Croydon FGM Conference

1. Croydon FGM Conference March 2016

2. Elaine ClancyDirector of Quality & Governance

3. End FGM: Is Europe Watching?

4. Beth Kelly FGM Project Consultant

5. The Project so far…

6. Progress

7. Training

8. #EndFGMCroydon

9. Natalie Reseigh Project Azure, Metropolitan Police Service - The reality of FGM and the police perspective

10. Project Azure The Metropolitan Police response to Female Genital Mutilation DC Natalie Reseigh Partnership Team Sexual Offences, Exploitation and Child Abuse Command This presentation contains images and details some may find distressing. All images contained in this presentation have been retrieved via open source on the internet

11. What is FGM? "Female genital mutilation ( FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non – medical reasons“ The World Health Organisation

12. Pre Conceptions ….. • Isn't it the same as male circumcision? • “If a boy or man underwent the same degree of mutilation as a young woman undergoing the most common form of FGM, he would have the head of his penis and around a third of the shaft removed” World Health Organisation • Isn't it cultural or religious issue? • There is not one holy book that advocates this practise.

13. The Different FGM Types Type 1 FGM Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals)  This practice is extremely painful and distressing, damages sexually sensitive skin and is an infection risk.

14. The Different FGM Types Type 2 FGMExcision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina). This practice is extremely painful and distressing, damages sexually sensitive skin and is an infection risk. 

15. The Different FGM Types Type 3 FGMInfibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and sewing over the outer, labia, with or without removal of the clitoris or inner labia. This practice is extremely painful and distressing, damages sexually sensitive skin and is an on-going infection risk.  The closing over of the vagina and the urethra leaves women with a very small opening in which to pass urine and  menstrual fluid. The opening can be so small that it needs to be cut open to be able to have sexual intercourse. Cutting is also needed to give birth and can cause complications which harm both mother and baby.

16. The Different FGM Types Type 4 FGMOther: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping, stretching and cauterising the genital area. This covers everything else that doesn’t fall within 1, 2 and 3

17. The Procedure NO ANESTHETIC The Instruments - Any crude cutting instrument such as a knife, broken glass, fingernails or razor blade will do, or the operator may have somehow acquired medical instruments like a scalpel, forceps or scissors. - The instruments may be new or may have already been used for other purposes and/or on other persons. - Sterilization is seldom known nor performed by these traditional operators. The Sutures - Regular surgical Catgut, Silk or Cotton thread. - Domestic sewing thread. - Vegetable or nylon fiber pre-selected by the operator.

18. Health Complications Death (Type III 10% mortality rate) Blood Loss Fractured bones Infection Shock Post traumatic stress disorder Urinary & menstrual obstruction, no effective outlet Pain during intercourse Infertility – Swollen tubes as a result of in effective outlet Childbirth complications

19. Motives and Functions • Psychosexual –Most often cited is the promotion of virginity and fidelity. Infibulation they believe almost guarantees monogamy because of the pain associated. Uncircumcised women are seen as highly sexualised. • Ceremonial - opening on wedding night. The husband sometimes forcibly performs penetration and bursts through the scar of the infibulation • Sociological – Practitioners see the circumcision rituals as joyful occasions that reinforce community values and ethnic boundaries, and the procedure as an essential element in raising a girl. Social integration. Safeguarding the family honour • Religious - Compliance with believed religious requirement. Children becoming too "western" • Aesthetics – Genital regarded as ugly & dirty, they believe it should be flat and dry. Its deemed masculine on a girl.

20. Survivors - In their own words • The parents cut the daughters, because they fear the girls could become too westernised.  'I felt my flesh, my genitals, being cut away. I heard the sound of the dull blade sawing back and forth through my skin. 'It's like somebody is slicing through the meat of your thigh, or cutting off your arm, except this is the most sensitive part of your body. I passed out. 'When I woke up… the worst part of it had just begun. The Killer Woman had piled next to her a stack of thorns from the acacia tree. She used them to puncture holes in my skin, then poke a strong white thread through the holes to sew me up.' - Waris Dirie, model and campaigner • Another survivor suffered the most extreme form of FGM in that her vagina was sewn up after she was cut. She was left with a hole no bigger than a matchstick that left her with a host of health problems and rendered her infertile. • Irecalled the moment I was cut. She said: ‘Your whole body is in pain, the scream that you scream, meant I lost my voice for a couple of days. 'The moment your genitals are cut, a part of your soul dies.’- Leyla Hussein

21. The cutters perspective • uncut girls 'are told they smell like a dog'. • There is also financial considerations. The family of a girl who is not cut cannot expect to a dowry for her hand in marriage. • 'The cut girls would get money and a lot of cows for their dowry. Girls who are not cut do not get many cows, in fact they would not get a dowry.' • A cutter from Kenya said: 'I was taught by the old people – my elders, my mother and my grandmother. I started to learn when I was about 12 and it took about four years to learn. After that I continued to practice. The cutter is more important than a midwife. • A cutter told MailOnline: 'We use a sharp instrument like a knife or a razor blade. I put millet flour over the organs so that is not slippery so I can hold it. And the flour helps to stop the bleeding.'

