia minora or clitoris.

The legislation provides that no offence is committed by a medical practitioner who performs a surgical operation on a girl which is necessary for her physical or mental health; or a surgical operation performed by a medical practitioner, midwife or trainee practitioner or midwife on a girl who is in any stage of labour, or has just given birth, for purposes connected with the labour or birth.

FGM terminology at a glance

Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Type IV: All other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterisation.

Infibulation: Also known as FGM Type III.

Deinfibulation: The medical procedure to open up the vaginal area of a woman who has undergone FGM Type III.

Reinfibulation: A re-suturing of FGM Type III after childbirth.

‘Closed’, ‘cut’ or ‘circumcised’: Terms that may be used by a woman in reference to FGM.

SOURCE: Female Genital Mutilation: Information for Health Care Professionals Working in Ireland (2nd edition), RCSI/HSE/Akidwa

Acquitted

In less than 30 minutes, the jury at Southwark Crown Court acquitted Dr Dharmasena of the charge of FGM. Another man was found not guilty of encouraging the act of FGM and of aiding, abetting, counselling or procuring Dr Dharmasena to commit an FGM offence.

In a statement, RCOG President Dr David Richmond stated that Dr Dharmasena was a doctor “providing emergency obstetric care to save the baby of a young mother in labour who had suffered FGM as a young girl. He was doing, to the best of his ability, what obstetricians do every hour of every day.

“Every member of this College abhors FGM as the very serious abuse of girls and young women. We must do everything we can to end this obnoxious practice. But this was the wrong prosecution at the wrong time of the wrong individual.”

In less than 30 minutes, the jury at Southwark Crown Court acquitted Dr Dharmasena of the charge of FGM

He also stated: “In an emergency situation, having never met the pregnant woman, he acted to save the life of a baby. In the heat of the moment some of his clinical decisions may, with hindsight, be regarded as wrong choices. But that’s what happens in medicine. We try our best in very difficult circumstances and sometimes we don’t get it right. But obstetricians — indeed, all clinical staff — must be able to exercise their clinical judgement to provide safe, high-quality care for the women they serve without the shadow of prosecution.”

He noted that it wasn’t the end of the matter for Dr Dharmasena, as he would be investigated by the General Medical Council.

‘Chilling effect’

Dr Dharmasena was the first person charged with the offence of FGM under the UK’s law which, in its original form, dates back to 1985. The Crown Prosecution Service has come under heavy criticism for having pursued the case, some describing it as having been nothing short of a ‘show trial’, but the Service stood by its decision.

More generally, there exists some concern about whether the legislation makes provision for the illegality of reinfibulation, which is not specifically mentioned in the UK (or Irish) law on FGM. A Department of Health spokesperson tells the Medical Independent (MI) that “no concerns have been raised or reviews instigated” on the lack of specific mention of ‘reinfibulation’ in the Irish legislation.

Writing in the 4-10 March 2015 edition of Nursing Times, midwife and co-founder of the UK’s FGM National Clinical Group Ms Yana Richens stated that reinfibulation of FGM — “the resuturing of women with FGM to the FGM state” —was not covered by the UK law, contrary to public belief.

She continued: “Bearing in mind that this group of women are more likely to have a difficult episiotomy with some significant tearing, suturing is often required. As such, it is important that there is clear guidance and education for clinicians in this area.”

Asked of a potential ‘chilling effect’, whereby clinicians may avoid necessary suturing for fear of being cited under the Act, Ms Richens informs MI: “It is my personal opinion that since the unsuccessful prosecution in London that clinicians require clarity around this. I think we should say something to the effect that women should be resutured to repair any damage which may have occurred during the birth, however the urethra and vagina should be clearly visible and accessible following the repair.”

Another important point made by Ms Richens is that the message is not always reaching healthcare professionals and pregnant women on the need for early presentation for deinfibulation, and this can lead to greater interventions in respect of labour.

In addition to the physiological aspects, some women may require psychological support, particularly if a history of PTSD and flashbacks are involved, she underlines.

The Irish legislation, which commenced into law in September 2012, is similar to that in the UK.

The Criminal Justice (Female Genital Mutilation) Act 2012 describes FGM as any act the purpose of which, or the effect of which, is the excision, infibulation or other mutilation of the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina of a girl or woman.

A person is not guilty of an offence if the act concerned is a surgical operation performed by a medical practitioner on the girl or woman concerned which is necessary for the protection of her physical or mental health; or if the act is a surgical operation performed by a medical practitioner or a midwife, or a person undergoing training to be a midwife, on the girl or woman concerned when she is in any stage of labour or has just given birth, for purposes connected with the labour or birth.

