How an FGM trial became a trial about witchcraft

10/02/2019 § 1 Comment

by Marge Berer

Background

This is the fifth time FGM has gone to trial in England since 2014. It is the first in which someone has been convicted. I attended most of the trial and shared notes with a colleague covering the days each of us was unable to attend. In spite of the punitive conditions for observers in the Central Criminal Court, including difficulty hearing those in the courtroom, what happened was clear: a woman was convicted of both FGM and witchcraft.

A few women’s rights advocates and health professionals have publicly opposed the way the criminalisation of FGM has played out in the UK,[1],[2] but more are recognising the demonisation of individuals, mainly from African communities who may have traditionally practised it, who are being treated with suspicion due to their ethnicity. FGM is a harmful traditional practice, but I believe it will only disappear when its practitioners become convinced among themselves that it is harmful. For this to happen, I believe education, understanding and support to alleviate its harms are the way forward. And with others, I believe there should be no further prosecutions.[3]

The trial took place from 14 January to 1 February 2019. This paper discusses my understanding of what happened during the trial and the issues it raises.

Although this is the first conviction since FGM was criminalised in 1985, the hegemonic belief is that many wily FGM practitioners have been escaping justice, based on inaccurate and exaggerated estimates of how many girls in the UK may be at risk, repeated in mainstream media. In the four previous trials, well-deserved acquittals made the police and the Crown Prosecution Service look bad. This was a high profile case, watched by many who wanted blood.

The case

The case involved a woman and a man from two different African countries, their daughter aged 3 in August 2017, and her son, aged 8.[4] At that time, the couple were no longer in a relationship but had remained good friends, living near each other and amiably sharing responsibility for the two children. On 26 August, the father’s mother died in his home country unexpectedly. He was devastated and spent most of his time over that weekend in the back garden of the mother’s flat, texting and on the phone with his family there, who were preparing the funeral. He stayed overnight as well, because he couldn’t bear to be alone, and slept in the sitting room. The children, who both lived with the mother, slept in the one bedroom with her.

On 27 August, the girl was running about inside and fell against the television, bruising her head, which caused bleeding. The mother called 999 but ambulances were in short supply. The bleeding stopped, the girl seemed fine, so the ambulance was cancelled. The little girl clearly enjoyed running about and was said to imitate her brother a lot, including his penchant for climbing on things.

On 28 August, when FGM was alleged to take place, the father was there in the morning, left to go back to his room to shower and returned. He was in the back garden with the girl, on the phone with his family. She was wearing a long dress and wellies and was happy and running about. It was noted that she was not wearing knickers, though he did not know that. The girl asked him if she could have a biscuit. They went up the stairs into the kitchen where he got her a biscuit from a bowl sitting on top the microwave on the counter. They went back outside together and he got back on the phone. Not long after, she said she wanted to go to her mother, and went inside on her own. The father said when questioned that a minute (or a few minutes) later, the girl was suddenly crying/screaming. He says he went inside as soon as he heard her. The mother and brother said they had been watching TV in the sitting room. The girl said she had climbed up onto the counter in the kitchen to get another biscuit and had fallen onto the open door of the cupboard below. No one else saw it happen. The cupboard door’s upper edge was a U-shape, with narrow protruding edges, described as “sharp metal edges”. She was bleeding from her genitals. Someone wrapped her in a towel, which was afterwards full of blood stains and was put into the washing machine and left there, unwashed, found the next day by police. The mother called 999, who told her how to stop the bleeding. Due to the shortage of ambulances, it was decided to take her to hospital by taxi. Mother took the girl to the toilet as the girl said she had to wee and cleaned her up there, trying to stop the bleeding. As they were leaving, mother asked father to take a photo of the cupboard door on his phone to show the hospital where she had hurt herself. Father said he had cleaned the blood up in the kitchen and the toilet room later that evening.

As I understood from the evidence, if FGM took place, it must have happened at the point when the girl said she fell onto the cupboard door, but I do not see how, because there was not enough time for it to happen in.

At the hospital A&E, the nurse called in a resident to see the girl. The resident suspected FGM and contacted the on-call consultant, who has experience of FGM. The resident didn’t say what he thought, just asked the consultant to examine her. Consultant said he thought the girl had had FGM. One of her inner labia was cut off completely. The tissue was not found. The other had also been cut but the tissue was still attached, described as “hanging by a thread”. There was a small cut around part of her clitoris. There was also a haematoma. The girl had to have anaesthesia as the examination was causing a lot of pain; suture of the tissue was done. She had lost so much blood that a transfusion was considered but not required. Mother stayed with her overnight. Father took the boy home; they returned to the hospital the next day.

The police were notified and came to the hospital the next day. Both parents were arrested. Boy was taken into emergency foster care. When girl was released, she went to the same foster mother, who kept them for almost two months. In late October, foster mother said in written evidence she couldn’t cope with them on top of four children of her own. It was not stated why. The children were moved to another foster home in early November 2017, and have been there since.

FGM in a three-year-old

One of the doctors who was a witness said that in a child this small, the inner labia would each be only about 1 cm long. The cuts would require skill and be very painful.[5] Only someone practised at FGM on small children could manage that in a short space of time. The girl would have to be held down, most probably by more than one person. The outer labia (about 3 cm long) would have to be held open. No one could have done this alone. Yet no evidence was found that anyone else was in the flat that day, and no cutting instrument was found.

Why a guilty verdict?

I believe the mother was found guilty for three reasons: 1) four doctors were sure the labia cuts looked like FGM, not injuries from a fall; 2) in the absence of direct evidence, the mother’s character was attacked and her credibility destroyed over the course of the trial, mostly through accusations that she practised witchcraft and spells and consorted with and took advice from several dubious-sounding men; and 3) both children made contradictory statements about what had happened as time went on.

The medical opinions

Four different doctors examined the girl’s genitals, at least two of them after she had been sutured. They all said that while the damage could have been caused by her falling on the cupboard door, and that one “could never say never”, none of them thought she had fallen. They all thought she had been cut because the tissue was not jagged. They said a “straddle injury” – falling onto the door with her legs on either side – would have caused different injuries as well as bruising, and that cuts in three different places from one fall were highly unlikely. Also, they said, there was no visible bruising, which would be expected.[6] Only the paediatric forensic pathologist had never seen a labial FGM-type cut. The others had a lot of experience. But…

The evidence

The timeline of events and movement on the day in question were based on 10,000 pages of details from the parents’ smart phone usage (both were constantly on their phones). The father’s barrister found proof of his absence at the time in question in that evidence, but said only a handful of those pages were relevant.

Given the very short space of time between the girl going back indoors and then starting to scream, if someone had cut her, it must have happened then. Who could have done it, using what instrument? Where? The police detected no traces of blood on the cupboard door or the kitchen floor, yet the father described cleaning a lot of blood up. No other place where cutting could have taken place was identified. How could the police not have found something?

Where could a cutting knife have been disposed of between the time the girl was found bleeding and taken to hospital? The mother did not go home again until after the police had visited the flat. One police officer, according to the Evening Standard, said he refused to rule out the involvement of a third party, but investigators found no such evidence to present in court.[7]

Without direct proof of anyone’s guilt, surely there is “reasonable doubt” as to what happened? This was not expressed strongly by anyone in court, except the mother herself who insisted, again and again, from the first moment she was questioned at the hospital until the moment she was found guilty, that she had not done it.

Both parents were interviewed (August 2017, November 2017, January 2018), as well as social workers for the parents and children. Much of this was presented in writing, and read out in court. The two foster mothers were interviewed; only one came to court. Both children were interviewed (the girl 3 times and the boy 4 times), including the boy (unexpectedly) on the cusp of the trial opening. The interviews with the children were videoed and shown in court. Both parents were questioned by the Crown and both their barristers for many hours over several days. In spite of intense and aggressive questioning by the Crown, both insisted on their innocence.

The father believed his daughter, her mother and brother, who all said the girl had fallen on the cupboard door. When questioned by the Crown, however, he was pushed to agree that hearing the medical opinions had made him believe his daughter had been cut. Yet it would have been impossible for anyone without relevant medical knowledge to question let alone reject those opinions. This “admission” was treated as accepting the mother’s guilt, however, even though the father stood by the mother until the trial. And he never changed his insistence that she had never said or done anything to make him believe she had had their daughter cut, let alone done it herself.

False claims that FGM is linked to witchcraft

Early in the trial a so-called expert witness for the Crown claimed (in a letter, not in court) that FGM and witchcraft in Africa are related. The implication was that anyone who practises witchcraft is also capable of and willing to practise FGM. There is no evidence for this. The mother’s defence team, presumably recognising the damage, brought a letter from a counter-witness who said the practice of witchcraft and FGM are not connected, but this was probably too late in the trial to make a difference.

The mother denied she believed in or practised “witchcraft”. It didn’t help her. She did acknowledge that she sometimes used “spells” to ward off danger to herself and her family, and to try to make trouble go away, and that she had taken advice by phone from a traditional spiritual advisor in Africa, whom she had never met, on “cleansing herself” while she was awaiting trial. Some of the “spells” came from an easily accessible website. One involved crushing half a lemon with a powder called alum on it under foot. These were harmless and I believe they should have been dismissed as irrelevant and not admitted in evidence – precisely because they did not and should not have been used to implicate her in FGM. Indeed, the defence tried to have at least some of this so-called “evidence” made inadmissible, but the judge refused.

This was willy-nilly a gift to the Crown, who successfully demonised the mother by giving “witchcraft” undue prominence and providing the court with every last detail (verbally and visually) of some of the practices, especially the most unpleasant ones. She tried to smear the father with it as well, but his insistence that he was a religious Muslim and did not believe in witchcraft deflected that.

Witchcraft played an important role outside the courtroom as well. Within an hour of the verdict being announced, the mother and FGM were associated with witchcraft in the media too. Perhaps these journalists believe in witchcraft themselves. For example, the Evening Standard asked one of the policemen involved if any of his officers had suffered any ill effects that could be explained by “spells”.[7]

In her summing up, the judge stressed a number of times that some of the mother’s beliefs and behaviour related to witchcraft must not be taken as evidence of guilt, even if they were “repulsive” to the jury or “made them uncomfortable”. While this was correct as a point of law, I believe it may have added to the negative image of the mother, already accomplished so effectively by the Crown. Yet surely it is obvious that the “spells” were because the mother felt powerless and wanted it all to go away.

Many innocent women were killed for witchcraft in this and other countries in earlier centuries. It seems a belief in witchcraft exists even today in this supposedly civilised country. The link with FGM was stressed in every news report I saw, including BBC News.

Where did this ill-conceived and false link come from? As far as I have been able to discern, it originated from the National FGM Centre, who are connected with Barnardo’s. On 20 January, I wrote to the senior press officer at Barnardo’s asking if he would send me the evidence they had for this link. The answer came back only on 2 February, after two follow-up requests – but the trial was over. The evidence was contained in a table with quotes and the following sources:

  • An article on an obscure website called Refinery29, which was reprinted in full by the Evening Standard, whose evidence for this link was that Barnardo’s/National FGM Centre had told the author there was a link. Yet this same article was cited by Barnardo’s as their source that a link existed.
  • A quote from a 2015 article about FGM on the website of broadly.vice, whose only mention of witchcraft was the following: “During one cutting procedure, the girl collapsed. Her elders’ explanation? ‘They tell you it’s witchcraft,’ she says. ‘If the girl dies, they’ll just say it’s because the mother is a witch’.” In other words, witchcraft is blamed for killing the child so that the real reason she died remains hidden. This is not a link as alleged.
  • A quote from a 2015 blog on the Orchid Project website, in which the only reference to witchcraft was the following quote: “Many people in Kuria [Kenya] fear the ‘witchcraft’ used by the Elders to incite people to cut their girls. They believe the Elders can reach out through this witchcraft and harm them and their loved ones.” This describes using fear of witchcraft as a form of control, to force unwilling parents to allow their daughters to be cut, but again, not showing the alleged link.
  • A quote from a 2009 publication entitled What is FGM? by Africans Unite Against Abuse, as follows: “It is believed that un-mutilated girls and women are unclean, promiscuous, and unmarriageable. It is also believed that the clitoris can be used to bewitch husbands and make it impossible for them to take more wives. In this instance, women who would not permit their husbands to take more wives are branded witches.” Beliefs about uncut women being unclean, promiscuous and unmarriageable were widely held historically, but much has changed. In a DFID meeting I attended on this subject in London some years back, a number of women from FGM-practising countries said that if the marriageability issue were resolved, i.e. convincing men to accept an uncut wife, FGM would quickly disappear.
  • A 2013 article by Johansen R et al in the journal Obstetrics & Gynaecology International (pp.1-10), quoted in a Barnardo’s publication, as follows: “One study in the Gambia and Senegal showed that only those who were already critical to FGM believed in the information of health risks [25,26]. One reason for this is that the immediate complications of FGM are often attributed to other factors such as witchcraft or evil spirits [27,28].” This is not proof of a link either.

That was it – no credible evidence of a link between the practice of FGM and the practice of witchcraft. But meanwhile, a woman is going down for it. Yes, dear reader, witchcraft is powerful.

But let’s return to facts. It is important to point out that when first accused by the police of FGM, the mother had asked them what FGM was, because she had never heard of it. She said FGM is not practised in the ethnic group she comes from. Indeed, in her country of origin, only 0.3% of girls/women have had FGM, mostly in one small part of the country, and only about 54% of women nationally had ever heard of FGM.[8]

This mother was never cut herself; she offered to have her genitals examined to prove it. She said no one in her family or ethnic group had been cut either. The ethnic group the father comes from does not practise FGM either, and he said no one in his family has ever been cut. This is critically important because there is no evidence that adults who come from non-FGM-practising backgrounds in Africa practise FGM. If these facts were put forward in defence of both parents, however, they were neither heard nor taken account of.

Evidence from the children

The children’s evidence from 28 August 2017 to 13 January 2019 was collected through formal interviews that were videotaped, as well as in reports of conversations they had with social workers and the foster mother who they lived with from 3 November 2017 until the trial. What both children said over most of that period was consistent but then, later, contradictory. In her summing up, the judge told the jury that they needed to decide whether the children’s evidence was reliable or unreliable. This is serious because their evidence was not only admitted, but was given a huge amount of time and attention throughout the trial. It was in fact key.

Both the children said until each of their last interviews that the girl had hurt herself by falling on the door. Then, separately, to different people and each at a different point in time, they said they had lied. These claims were damning because they were not retracted (if indeed anyone kept asking, in case they changed their minds again) and must surely have influenced the verdicts more than any other evidence.

The reason the children’s evidence could be considered unreliable was because both of them had made up elaborate stories at different moments when being interviewed, that were complete fantasies. The boy invented a family summer holiday trip to Blackpool replete with details and what a good time they had all had, but it had never happened. The girl made up a story about what happened at her foster mother’s house when she was bathed – that an adult male relative of her foster mother would bathe her while she was naked, that her foster mother and her brother were also in the bathroom, and that her brother would cover his eyes so he couldn’t see her. She also claimed that the male relative had touched her inappropriately on her private parts. She even drew pictures about it. Then she said it was all untrue, just a joke. Children, right!

In a case like this, lasting almost 18 months, the children would be exposed to many conversations among the adults around them – hospital staff, medical experts, police, social workers, foster parents – who may not have noticed the children were listening or realised they could understand (or misunderstand) what was being said. Who can say how that influenced them, except that each of them felt they were to blame for what was happening.

The court was shown videos of all three interviews with the girl, all with the same two social workers. In the first two interviews, she was allowed to run around the room, draw pictures, chatter, laugh. Each time, she was asked questions to try and probe whether she had fallen or been cut. For example, it was considered significant that when asked to point out things that were wood, plastic and paper, she was able to do so, but she did not know what metal was – even though she had claimed she had fallen on the metal on the cupboard drawer. Her third and last interview, took place (I believe) because of what the girl told her foster mother as a secret. She said she knew that: a) people who go to jail are bad, b) her mother was bad, c) her mother was going to jail, and then d) that she had lied, that she had been cut. This was of course reported onwards. In the third interview that followed, the girl was again asked how she had hurt her private parts, and at first she again said she had fallen when trying to get a biscuit. But she was pressed and questioned increasingly heavily and made to feel she had done something wrong. There was no running about this time. No laughter. As the social workers continued to question her, sitting cross-legged on the floor facing each other with her in the middle, the one woman wrapped her in a small blanket and clamped her into her lap facing the other woman, and they continued to ask questions until the girl said she had been cut. Oh!

But here is what was said: The girl said there was another woman in her mother’s kitchen that day. The woman had pink skin (Was she black like you or white like me?), old (Was she young or old?), with silver hair (What colour was her hair?), and had hurt her on her private parts (Where did she hurt you?). She also said she had been standing up when it happened (Were you lying down? No, I was standing up). When asked what the woman’s name was, she replied that her mother had called the woman a witch.

The father was asked, in giving evidence, whether the mother had any women friends who were white who came to the flat. No, he said, except for one neighbour, who had been there perhaps a month before. Two of us observing the trial wondered whether this woman might have been someone at the hospital involved in examining or repairing her labia. In any case, no such woman was ever identified.

As a description of FGM, this story is not credible. The damage to her labia (1 cm) could surely not have been caused by cutting while she was standing up, no matter how skilled the cutter. Do old, fat, white women with silver hair carry out FGM here? No. Indeed, the girl also said at another moment that her parents had held her while she was cut. So, was any of this true? Surely to express disbelief would be fair. Yet no one did.

I did not watch the four interviews with the boy except for the first 10 minutes of the first one. But no witness placed him where he would have been able to see the fall (or cutting) of the girl. In all four of his interviews he said the girl fell in the kitchen and injured herself. But the day before the trial started, he told the foster mother he wanted to write a letter to one of the policewomen and to one of the social workers. The foster mother gave him two sheets of paper, a pen and envelopes. He wrote the letters, she said, alone in his room. When the foster mother told the police why he had told her he wanted to write them, his reply to her was either: “I want to tell the truth” or “I want to prove our case”. These two versions of what he said were both reported in court because after handing in the boy’s letters, the foster mother had made a statement to the police in her own language, which was translated into written English by an interpreter. She was not shown a copy of what she had said in her own language, only the text in English to sign.[9] This came out during her evidence in court. In any case, the letters were almost identical. In both, he said he had lied and that his mother sometimes told lies to get out of trouble. One of his letters was read to camera by him and signed by him, and shown in court. Arrangements were made to bring the boy to court on 28 January to corroborate what he had said. But on the morning, he refused to attend.

What was going on for him in all this? He seemed a shy, soft-spoken boy who was described as very anxious about what was going to happen to him and his sister, and whether he would ever go back to his mother or not.

The ethics of depending on children as witnesses

According to InBrief, subject to some exceptions, unreliable evidence is normally excluded from trials. InBrief also states that “the Youth Justice and Criminal Evidence Act 1999, section 53(1) says that at every stage in criminal proceedings all individuals are (whatever their age) competent to give evidence”. But “a child’s competency depends on their understanding and not their age”. Was this little girl competent to give accurate evidence more than a year after the incident happened? Could her brother have been expected to know what happened?

The 2011 Guidelines in Relation to Children Giving Evidence in Family Proceedings[10] specify that in deciding whether a child should give evidence, the court’s principal objective should be achieving a fair trial. With that objective the court should carry out a balancing exercise between the following primary considerations: i) the possible advantages that the child being called will bring to the determination of truth balanced against; ii) the possible damage to the child’s welfare from giving evidence i.e. the risk of harm to the child from giving evidence….”

Over 25 serious considerations are then listed to take into account. These include: whether the case depends on the child’s allegations alone; corroborative evidence; the length of time since the events in question; whether the child has retracted allegations; and much more. Working from these guidelines, should the children’s evidence have been admitted the way it was?

What will happen to this family?

The father had already lost a wife and daughter, who had died in a car accident in his home country before he came to the UK. While awaiting trial, he lost his job and the room he was living in. His visa to remain in the UK expired while he was in detention before the trial – for having broken his bail conditions by talking to the children’s mother. Will he have a difficult fight on his hands to gain custody of his daughter, whom he adores, as well as custody of the boy, whom he also loves dearly, even though their mother will probably be in prison a long time? Is he at risk of being deported? Why otherwise, although he was acquitted of all charges, was he not released at the end of the trial? Will the mother too be deported? Will the children be forced to stay in foster care until they are of age? This family’s lives have been blighted. Was this justice or an outcome worth achieving?

Final thoughts

How might this trial have ended had the children’s evidence and the evidence on witchcraft and spells been excluded? I question whether it was proven beyond a reasonable doubt that the mother was guilty of FGM. I also have to ask about the children’s long-term well-being, given their pivotal role in condemning their mother. Lastly, considering the backdrop of witchcraft pervading this trial, and the hope for a guilty verdict by far too many people watching it, it seemed far too close to what I fear witchcraft trials in the past must have been like.

The use of the criminal law and current requirements on the NHS and others to report cases in the UK have been seriously damaging. Should FGM be treated the same as other child abuse? Though harmful, it was a communal rite of passage into adulthood in Africa for girls in the ethnic groups who practised it. There is growing evidence that it is happening less than in the past, including among women who have come to the UK,[11] and that it never was much done here.

I believe the UK government, Parliament, Crown Prosecution Service, members of the judiciary and legal profession, the police and the NHS must reconsider and call a halt to further FGM prosecutions, and join with the communities among whom FGM used to be a traditional practice, who are saying they feel oppressed and silenced by current UK law and practice, to find a better way forward. A positive approach is far preferable, including in schools; specialist clinics for women with complications of FGM[12] are a good example of the way forward.

FURTHER READING

See my blog for articles on previous FGM trials, the blog A miscarriage of justice by Brid Hehir, 5 February 2019 on this trial, blogs about FGM on Shifting Sands, and articles in Reproductive Health Matters about FGM around the world.

REFERENCES

[1] “Current response is disproportionate and should be reconsidered.” Sarah M Creighton, Zimran Samuel, Naana Otoo-Oyortey, Deborah Hodes. Tackling female genital mutilation in the UK. BMJ, 2019;364:I15.

[2] Brenda Kelly, Filsan Ali. The narrative around FGM needs to move beyond prosecution. BMJ Blogs, 15 February 2018.

[3] Marge Berer. The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain? Reproductive Health Matters 2015;23(20).

[4] I will call them mother, father, girl and boy here, as nothing can be published that might identify them, by court order.

[5] From a skilled FGM cutter in Kenya, 2015: “…It can be slippery, so we use some ash to get a good grip. There are veins there. It’s very difficult, very technical. You have to be really careful.” Broadly Vice.

[6] The haematoma apparently did not count.

[7] Evening Standard, by Katy Clifton, 1 February 2019.

[8] I will not give details of the source (a 2016 Demographic & Health survey) because it identifies her country.

[9] Issues of English as a second language, translation and interpreters in this trial also deserve examining.

[10] This is not applied to criminal proceedings in the guidance.

[11] FGM has stopped in Wales but women still ‘persecuted’, by Sarah Hibbard. BBC Wales News, 12 June 2018.

[12] NHS Specialist Services for Female Genital Mutilation. NHS England, October 2017.

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The role of the police and the courts in prosecuting allegations of FGM: a review of “The FGM Detectives”, Channel 4 TV, and the case that just ended at the Old Bailey

26/03/2018 Comments Off on The role of the police and the courts in prosecuting allegations of FGM: a review of “The FGM Detectives”, Channel 4 TV, and the case that just ended at the Old Bailey

The Channel 4 TV programme was shown on 27 February 2018, reported by Cathy Newman. It depicted the failure of a British detective named Leanne Pook to bring a successful prosecution against a Somali father of a six-year-old girl for allegedly arranging for her to have FGM, after an investigation that took two years. The programme was supportive of the police action right to the end, yet it provides a disturbing picture of why the police and the Crown Prosecution Service have failed to successfully prosecute cases of FGM four times now. The case also highlights, as have previous court cases, the important role of the court in not allowing the accused parent to be found guilty, due to the lack of evidence. It shows, in my opinion, that the involvement of the police and the criminal law is not the way to prevent FGM, or to support those who have had or may be at risk of FGM.

The programme illustrated how the right to bodily integrity of a six-year-old girl believed by the police to be a victim of FGM was violated by the police. The investigation was based entirely on the uncorroborated report of a conversation between a taxicab driver, the girls’ father, and a passenger in his cab. The passenger, who was a member of an anti-FGM group in Bristol called Integrate, presumably raised the issue of FGM with the driver because he was Somali. The passenger alleged that the father said he was not against minor forms of FGM, and that he had had that done to his daughter.

The programme opens: “Thousands of British women and girls have had their vaginas deliberately mutilated.” This is false. First, there is no evidence worth the name that most of those living with FGM in Britain have had FGM in Britain. Secondly, FGM is practised on the external female genitalia, the clitoris and labia, and sometimes also by sewing the edges of the vaginal opening together. There is no mutilation of the vagina.

DCI Pook, who led the investigation of the case was, in addition to being a police officer, a trustee of the local anti-FGM group in Bristol called Integrate. The taxicab passenger reported his conversation with the driver to someone more senior than him at Integrate, who in turn reported it to DCI Pook. The programme follows her investigation of the taxi driver, his wife and his six-year-old daughter, and her unsuccessful attempts to gather any evidence to prosecute the father for FGM beyond the passenger’s description of his conversation with the father.

The police considered the passenger’s statement to be enough for them to pursue the case. DCI Pook was very keen to do this; she wanted to be the first to bring a successful FGM prosecution in this country, which emerged strongly during the programme, raising questions about her ability to be impartial, question which were asked after the trial collapsed.

The programme was extremely vague about why the investigation should have taken two years. The police did not prosecute the girl’s mother, though they found the phone number of a “circumciser” on her phone, who the father said had been contacted to circumcise one of his sons. The programme did not indicate whether the circumciser was ever questioned and nothing more was said about him. In the programme, the investigation never went beyond the questioning of the girl and her parents, and discussion about the examination at two different times of the girl’s genitals. Yet one would expect other family members, friends, neighbours and other Somali community members close to this family to be questioned.

Yet, 17 minutes into the programme, DCI Pook is shown to be participating in a street demonstration against FGM with women and children from Bristol and is also shown talking to a group of parents and adults, about the importance of investigating FGM. This is followed by a meeting with youth members of Integrate, where a discussion about claims that a small nick is not abuse are challenged. This shows that DCI Pook’s role as both the investigating police officer and anti-FGM advocate are completely intertwined in this investigation, with no question of a possible conflict of interest being raised. The question of the consequences for the child or her parents that the whole community knows about this investigation is never mentioned.

The girl’s parents deny ever having had anything done to their daughter, and her father denies ever making the comment that he was accused of making while driving his taxi.

The only other possible source of evidence shown by the programme to be sought, was the girl herself. Investigating her took two forms: first, she was questioned by someone considered to be an expert at using drawings with children as a means of getting information from them. The girl was asked to do a drawing of her body in the hope she would recall the FGM because it would have been traumatic, so she might say something about it. This did not happen, however. The expert failed to elicit any verbal or visual evidence that FGM had taken place.

The second step was to examine the girl’s genitals. In order to do that, the programme reports, she had to be willing, so she was interviewed at her school. There is a meeting with 5 or 6 staff from the school. We are not told who was present when the girl’s permission was sought nor what was said to her, but we are told she agrees. The child’s parents are informed it will happen but they are not permitted to be present, nor was their permission sought. The programme gives no information about who conducted this physical examination. We learn later that some kind of equipment (unidentified) was used and that pictures were taken of her genitals. We have to assume the examiner would have opened her labia and closely examined her clitoris for evidence.

The police were at least honest enough to say at some point afterwards that the little girl described the examination as disgusting. This is hardly surprising. In my opinion, the examination constituted a serious violation of her bodily autonomy, of her right to privacy and to be able to withhold her consent. Yet a six-year-old girl could not possibly have understood what the examination would involve, and even if she had, how could she have refused? Adults from her school, the police, all apparently supporting it, her parents absent – all major forms of pressure. Even if she had had FGM in the past, it is highly questionable that this is ethically acceptable.

But that’s not how DCI Pook saw it. Her response to the girl’s reaction is that an investigation must be thorough enough that the victim is not relied upon alone for the evidence (or in this case lack of evidence). The child was in fact examined twice, we learn later, but we were not told how often she was questioned nor what the questioning covered. DCI Pook reports that the first person who examined her found something that might have come from a small cut on the child’s clitoris. A detective reports that the girl had at some point been taken out of the country during school holidays, which he describes as an opportunity for her to have been cut elsewhere. Indeed, or it might have been a holiday or a family visit. No further details are given, and no evidence is offered of this being more than a supposition.

By this point in the programme, however, the lack of evidence is becoming obvious. To counter this, DCI Pook embraces the idea that a “small cut” may have been done without leaving visible damage or scarring – a tiny nick (enough to draw a drop of blood) or a pinprick – and she decries the belief that this should not be prosecuted as FGM, and indeed she seems to conflate it with a severe or mutilating cut. Another officer says a nick or a pinprick of any kind is still painful. Several of the male officers talk about the importance of the police protecting little girls from such abuse. Yet they have protected this little girl from nothing whatsoever.

The facts of this case are, whether she had been subjected to any form of FGM or a pinprick or not, no mark nor scar nor any other evidence from any person was found to indicate that anything had been done to her.

Moreover, it is reported that the photographs of the little girl’s genitals from the first examination were sent to an “FGM expert” to analyse. While this expert says she thinks the photos may indicate an injury, she believes they are “not good enough” as evidence. So she asks to conduct her own physical investigation of the girl as she wants to feel 100% sure there is an injury before she is involved in sending someone to prison. Hence, and the timeline here is totally unclear, it was agreed that a second physical examination of the child would be carried out by this expert, who is again not identified in the programme, and whose credentials are therefore unknown.

One of the male police officers is unhappy about a second examination because the first examination was unpleasant for the child, and this upsets him. Even so, and for reasons best known to themselves, the police decide it is time to arrest the parents, take them into the station and question them separately. Were they not questioned before the child was examined? We don’t know.

More than half a dozen police officers dressed in jeans and t-shirts, not in uniform so as “not to upset the community” set off to the family home. Unfortunately, the parents are not at home so they are asked to attend the police station, which they do and are arrested there. Their home is searched by a police team in their absence.

The father, it is reported, is questioned through an interpreter. This implies his English is limited, which is a critical matter but the programme does not treat it so. Yet in the second FGM trial in London, in 2015, in which another Somali man was accused of asking for his wife to be re-sewn up following delivery of a baby, he needed an interpreter in order to be questioned in court, and he was acquitted in part due to the probability that his English in the delivery room was misunderstood.

In any case, the programme reports that during questioning, the father denies there had been any FGM or any intention of FGM, and he denies ever having had the conversation with the Integrate team member in his taxi. The police officer questioning him says to him that the examination of his daughter had indicated an injury to her genitals and that the expert who had examined the photographs had also seen an injury. Although both these claims are patently false, the programme does not note it. The mother is similarly told that an injury had been identified. She reads out a prepared statement that she is opposed to FGM, and she refuses to answer any questions. Did the parents have any legal advice? We are not told. Had it been my programme, I would certainly have interviewed their legal team.

Meanwhile, in between each of these bits of the programme, there are shots of traffic on Bristol’s roads, sometimes speeded up, and shots of DCI Pook driving her car and talking to the camera… often with tense music playing which is totally out of place.

The search of the family home yields half a dozen plastic bags full of papers, but the only possibly incriminating item found is a phone number on a small bit of paper stuck behind a picture hanging on a wall. The phone number turns out to be the father’s phone number, however, not incriminating at all. How disappointing for the police, who still assert that if you hide something behind a picture frame like that, it is usually incriminating in some way. DCI Pook is not discouraged though. She explains that you rarely get one big piece of evidence in a case, as happens on TV. So they are cracking on.

It is time for the second examination of the girl’s genitals, by the “expert”. This examination found her genitals to be completely intact, with no evidence of any injury or FGM. We learn this indirectly through watching DCI Pook listening to the expert on the phone. The expert appears to apologise for disappointing her, and we hear DCI Pook say (in a very disappointed voice) that it was OK, never mind, the expert was just doing her job.

After she hangs up the phone, DCI Pook doesn’t say: “Isn’t it wonderful that this little girl has no evidence of any injury!” No, she says this news is a disaster for the police, and one of her male officers agrees. It seems they really wanted this little girl to have had FGM. DCI Pook looks straight into the camera and says: “This is a hammer blow to our case… I’m disappointed because I think we won’t get justice for this little girl.”

Oh, it seems that in spite of this phone call she remains convinced that FGM has happened to this child! What did the expert say to make her think so? DCI Pook tells us that the expert’s written report of her examination states that the lack of genital evidence may indicate that any injury may have healed. I would have liked to see the report myself, however, as this beggars belief.

But meanwhile, DCI Pook is good to go again, though she needs to find something to “strengthen the case”. The girl’s mother’s cell phone provides it, as noted earlier. They find a text and a phone number of a man whom the mother says has recently circumcised one of her sons. When she is asked if she has also had her daughter circumcised, she says “No comment”. Of course, if someone says “No comment” instead of yes or no, the assumption is that they are guilty. Does this prove they are? No. The programme does not report whether the son is examined for evidence of recent circumcision, surely an extraordinary omission. Nor does it say whether the alleged circumciser, whose evidence would surely have been key in this case, was found and interviewed. This is even more extraordinary.

At this point in the programme, we learn that “the evidence” has been submitted to the Crown Prosecution Service (CPS) to see if they think it is enough for criminal charges to be brought. After more speeded up footage of Bristol, of boats on the river this time, and to increasingly loud tense music, we learn that the CPS has given permission for a charge of child cruelty against the father to be brought and for “allowing or arranging for [the child] to have FGM”. They give permission for the father to be arrested and charged. If found guilty, we are told, he faces up to 10 years in prison.

When the court date is set, DCI Pook tells the camera, some of the Somali community have been heard to say they may organise a protest. Who has reported this to her is unstated, but the implication is that someone has been monitoring the Somali community’s response and reporting to the police. DCI Pook expresses concern that her witness, the taxi passenger, may be threatened, and she is shown talking to him on the phone to get reassurance that this has not in fact happened.

he next thing covered by the programme, although far too briefly, is when the Bristol Crown Court hears the evidence. The courtroom is packed. DCI Pook thinks this is mainly journalists, which she thinks indicates the importance of the case. However, the outcome is not at all what she is looking for. After what seems to be a very short space of time, the judge questions inconsistencies in the main witness’s statement and the evidence is described as “beginning to unravel”. The judge concludes that on the basis of the existing evidence, he would direct the jury to acquit the defendant. The programme tells us that the judge found the evidence deeply troubling and “wholly inconclusive at the highest”. She reports that the judge describes the equipment used to examine the little girl the first time as being 15 years out of date (what equipment was this, I want to know!) and that the photographs taken at that time were so blurry as to be of no use clinically or forensically as evidence. The main witness, though honest, the judge believes, had been influenced by his role in the charity Integrate. The CPS accepts the judge’s decision, but they also defend themselves by saying they thought there had been sufficient evidence to prosecute and that it was in the public interest to do so. Thus, the CPS also seems to have learned nothing from two previous failures, the first of which was comparable to this case.

And thus, if we forget the child and her parents for a minute, there is total self-justification all around. Thank heavens for the competence of the judge.

The programme returns to DCI Pook, now sitting by the river, who claims this is all part of the job. She is shown justifying herself to the media, and then says to the camera: “There were some evidential difficulties, we never denied that…”. She remains firm, however, that in spite of the negative impact on the family and the community, the police had a job to do and they did it. She says they have children to protect and that’s what they were doing. But were they, in this case? I don’t think so.

As DCI Pook walks away from the camera, the reporter says the police have had difficulty prosecuting anyone successfully because young victims keep silent – thereby implying that the child in this case had been silenced or was lying. This is frankly outrageous. “Victims” who are old enough to understand what has happened to them are not keeping silent. Yet it seems that no one involved in this criminal investigation or in making this TV programme thinks it is even remotely possible that the child concerned had never had FGM, in spite of the lack of evidence and the judge’s unequivocal assessment of the situation, which the programme corroborates in spite of itself. I’m left speechless. The programme closes with a report that yet another FGM case was due to be heard in London in the third week of March 2018.

And so it was.

This most recent case was heard at the Old Bailey in London, ending on 22 March in an acquittal. Here is how the Mail Online reported it in cringe-making language:

“The 50-year-old man, who cannot be named to protect the identity of the child, was cleared of two charges of FGM, alternative charges of wounding with intent and child cruelty… The defendant had been accused of twice arranging for someone to go to the family’s home in south London to cut the young girl with a razor as she lay on a mat in the hallway. The girl said she cried in pain and begged for it to stop but her father just encouraged the cutter, jurors were told. The child could not recall the identity of the person who allegedly subjected her to the ordeal twice… The prosecution said it did not happen for cultural or family reasons, but as a punishment. The allegations came to light after the girl told a friend, whose mother contacted Childline.”

I was unable to attend this trial and no one has covered it in a TV programme (yet). Here are the only other things I have found about it in the Guardian: During an interview in July last year, the daughter, now aged 16, said she had been subjected to FGM twice between 2009 or 2010 and 2013. On each occasion she claimed she was made to lie on a mat in the hallway of her home, naked from the waist down. Jurors also heard that she could not identify the cutter but said she recalled her father “egging the person on”.

The Guardian said the father was a 50-year-old solicitor and a Catholic. He was accused in court of being violent towards his children as well. His defending counsel said the divorce of the girl’s parents had led the mother to turn the children against him, and that they had rewritten their own histories as a result. Oddly, the Guardian reported: “The court heard the girl had been cut as a form of punishment after stealing money from the family home.”

As part of her defence of the father, Kate Bex QC, suggested that FGM was “predominantly perpetrated by female cutters on women” for reasons including “purification, honour and social acceptance”. But it is not true that only women do the cutting; it is also known to be done by men. The QC also apparently claimed the father could not have been responsible for the FGM because he was a Catholic, yet that is irrelevant. FGM is a traditional cultural practice and while some people claim it is an Islamic practice, those who have studied religious texts and history have shown it is not. Moreover, while FGM is found in some predominantly Muslim countries, it is not found in others, while it is found in certain predominantly Christian countries, in the Middle East and North Africa and also in sub-Saharan Africa and parts of Asia. Yet these two claims by the QC were reported by the Guardian to be (among) the reasons why the father was acquitted.

Evidence appears to have been submitted to the court that examination of this girl showed she had actually had her genitals cut in some way. But as the father denied arranging it and the girl had no memory of who had done it to her on either occasion, and no news report mentions further evidence, the father was acquitted. The Guardian says the jury deliberated for more than six hours before finding him not guilty of two counts of FGM, two alternative counts of wounding with intent and three counts of cruelty to a child. It seems that even though FGM was done, and perhaps more abuse, who had actually done it was not known. Why the father was not found guilty of anything is unclear, though it seems it was his word against his daughter’s. Without having heard the trial, however, it is impossible to know, and speculation is useless.

Conclusions

The four cases have one thing in common. There was insufficient or no evidence presented, and there was an absence of credible witnesses or corroborating statements. In three of the four cases, no genital evidence of FGM was found either. Hence, it can be concluded that these four cases were all doomed to fail.

Moreover, limited knowledge of English among those put on trial was recognised in interrogations of them through the use of interpreters, but this was not properly taken into account as a complicating factor in two of the four cases. Perhaps most importantly, in three of the four cases one onlooker reported someone they thought was suspicious to the police. I believe that the way the police and some anti-FGM activists are presenting this situation, as illustrated in the Channel 4 programme, it sounds like a witch hunt and the consequences for the communities affected and the children concerned are being swept aside in the fervour of wanting to find someone to hold responsible.

Lastly, although no one has yet publicly questioned whether the examination of the genitals of babies and small children for FGM is a violation of those children’s rights to privacy and bodily integrity, I am absolutely convinced it is. I am aware that this is also an issue with accusations of sexual abuse and rape of children, which I cannot comment on, but it would appear that the people who have carried out FGM examinations seem to be anything but experts.

The Guardian article ends with a quote from Leethen Bartholomew, the head of the National FGM Centre, which includes this statement: “The effects of FGM have a lifelong impact on survivors, both physically and psychologically, so it is vital support is in place for her for as long as she needs it.” This makes it seem that women who have had FGM are incapable of living their lives on their own two feet. It is the sort of statement that fuels extremist responses.

Criminalising FGM has stigmatised whole communities in the UK, such as the Somalian community. FGM has been falsely identified as an Islamic practice, thereby contributing to the stigmatisation of the religion and those who practise it as barbaric, alongside the link to terrorism. People who believe some form of FGM is necessary in order to remain part of their community are seen as monsters. Even the use of a pinprick to replace actual genital cutting, a positive sign that the practice is being transformed into something symbolic but not damaging, is still condemned as horrific and an abuse. When mothers argue that it is the only way their daughters will be accepted as marriageable, in a community where marriage is critical to belonging, this should not be seen as violence for its own sake but as a patriarchal demand that must be challenged among both men and women. Meaning that the way to try to prevent it should not be the use of criminal law.

There have been exaggerated claims of FGM prevalence in the UK, without any distinction between those adults who may have been cut in their home countries as children before coming here, and the completely unknown prevalence in children today who were born here. Health professionals are required to act like the police and to question women patients with girl children, on the assumption that their nationality/background is enough to indicate their children are at risk. Although no one has yet been identified as having done even one cut on one little girl in this country, there is an assumption put about that it is not only happening, but happening widely. All this is indicative that the practice has been demonised in many people’s minds.

I believe it is past due time to give serious reconsideration to how FGM is dealt with and perceived in the UK, and to finding ways of addressing it completely differently. The communities concerned need to have the leadership in this – for example, community-led educational information, based on the understanding of women who have experienced FGM and their families as to why they should not make their daughters and grand-daughters go through it too. Moreover, communities where FGM is/was practised should not be described individually or collectively as uncivilised, abusers or criminals by anti-FGM activists. That is racist.

In a paper I published in 2015, I called for the health consequences of FGM to be addressed because these are what women with FGM have asked for help with. A study among midwives in Belgium, published in Midwifery in 2014, found that the most common complications midwives said women sought help for were: psychological problems (63.1%), chronic pain (32.3%), sexual problems (30.8%), recurrent urinary tract infections or incontinence (24.6%), fistula formation (13.8%) and bleeding (9.2%). Complications in pregnancy and childbirth have been described in the UK as well. Practical help with these sorts of problems are a much more supportive way to address this issue with affected women. Health professionals need training to do so.

The police and the criminal justice system are not the answer.

 See my previous writing on this issue which covers the first two cases that took place in the UK:

Reflections on the recent arrest in London of two people for female genital mutilation (FGM). Berer Blog, 14 April 2014.

Acquittals in the FGM case in London: justice was done and was seen to be done, but what now? Berer Blog, 10 February 2015.

The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain? Reproductive Health Matters 2015;23:145-157. https://www.tandfonline.com/doi/full/10.1016/j.rhm.2015.10.001

 

 

The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?

24/12/2015 Comments Off on The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?

This article was published online in Reproductive Health Matters 2015;23(46):145-57. DOI: http://dx.doi.org/10.1016/j.rhm.2015.10.001. Here is the abstract in English, French and Spanish:

Abstract

The history of campaigns against female genital mutilation (FGM) began in the 1920s. From the beginning, it was recognised that FGM was considered an important rite of passage between childhood and adulthood for girls, based on the importance of controlling female sexuality to maintain chastity and family honour, and to make girls marriageable. How to separate the “cut” from these deeply held norms is a question not yet adequately answered, yet I believe the answer is key to stopping the practice. Since the 1994 ICPD, national and international action against FGM has grown and resolutions have been passed in global forums which define FGM as a form of violence and a violation of children’s human rights. These resolutions have contributed to building consensus against FGM and developing national legislation criminalising FGM. Prosecutions or arrests involving FGM have been reported in several African countries and Great Britain, but apart from France, there have been very few. This paper summarises this history and how FGM has been criminalised. It argues that criminalisation may not be the best means of stopping FGM, but can have serious harmful effects itself. It calls for community-led educational information and more support for dialogue within FGM-practising communities, and argues that what is important is addressing the sexual and reproductive health consequences of FGM and gaining the understanding of women who have experienced it and their families as to why they should not make their daughters and grand-daughters go through it too.

Résumé

Les campagnes contre les mutilations sexuelles féminines (MSF) ont commencé dans les années 20. Dès le début, il a été admis que les MSF représentaient pour les filles un important rite de passage entre l’enfance et l’âge adulte, fondé sur l’importance du contrôle de la sexualité féminine afin de préserver la chasteté et l’honneur familial, et de permettre aux filles de se marier. Comment séparer la mutilation de ces normes profondément ancrées est une question encore sans réponse ; ce serait pourtant, à mon sens, une démarche essentielle pour mettre un terme à cette pratique. Depuis la CIPD, en 1994, l’action nationale et internationale contre les MSF s’est étendue et des forums internationaux ont adopté des résolutions qui définissent les MSF comme une forme de violence et une violation des droits fondamentaux de l’enfant. Ces résolutions ont contribué à dégager un consensus contre les MSF et à élaborer des législations nationales qui répriment cette pratique. Des poursuites ou des arrestations liées aux MSF ont été signalées dans plusieurs pays d’Afrique et en Grande-Bretagne, mais, à part en France, elles ont été très rares. L’article résume cette histoire et montre comment les MSF ont été sanctionnées par la loi. Il avance que cette pénalisation n’est peut-être pas le meilleur moyen de faire cesser les MSF et qu’elle peut avoir elle-même de graves conséquences. Il préconise une information éducative collective et davantage de soutien au dialogue au sein des communautés qui pratiquent les MSF. Il fait valoir qu’il est important de traiter les conséquences des MSF pour la santé sexuelle et génésique et de faire comprendre aux femmes qui les ont subies et à leur famille les raisons pour lesquelles elles ne devraient pas obliger leur fille ou leur petite-fille à en passer aussi par là.

Resumen

La historia de las campañas contra la mutilación genital femenina (MGF) comenzó en la década de 1920. Desde el principio, se reconoció que la MGF era considerada un importante rito de paso entre la niñez y la adultez para las niñas, basado en la importancia de controlar la sexualidad femenina para mantener castidad y el honor de la familia, y para preparar a las niñas para el matrimonio. Cómo separar el “corte” de estas normas tan arraigadas es una interrogante que aún no ha sido contestada adecuadamente; sin embargo, creo que la respuesta es clave para eliminar la práctica. Desde la CIPD de 1994, la acción nacional e internacional contra la MGF ha incrementado y se han aprobado resoluciones en foros mundiales que definen la MGF como una forma de violencia y una violación de los derechos humanos de las niñas. Estas resoluciones han contribuido a fomentar consenso contra la MGF y a formular leyes nacionales que penalizan la MGF. En varios países africanos y en Gran Bretaña se han reportado enjuiciamientos o arrestos relacionados con la MGF, pero aparte de Francia, ha habido muy pocos. En este artículo se resume esta historia y cómo la MGF ha sido penalizada. Se argumenta que la penalización quizás no sea el mejor medio para eliminar la MGF, ya que puede tener graves efectos dañinos. Se hace un llamado a la información educativa dirigida por la comunidad y a brindar más apoyo para el diálogo con las comunidades que practican la MGF. Se argumenta que lo importante es tratar las consecuencias de la MGF en la salud sexual y reproductiva y lograr que las mujeres que han pasado por esta experiencia y sus familias entiendan por qué no deben obligar a sus hijas y a sus nietas a hacer lo mismo.