22. The cutters perspective • The clitoris is put on the ground to be carried away by Safari ants, as part of the tradition. • 'A neighbour might ask a mother if her daughter has fed the ants, as a way of asking if the girl has been circumcised.'  • Cutter women are paid less than £13 [2,000 Kenyan Shillings or $20.20] to carry out the life-changing procedure. • Both cutter women admit that FGM victims can suffer terrible complications from the crude surgery. • But perversely if a girl dies following the procedure her mother is blamed. • 'If the girl becomes sick it is the failure of the mother because she should be at home looking after her daughter. I know two girls from this village who have died [after FGM].

23. A Kenyan Cultural leaders perspective • Giving an insight into the pressure families are put under, a cultural leader of Kenya's Kisi tribe, said that ending the barbaric practice will turn Africans into 'slaves' of the West. He said: 'Circumcision is carried out by families who have left Africa to maintain their culture. Some [African families who have moved abroad] have been told to forbid their girls from getting cut.  'But these girls have no discipline and show no respect towards their relatives. The families become isolated in their own community, they become lost from their own culture and traditions.  'In Africa culture is everything. If you are out of the culture you are lost from the community. Not being circumcised is a cultural taboo. Someone who is without their culture is a slave to another culture.'

24. Prevalence In more than 28 countries in Africa and parts of the Middle East. FGM is reported amongst Bohra Muslims in India, Pakistan and East Africa, Malaysia and Indonesia. Due to migration its happening in Australia, Europe and here in the UK. In communities where FGM is the social norm, its practised by Muslims, Christians and followers of indigenous religions which suggests that the practice is more cultural than a religious practice.

25. Who is at risk? 2 million girls around the world every year are mutilated Mainly African and Middle Eastern countries and alarmingly now in the immigrant population of Europe, America and Australia Approximately 24,000 girls in the UK and 6,500 girls in London are at risk of FGM every year

26. FGM is a safeguarding issue FGM IS CHILD ABUSE!! FGM is a gender based violence, it violates a number of human rights principles, including equality and non discrimination on the basis of sex. It is Violence against women and girls and is child abuse…… It highlights the subordinate role of a woman Section 11 Children's Act 2004 - makes it everyone responsibility to act and share information to safeguard a child Section 47 Children's Act 1989 – Is a Joint investigation between Police and Children's Social Care

27. The Law Prohibition of Female Circumcision Act 1985 Penalty – 5 years imprisonment Female Genital Mutilation Act 2003 Penalty – 14 years imprisonment

28. FGM Act 2003 • Offence to commit FGM [S1] • Offence to assist a girl to commit FGM on herself [S2] • Offence for someone in the UK to arrange or assist FGM outside of UK even if carried out by a person who isn’t a UK national or resident [S3] • NO AGE LIMIT - ‘Girl = woman’ • Defence = If it is a surgical operation • necessary for physical / mental health • Mental health does not include belief that FGM is required as a matter of custom or ritual • Consent is not a defence

29. New This year • Extension of extra-territorial liability to "habitual" UK residents • Lifelong victim anonymity • Parents's and guardians' liability for failing to protect a child from FGM (Serious Crime Act 2015)

30. New this year • Civil Protection Orders for FGM • Mandatory reporting for relevant professionals

31. BarriersChildren are unlikely to ‘tell on their parents'/ too young to remember • Many from parents not known to agencies • Once in a lifetime event • Honour Based Violence • Community Acceptance / Marriage • Language / Immigration status - In Somaliland the women refer to their procedure by two names, the Sunna and the Pharaonic. In Sierra Leone its known as Bondo In Liberia its known as Sande. • Unaware of the law • Lack of understanding of health implications

32. Indicators FGM may be about to take place Family from an affected community; Mother or siblings have had FGM Extended holiday, particularly to a practicing country; Child is going to “become a woman” or have a “special celebration”; Child may begin to display a behavioural change…… Indicators - FGM has already happened Girl may spend long periods of time away from the classroom associated with bladder or menstrual problems; The child requiring to be excused from physical exercise; Prolonged absences from school plus a noticeable behaviour change…..