It is also an offence to remove or attempt to remove a girl or woman from the State for the perpetration of FGM.

A spokesperson for the Office of the Director of Public Prosecutions (DPP) informs MI that its Directing Division — which examines criminal investigation files and decides whether prosecutions should be taken — has not to date received any files related to alleged acts under the Criminal Justice (Female Genital Mutilation) Act 2012.

Furthermore, when MI asked the Department of Health if it was aware of any suspected cases of FGM in Ireland, or of suspected instances where residents of Ireland had allegedly been brought overseas for FGM, a spokesperson responded: “No cases alerted.”

However, the Department has previously stated its awareness that NGOs and “public health services” working with affected immigrant communities “have voiced concerns that families are coming under pressure to have the procedure carried out on their daughters in Ireland or upon visiting their country of origin.” The Department stated at the time that it was hoped the legislation would act as “a powerful deterrent in these cases”.

Prevalence

According to Female Genital Mutilation: Information for Health-Care Professionals Working in Ireland (2nd edition), published in 2013 by Akidwa, the HSE and RCSI, it is estimated that 3,780 women between the ages of 15 and 44 residing in Ireland have undergone FGM.

This estimate was reached by obtaining census statistics (CSO) from 2011 and other relevant population data on the number of women residing in Ireland, originally from FGM-practising countries. These statistics were then synthesised with global FGM prevalence data.

Women from Nigeria, Somalia, Northern Sudan and Egypt are estimated to be the most frequently-affected nationalities in respect of Ireland’s immigrant demographics.

The National Maternity Healthcare Record has an entry for FGM as a risk factor, but the HSE said there is no cross-service collection of this data.

Meanwhile, data on the estimated number of girls and women at risk of FGM in Ireland, Portugal and Sweden will be released in April. The over-arching aim of this research by the European Institute for Gender Equality is to establish a methodology that EU countries can use to estimate numbers at risk and develop appropriate policies.

A spokesperson for Tusla, The Child and Family Agency, indicates to MI that it cannot respond on whether any child/children had been in receipt of services under its auspices, to help safeguard against possible exposure to FGM.

The spokesperson says Tusla records abuse under four categories: physical, sexual, emotional and neglect. “The Agency does not record specific issues like FGM,” she says.

According to the spokesperson, FGM is a serious child protection issue “and Tusla is certainly part of the response”.

FGM is specifically mentioned in The Child Protection and Welfare Practice Handbook, it was also noted.

A concrete development in the Irish context has been the establishment of a dedicated FGM clinic in Dublin. Opened in May 2014 by the Irish Family Planning Association (IFPA), with funding from the HSE, the primary care service offers “free, specialised medical care and counselling to all women and girls in Ireland who have experienced FGM”.

HSE funding for the service is negotiated on a year-to-year basis and current funding has been approved until the end of this year.

IFPA Medical Director Dr Caitriona Henchion tells MI that, to date, numbers presenting to the clinic have been small. According to Dr Henchion, the service will need to be promoted among immigrant communities and the healthcare professions.

On the latter point, Dr Henchion has been in ongoing dialogue with the ICGP, for example, in relation to ongoing doctor education pertaining to FGM.

She says it is vital that doctors are aware of what communities might be at risk of FGM, so that the opportunity to raise the matter is not missed.

“Unfortunately at the moment, I would say, through no fault of their own, in the vast majority of cases, if a woman came into any doctor in the country and had FGM-related problems, they wouldn’t know where to turn or what to do. And that is what we need to change.”

The clinic has established a referral pathway into the Rotunda Hospital for situations in which a client may need surgical care. This would most notably concern deinfibulation.

Commenting on the generalities of the recent UK case, Dr Henchion says a “glaring” aspect was that the doctor had no training on the issue of FGM and had not known that the woman travelled through care services without a history of FGM having been adequately recorded.

“I would have thought [the UK] has had a long time of much higher awareness, and yet that can happen there. So I am sure that can happen here.

“That is the really big thing —that everybody needs to know about this,” Dr Henchion continues. “You mightn’t see it very often, but if you consider that most people who train as GPs have to do a certain amount of obstetrics, and if you have big immigrant populations, the chances are it might happen to them once.

She adds: “We do really need to incorporate it into undergraduate training so that people are not relying on somebody who has an interest in it at some stage along their career to actually tell them about it — that it actually has to be incorporated in some basic way.”

Dr Maeve Eogan is a Consultant Obstetrician/Gynaecologist at the Rotunda who has been liaising with Dr Henchion and her IFPA colleagues on issues of care for women affected by FGM. She tells MI that, presently, management of FGM does not formally exist on the BST or HST curricula in obstetrics and gynaecology, “although there is generally practical and theoretical training in care for women who have experienced this in the course of postgraduate training”.

Clitoral reconstruction ‘needs greater evidence-base’

Clitoral reconstruction is an emerging technique that shows some promise in respect of pain reduction and improved sexual function, but detailed research is needed to determine if and why it may be effective, say experts.

Dr Jasmine Abdulcadir of the Department of Obstetrics and Gynaecology at Geneva University Hospitals, the Faculty of Medicine at University of Geneva and the Department of Reproductive Health and Research, WHO, tells the Medical Independent (MI): “Even if it is a very interesting technique, we need more evidence and to organise best practices and multidisciplinary care.

“This surgery re-exposes something which is buried under the scar — so something is clearly there. Sometimes education on anatomy, on where the clitoris is, on sexuality, can also improve the sexuality [of the woman].”

Dr Abdulcadir explains that, in her own practice, she has observed that some women requesting clitoral reconstruction surgery cannot describe or visualise the clitoris and lack knowledge of their anatomy. When equipped with this knowledge, they may find that the clitoral area can be effectively stimulated and decide against surgery.

Widespread advertising of the procedure of clitoral reconstruction presents some concern, agrees Dr Abdulcadir.

As she notes, there are studies that have shown that some women who have undergone FGM can have a positive experience sexually.

“So, if they have access to all of this information [on clitoral reconstruction surgery] influencing their body image, their future sexuality, maybe they will start asking about surgery even before starting sexual intercourse. If we just offer the surgery without education and counselling, we risk harm.

“In my opinion, we have to be very careful, as we risk saying to women with FGM that they are ‘incomplete women’, that they are not ‘real women’ without the surgery, which is not the case.”

Nevertheless, she says, some women can benefit from the surgery, which should be accessible. A recent study she co-authored in the Journal of Sexual Medicine reported on outcomes of two women who received multidisciplinary care, including psychosexual treatment, with clitoral reconstruction. It showed a positive outcome in pain reduction and improved sexual function, for example, but noted that more evidence was needed to develop best practice guidelines.

Clitoral reconstruction as a surgical procedure is not particularly difficult, Dr Abdulcadir tells MI. The most challenging aspects surround the psychosexual care and counselling and cultural aspects that are fundamental to the overall care required.

The Rotunda and Coombe hospitals both confirmed by press time that this procedure had never been carried out at their facilities. MI understands that no Irish public hospital has, as yet, undertaken this procedure.

More generally, Dr Abdulcadir suggests that advocating for training for healthcare professionals on recognising FGM and its complications should be the first step in terms of progressing standards of care and services.

She says training and sensitisation reduces the potential for missed diagnoses of FGM and improves the rapport between a healthcare provider and the woman, leading to better treatment and documentation of the woman’s clinical condition and health needs.

The aspect of return appointments is especially important, as this population often has other comorbidities or health disparities, often related to decreased access to preventative health screening. “So I think training is the first step — good training,” she tells MI.

Training should also encourage greater sensitisation among clinicians on this issue, including awareness of countries with high FGM prevalence. This knowledge should be applied when taking medical history, with a woman’s potential experience of FGM queried “with the right words and right cultural information” so that doctors “avoid stigmatisation”.

Within medicine and the speciality of gynaecology in Europe, awareness on FGM varies, indicates Dr Abdulcadir. “For example, here in Switzerland, during the training in medicine, and then of gynaecologists, we do not have any training on FGM in spite of the cases that we see, especially in Geneva, Lausanne and Zurich, for example.”

Following a study co-authored by Dr Abdulcadir that revealed the scale of missed diagnoses, there was some soul-searching as gynaecologists and obstetricians pondered why so many cases had not been recorded.

“Well first, we [in gynaecology] don’t know how to recognise them, because some types are really evident but some types are not so easy to recognise,” explains Dr Abdulcadir. There were also issues of time, language and cultural barriers. “It is not only the [clinical] training on the subject — we also need tools to talk,” she underlines. “Many colleagues, when we discussed these results, said ‘I don’t know how to ask, I’m afraid of stigmatising the woman, I don’t know what word I can use to ask about this’ — it is not like ‘an appendicitis’, for example. ‘And once I ask, what do I propose?’”

Some doctors may believe that nothing can be done to address potential sexual problems and reduce pain, she adds. However, care options may include sexual therapy, deinfibulation surgery and clitoral reconstruction, in some selected cases.

  1. mariella catania on March 19, 2015 at 1:41 pm

    complimenti all’impegno di tutti voi!

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