Episode 133 FGM

FGM or female genital mutilation can be a tricky topic that we feel uncomfortable talking to women about. Here I sign post some useful NHS training and resources and remind people its the little things , kindness and compassion that will make a difference to these difficult conversations.

Want to know more?
Information
https://www.forwarduk.org.uk/violence-against-women-and-girls/female-genital-mutilation/?gclid=EAIaIQobChMIno3sl_Kc_QIVxN_tCh2rVwaDEAAYASAAEgLdwfD_BwE
https://www.building-bridges-training.org/fgm-14-page-easy-read-information-leaflet
https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
https://www.nhs.uk/conditions/female-genital-mutilation-fgm/
Training
https://www.youtube.com/watch?v=CBYL9UMqshA
https://www.e-lfh.org.uk/programmes/female-genital-mutilation/

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Transcript

Episode 133 FGM

Florence: , [00:00:00] episode 1 33, FGM Female Genital Mutilation. This episode has come to life because of a request from Joanna, who's a midwifery lecturer in Birmingham. She told me that she shared her podcast with her student midwives, and she wondered if I would do an episode on FGM and apologies, Joanna, because it's taken me quite a long time, but here we go.

I'm hoping that this episode will be useful both for maternity staff, but also for women that have experienced fgm. But I am also aware that discussing it could trigger some people. So please only listen to this if you feel ready and able to take.it in . I work in an area of the country where I don't [00:01:00] see that many women with fgm.

So again, this is not an all-encompassing guide. As usual, this is my thoughts and some signposts to some resources that I hope will be helpful. I think we should start by talking about what fgm. and what is the scale of the problem? There is a really good e-learning for Health module actually, and to brush up my knowledge for this episode.

I worked through it this week. In doing so, I was quite shocked to discover that there's an estimated 200 million girls living with FGM

and these girls or women are mainly from 29 different countries in [00:02:00] Africa, although FGM is practiced in other parts of the world as well. And there's a huge variation in rates across Africa from less than 5% in some countries to 90 to a hundred percent in others. That's global , but what about the uk? In the training, there's some data that around one and a half percent of women giving birth in the UK have had fgm.

It's a little out of date because that's from 2008, but that equates to over 137,000 women affected in the uk. I must admit, I was a bit stunned by those figure. probably because of where I work. I don't appreciate that it's as common as it is. What do we mean by fgm? Well, [00:03:00] we divide it into types, and the type is important because of the impact it can have on a woman.

There are four types. The first type is clitoridectomy that means removing part or all of the clitoris

type two is called excision where all or parts of the clitoris is removed and the inner labia, that's the lips that open around the vagina and the outer lips. The labia majora may also have been removed.

Type three infibulation. Is actively narrowing the vaginal opening by creating a seal. This is formed by cutting and repositioning the labia. And type four is other harmful procedures to the female [00:04:00] genitals, including pricking, piercing, cutting, or scraping, or even burning the area. So there's quite a lot of variation in what we describe as FGM

and there's also considerable variation in what age it may be done at. 50% will be done between birth and five years as a very young child. The rest will be done between five and 15 years. FGM is important in the physical care of the women. We look after , yes. We have to remember that FGM is illegal in this country and it's also illegal for a child to be taken abroad for this practice to be undertaken.

But first and foremost, where health practitioners, [00:05:00] our duty is to the care of that woman in front of us in maternity. , we need to ask all women about this regardless of where they're from, and it can be helpful to frame this in the context of their physical health as emphasized by Wan. When I spoke to her in the City of Sanctuary episode, her midwife addressed it in a sensitive way because Wan wasn't aware

that this was illegal or that this was unusual in the uk, but addressing it through her physical needs of we are going to care for you and look after you in pregnancy, made her able to understand that this was an important examination. Women that have had FGM may have [00:06:00] physical complications as a result, both in the immediate time of having had the FGM

but also later on at the point at which we are likely to meet her in maternity care. She may have chronic pain from the procedure. She may have an increased chance of urinary tract infections and she may have sexual dysfunction. Sexual problem. problems with being touched in her genital area and also the effects of trauma on her mental health.