33. MPS Response • 1. Project Azure • Dedicated SPOCS on each CAIT team and across 9 priority boroughs • Supported Dept. Of Health with conferences across the UK • LSCB training events for harmful practises • Training for Police/UKBF/Health/Education • Operation Limelight • Hosted FGM Conference and harmful practises events • NSPCC Helpline / Protocol with CPS • Produced a guidance for schools

34. Where do you stand? Thank you for listening…Any questions? projectazure@met.police.uk 020 7161 2888

35. Lucy Njomo My Story Registered as International charity in February 2008  Helping to educate and campaign against FGM  Provides a community support group focusing on FGM

36. Emma Scutt FGM Survivors Artwork An illustration created for an FGM event at Waltham Forest Town Hall Alimatu Dimonekene, Hibo Wardere, Leyla Hussein, Stella Creasy MP and me pictured at the original exhibition, at St Barnabas Church June 2015 

37. 11:30 – 11:50 Refreshment break

38. NSPCC Ending FGM

39. FGM ConferenceCroydon University HospitalPerineal clinicRanee Thakar (Consultant); Adeyemi Johnson(Midwife)

40. Gynaecological complications Sexual dysfunction with anorgasmia Pain & tenderness in scar tissue Lacerations/haematomas/genital swelling Infertility - failed intercourse, pelvic infection and obstructed menstruation Difficulty in gynae. Exams/cervical screening

41. Long Term Implications (particularly type 3) Vaginal closure b/c scarring Impair menstrual flow & Painful menstruation Sexual dysfunction; bacterial vaginosis (Berg 2014) Urinary flow obstruction - poor flow, pain, UTIs, Chronic vaginal/pelvic infections/ local irritation Cysts and keloid scar formation Psychological damage/depression

42. Obstetric complications Difficult vaginal examinations and inhibits identification of complications e.g. mal presentations Difficulty in applying and obtaining FSE; FBS and catheterising of the bladder Prolonged labour/maternal deaths Perineal tears/ Postpartum haemorrhage Increased risk of c/section/instrumental deliveries extended maternal hospital stay High standard of obstetric care minimises risk Infant resuscitation & stillbirth/early neonatal death Banks et al 2006; Vangen et al 2002, Chibber et al 2011, Raouf et al 2011; Berg et al 2014)

43. Perineal clinic Full history, assessment of external genetalia Type of FGM, abnormalities, urethra; infections Documented of findings in pregnancy notes Illegality of FGM discussed and documented Psychosexual counselling/Referrals/Treatment Deinfibulation – antenatal/not pregnant - de-infibulation is offered or performed; - Consented for de-infibulation - After procedure review - Urinary/vaginal/menstrual/sexual issues - Partner counselling

44. FGM PATHWAY (ANTENATAL)

45. FGM PATHWAY (LABOUR)

46. FGM Type 3 (Infibulated)- Labour

47. Non- Pregnant woman/girl with FGM

48. Training at CUH Raise awareness amongst Health professionals about FGM Discuss the health/ psychological and emotional consequences and offer the family support Deal with FGM in a sensitive & professional manner, & do not exhibit signs of horror or revulsion when treating individuals with FGM. Identify and classify FGM and record and treat comorbidities Discuss the UK law i.e.: it is a criminal offence to perform FGM What is the family’s view and view of the extended family? Discuss the specialist services for any health or psychological needs Discuss the obligation to refer to social services Female genital cosmetic surgery (FGCS) may be prohibited unless it is necessary for the patient’s physical or mental health.

49. Questions to ask women regarding FGM Speciality/department where FGM identified: Patient hospital No: DOB 1. Date FGM identified 2. Have you had female circumcision/surgery/cutting to genital area? YES (if yes what type) 3. Types of FGM : 1 ( ) 2 ( ) 3( ) 4 ( ) unknown ( ) 4. Do you suffer from any complications as a result of this procedure? 5. For Type 3 – Have you been deinfibulated? 6. If Yes: Non-pregnant Antenatally In Labour 7. Have you been vaginally examined by a Doctor/midwife or nurse? 8. Have any members of you/your husband’s family been cut/circumcised? 9. If yes - Who 10. If you have a female child, would you feel under pressure to continue this practice from any relatives? 11. Are you & husband aware that it is illegal in the UK to practice any form of female circumcision/cutting/pricking to genital area? 12. Are you aware that it is also illegal to send a female child abroad to have this done and in both cases are liable for prosecution? You Husband/Partner

50. Group Activity – The Croydon Pledge Nominate a spokesperson and a scribe from your table. As a group you need to have a discussion about what you can do following the event today to ensure that you are considering children/adults who are affected by FGM or are at risk of FGM in your service area AND responding to their needs. In addition, we would like you to discuss what activities you think could be built into Croydon’s approach to addressing FGM – prevention /support? What can your service contribute to these activities? We would like you to come up with 3 key elements of good practice that you think are essential to the development of high quality services that children and adults affected by FGM would feel happy to use. Please write the 3 key elements in the thought bubble on the papers given and they will be collected and added to the Croydon FGM pledge. EXAMPLE: