Would you know what to do if your patient told you she had experienced FGM? Or if you examined a patient and saw evidence of it? Here Dr Sharon Raymond, medical lead for a NW London primary care out of hours service and a member of the NHS England FGM steering committee, provides advice for doctors with patients presenting with FGM.
The case of ‘Aisha’ is based on a combination of cases that have presented to clinical practice. Find out what advice the GMC gives and how others can support you in this area on our new FGM resource page.
16 year old Aisha came to see me on a busy Friday afternoon surgery
She was with her mum and her 6 year old sister Jamila. The family were originally from Egypt and had been in the UK for the last 6 years. They had joined the practice a couple of months ago having recently moved. Aisha disclosed that she had been depressed and self harming for the last 2 years. Mum, a single parent, had accompanied her to the surgery to support her in getting help.
How do I manage Aisha’s care? What are my duties as defined by UK FGM legislation?
I explored the history of Aisha’s depression and undertook a risk assessment. Bearing in mind that the family are Egyptian in origin where the prevalence of FGM is very high, I wondered whether Aisha may have undergone FGM. The 4Cs FGM risk assessment tool guided me in asking the question and assessing the risk of FGM to others, including 6 year old Jamila.
4Cs FGM risk asessment tool *
- Do you come from a community that practices Cutting?
- Have you or any member of your family been Cut?
- Does anyone intend to Cut you or anyone you know?
- For patients who are pregnant or mothers of daughters ask: Do you or anyone you know intend to have your daughter(s) Cut?
*Copyright Dr Sharon Raymond 2015
A yes to at least one of these questions increases the risk of FGM to Jamila. Aisha answered yes to questions 1. and 2. but both her and her mother were adamant that there was no risk to young Jamila, the only other female sibling.
Aisha disclosed that the trigger to her depression was the FGM she had undergone some 5 years ago in Egypt. Her father had decided that FGM was necessary, despite her mother’s objections, and had taken her to get it done. She found it hard to walk for days due to the pain between her legs and gets flashbacks. Dad had since divorced her mother and returned to Egypt. Jamila had not undergone FGM as Mum is against the practice and they no longer have any contact with Dad or any other family members who support FGM. Mum had booked an appointment in a couple of days to see me alone to discuss her own problems due to the FGM she had undergone.
Aisha’s care – managing the complications of FGM
- Psychological complications: I undertook a risk assessment to address suicide risk which was low. Aisha had no plans to kill herself and had been cutting her arms superficially with nail scissors. She said just wanted help to get rid of the pain and was relieved to share her experiences with me. Mum was very supportive. Aisha was suffering from post-traumatic stress disorder and I referred her to local children’s mental health services. She was commenced on anti-depressants and cognitive behavioural therapy. I also signposted her to agencies which could support her and her mother.
- Physical complications: Aisha had undergone type 1 FGM, clitoridectomy, known as ‘Sunna.’ Her physical complications mainly entailed chronic pain and I referred her to a nearby FGM clinic for a full assessment and consideration of the management options.
- Safeguarding duties: In order to fulfil safeguarding duties the welfare and risks to Aisha, her sister and her mother, as well as to members of the wider community must be considered. Referral to children’s social care is required. FGM is illegal and an abuse of children and falls into the category of significant harm, i.e. section 47 of The Children Act 1989. A strategy meeting was held within 2 days. The meeting assessed Aisha’s case. The risks to Aisha, Jamila, their mother and other women and girls in the wider community were also considered. It was established that the risk to Jamila was low- although mum had undergone FGM as a child which increases the risk to her children, mum was very clear that she is opposed to the practice due to the harm it had caused Aisha. A second strategy meeting took place within 10 working days of my referral to decide whether a child protection conference should be convened.
It is expected that by the end of this year doctors must comply with the Mandatory Reporting of FGM as specified in The Serious Crime Act 2015 which extends UK FGM legislation.
Mandatory reporting places a duty on doctors to report to the police any girl or young woman under the age of 18 years old discovered to have undergone FGM (either on examination or if disclosed by a patient). Reporting must be within a day of FGM being discovered (unless there are exceptional reasons that justify a delay of up to a month)* and is to be made to the police. The process awaits clarification.
Doctors play a crucial role in identifying the possible signs and symptoms of FGM, managing the complications both physical and psychological, as well as safeguarding patients at risk of FGM, such that women and girls who have survived FGM get the care and support they need and that those at risk of FGM are protected from this harmful practice.
*This blog was originally published before the final details of the reporting procedure were published. This was updated on 2 December 2015 to reflect the government’s procedural information.
Dr Sharon Raymond MBBS MRCGP is medical lead for NW London primary care out of hours service and Safeguarding Subject Matter Expert at Care UK. She also works as Named GP for safeguarding children in Croydon. She runs ‘Safeguarding Updates’ training clinicians to level 3 in safeguarding children and adults, incorporating training on FGM. She is a member of the NHS England FGM steering committee, and has lectured widely and written articles on FGM. Her handbook on FGM is due to be published later in October 2015.