Therefore, whilst we need to ask the question, we also need to do so in a sensitive, caring, and compassionate fashion. For me, the consultation is slightly easier [00:07:00] because the midwives have had that first conversation at booking. When a woman comes to me, it's already been flagged to me by the midwife that she may be here to discuss fgm.

Although in my experience, it's not always the case that the woman realizes that's why she's been sent to see me. So the same sensitivities and care and communication, of course. just as they do in any interaction. I find it hard to broach with women the fact that it's illegal because as well as having a physical duty of care, we have to think about the unborn baby.

What if that baby's a girl? Is she going to be expected to undergo the same FGM as her? . But in my experience, when I [00:08:00] talk to women that have undergone fgm, they are very clear that they would never subject their child to what they themselves have been subjected to. But it's not always that simple. And we do have a role to play in discussing with women

what the expectations are, not only of herself but her wider family because this may be culturally expected and we have to gently explain that this is an illegal practice and realize that whilst she may not wish this to happen to her, , other members of her family may still have that expectation, and we need to provide help and [00:09:00] support and signposting to resources and if necessary, referral to the relevant safeguarding authority if we think this child could be at risk

if we unpick why FGM happens, it's for cultural reasons. There can be a misconception that this is a religious practice, but actually if you unpick it, there is no religious reason to go ahead with fgm. And it's not only that it's unacceptable and illegal in this country , the World Health Organization has a program to attempt to eliminate FGM and has clear guidance for [00:10:00] healthcare workers about how they might help support doing this, and clear statements on the rationale as to why this is not

an acceptable practice. There are no health benefits and it can cause health problems. Their resources are printed in a range of languages and it may be helpful to share this information and talk through it with women if they are feeling this is something that is UK based only and a lack of understanding by us of their cultural background.

Let's imagine now I've got a woman in front of me who's been sent to see me because [00:11:00] she has fgm. I need to examine her because I need to establish what degree of FGM she has. , but it can be difficult to broach the topic. And we also need to be careful about language fgm, female genital mutilation. That's not something that is easy to talk about.

Mutilation brings a value judgment, and I also have to bear in mind. That the woman in front of me, English may not be her first language, and indeed, I could even be having this conversation for an interpreter, which is far from ideal because the nuances and the care with which I communicate could be lost.

Women may describe it [00:12:00] as being cut or cutting or special ceremony. . So I will probably start the conversation by saying that the midwife noted that she had been cut at some point in the past, and that I need to know a little bit more so I can be sure that she's okay and safe during her pregnancy and that this isn't going to have an impact on her pregnancy or giving birth to her baby.

particularly if it's her first baby. In my experience, this gives me an opening and the women will then talk about it as much or as little as they want to. I will then follow up with, would it be okay if I could gently take a look and see how [00:13:00] things. because in that way, I can decide whether we need to give you any treatment during pregnancy or whilst giving birth to your baby.

Don't forget that non-verbal communication is a really key component. The women's got to trust me to look at her most intimate part of her body . So eye contact, active listening, all those good communication skills are really important. Giving the woman some privacy in which to undress and prepare herself.

Giving her a chaperone, someone else in the room to maybe hold her hand, make her feel safe. , the importance of touch to reassure her, a [00:14:00] midwife to stand and be with her perhaps, or support worker, or maybe she's got a relative with her. And then I will start by just looking, not touching at all. And then if I need to touch, warning the woman that I'm going to touch her, asking her if she's ready for me to touch her

afterwards, giving her time to get dressed, sort herself out, and then sitting down and having a consultation explaining to her what type of fgm she has. After all, it's very difficult to examine yourself and all women. If you go back to my episode, anatomy, often have very little knowledge of their own genitalia.

So to explain clearly [00:15:00] what type of FGM she has and what I think the impact will be on her giving birth, if any, asking her has she had problems with urine infections, because this is really important in pregnancy and we need to be very vigilant. with our urine dips, sending things off to the lab and making sure we give her treatment because urine infections can have a negative impact on the pregnancy, including the possibility of triggering preterm birth.

Checking if she needs any psychological support. Does she need a referral to talking therapy or the perinatal mental health service? Is she triggered or got trauma? is she having sexual difficulties? And this may all be too much to discuss in one consultation, so this may be something that I need to [00:16:00] drip through a series of appointments when I've built a bit of trust and rapport.

And I would say that's the same for the midwives. If we practice continuity of care. In an ideal world, this won't be the only time you are seeing this woman. You'll have a chance to say to her, we can discuss this further at your next appointment, or we can discuss this later in pregnancy. When you're closer to giving birth, we may need to address issues around vaginal examinations in labor.

Is she going to find those difficult? Do we need a strategy to try and avoid those?

does she have issues around vaginismus? Does she need some psychological support to help her prepare? We could also talk to her about perineal massage. [00:17:00] Would that be helpful if she gets used to touching herself? Could that help protect her perineum and reduce the. Of her needing an A episiotomy and therefore further experiencing trauma in the genital area.

What if she has type three FGM infibulation? This needs addressing. This is where the entrance to the vagina has actively been narrowed, and this needs separating. Ideally, this should be done. As an elective procedure during the pregnancy, during the antenatal period, and if the woman is booked and is receiving antenatal care, then it's possible to arrange this either with local or regional anesthetic.[00:18:00] 

It can open up the labia and expose the vagina because without that, The vagina may not be big enough for her to give birth, and she may experience obstructed labor as a result. If, however, a woman has just arrived in this country or booked late for whatever reason. She hasn't been seen in the antenatal period and she presents in labor.

This may need to be undertaken in second stage with appropriate pain relief. This is called deinfibulation. It's not a reversal of the FGM because the tissue that's been removed cannot be replaced, and it will not [00:19:00] undo the damage that's being caused, but it is reopening up the vagina opening that scar tissue.

This may help her pass urine effectively or have sex or be able to birth her baby. What's my zesty bit? I think my zesty bit is for health professionals. There's lots of really good training. It's not unexpected that we might feel that this is a difficult topic to talk about. If you have access to the NHS E-Learning for Healthcare, then there's a great learning module with videos that you can undertake to increase your knowledge and make you more comfortable with having these conversations.

There's also a great little [00:20:00] animation, which is actually based on having a cervical smear test prompting the discussion. But many of the things discussed in that little animation are relevant to maternity care as well. So if you're a healthcare worker, explore the resources I've shared in the program notes.

Try and think about being comfortable having these conversations . Essentially, if you're compassionate and kind, think carefully about your body language. Give a woman time. Don't rush her. Try and ask open questions and be aware that these women may be very traumatized, embarrassed, and sensitive. Address things through the medical model.

We need to understand this. We need to [00:21:00] examine you. We need to talk about this so that I can look after you properly during your pregnancy and your birth. If you're a woman listening to this and you've undergone FGM and you want to understand a bit better what's happened to you and what the health impact is, I've signposted you to some resource.

don't be frightened to talk to your midwife or obstetrician about any resulting difficulties. We really are here to care for you and not to judge. If we can talk to you and understand what's happened to you, then we can care for you more effectively.

All we want to do is give you the best possible care We can, both with your physical health, but also your mental health. [00:22:00] And we also want to help you so that if you have a girl, your baby is a daughter, we can try and break the chain and make sure that she doesn't undergo the trauma, distress, and physical pain that you have.

Finally. On the N H S website, there's a list of national FGM support clinics. Whether you are a member of staff working in maternity services, or a woman who's experienced fgm, contacting one of these clinics for advice, help, support whatever it is you need. That's the place to go , these support clinics contain expert clinicians, so use them.[00:23:00] 

That's what they're there for.