Another FGM case in Britain that found no harm

05/09/2015 Comments Off on Another FGM case in Britain that found no harm

Another FGM case, which did not involve the criminal law but family law, and that took place in November 2014 in Leeds, two months before the first criminal trial in London,[1] involved an attempt to take two small children into care: a girl G aged ±3 and a boy B aged ±4, whose parents were of African origin. The children had temporarily been placed with foster parents as the mother was having mental health problems. The judge’s write-up of the case,[2] on which this blog is based, said:

“The suspicion that G had been subjected to FGM first arose in November 2012 in country S after blood had been found in her nappy when she was at nursery. She was examined by two doctors who found (I quote the translation) ‘no sign [she] had any damage to female organs’. A further medical report states ‘outer and inner labia normal and the clitoris is normal. No sign of any circumcision’. The question was raised again in November 2013 when the foster carer reported G’s ‘irregular genitalia’.”27

Three people, invited to examine the girl and give evidence because all were considered to be experts and presented themselves as such, gave testimony in court. According to the judge’s report, Expert 1 was an expert in child sexual abuse and described herself as an expert in the assessment of female genitalia ‒ but not for FGM. She had examined approximately five girls with FGM over the previous three years, but only one was a baby. Expert 2 was a midwife with extensive experience of pregnant women with FGM; she described herself as an FGM, reproductive and public health specialist. She had knowledge of and expertise in many aspects of FGM and its medical and other consequences, which she has published and spoken on extensively, both in Britain and abroad. When she gave oral evidence, however, it became clear she had almost no experience of FGM in babies. Expert 3 had established a specialist clinic in 1999 for women with health consequences of FGM, and had a great deal of experience of them; moreover, her clinic was the only specialist paediatric FGM clinic in the country.

Experts 1 and 2 both examined G and both said in written and oral evidence that they thought they had seen evidence of FGM. However, their descriptions of the mutilation differed from each other’s. Expert 1 later changed her evidence and admitted to having made a mistake. Expert 2’s evidence was described by the judge as: “confused, contradictory and wholly unreliable”. Expert 3 did not examine G in person but saw the reports of the other two and watched the DVD of their examination of G. She said she saw no evidence of FGM. Both parents also denied that G had been subjected to FGM. The judge dismissed the FGM charge.

The local authority who brought the case argued that if G had been subjected to FGM it was reason enough to initiate adoption proceedings. Sir James Munby, President of the Family Division, who heard the case, said there were three issues to consider: Had FGM occurred? Did it amount to significant harm, and if so, what were the implications. Having heard the evidence, he concluded that the “local authority is unable on the evidence to establish that G either has been or is at risk of being subjected to any form of FGM”. In a lengthy and thoughtful consideration of the implications, he also cautioned that even had FGM been found, “local authorities and judges are probably well advised not to jump too readily to the conclusion that proven FGM should lead to adoption”.

This case illustrates that even experts cannot always tell or agree whether a child has had FGM. The implication, as I see it, is that allowing uncalculated numbers of children to be examined for FGM by people who are likely to have even less expertise than the witnesses in this trial, is a recipe for disaster.

References

[1] See Berer M. Acquittals in the FGM case in London, justidce was done and was seen to be done, but what now? Berer Blog, 10 February 2015. https://bererblog.wordpress.com/2015/02/10/acquittals-in-the-fgm-case-in-london-justice-was-done-and-was-seen-to-be-done-but-what-now/.

[2] Sir JamesMunby, President of the Family Division. In the matter of B and G (Children) (No 2). Neutral Citation Number: [2015] EWFC 3. Case No: LJ13C00295. 14 January 2015. https://www.judiciary.gov.uk/wp-content/uploads/2015/01/BandG_2_.pdf.

Is the NHS collection of patient identifiable data of women with FGM unethical and a breach of confidentiality?

16/08/2015 § 2 Comments

Female genital mutilation (FGM) has been illegal in the UK since 1985, and taking a child abroad to undergo FGM, as legislated in the 2003 Female Genital Mutilation Act and 2015 Serious Crime Act is also illegal and is recognised as a form of child abuse. Until 2014, however, no one had been prosecuted  for FGM and to date, no one has been convicted of this crime.

In response to calls for ‘something to be done’ to address this failing, the UK government has taken a number of steps. They include encouraging the Crown Prosecution Service to scour the landscape for possible perpetrators, sending the Police to airports to hand out leaflets to suspicious travellers and tell them that FGM is illegal, and encouraging Border Agency staff to be on the lookout for victims who might have undergone the procedure abroad, particularly during the so-called ‘cutting season’ (summer holidays).

New regulations and guidance have also been issued to professionals. Among them has been a requirement to gather data on the prevalence of FGM among girls and women living in the UK. Contrary to long-established practice in epidemiological study, however, the data include a long list of identifying information on the women, including their names and NHS numbers, and the governmental Health and Social Care Information Centre are being sent this data, quarterly, since April 2015.

Epidemiology, according to a BMJ handbook, is “the study of how often diseases occur in different groups of people and why. Epidemiological information is used to plan and evaluate strategies to prevent illness and as a guide to the management of patients in whom disease has already developed.” Epidemiological study requires the identification of the population at risk. Not everyone with a disease or who is at risk is studied, however; rather, a representative, sample population is identified for study. Individuals being studied remain anonymous because the aim is not to study or treat individuals, but to study them as a population group, through random selection among those at risk. There is almost never an attempt to find everyone who may be at risk or affected, but only a representative sample. On the basis of this information, health professionals can be trained in addressing the disease concerned and services directed at those who need them.

FGM is not a disease, of course, but a harmful traditional practice, However, FGM is not a new condition nor one about which little is known. For women with problems arising from FGM, a number of NHS specialist centres have existed in Britain for many years and provide care for women with these problems. They are staffed by specialist clinicians, mainly midwives and doctors.

Still, the study of FGM epidemiologically is valid in that the findings can be used to ensure that the services women may need can be planned and made accessible to them. It has long been recognised that some of the women who migrated to the UK from FGM-practising countries had experienced FGM as children in their country of origin. Bindel estimated that the numbers could be as high as 170,000. A provisional estimate of FGM prevalence in England and Wales, published by City University and Equality Now in 2014, however, suggested this figure was 137,000 women and girls. This is a not inconsiderable difference. (Note: Neither the Bindel nor the City University data were accessible on the web at this writing.)

In the latter estimate, prevalence data were “derived from reports of household interview surveys in 2011 in the countries in which FGM is practised and extrapolated to the number of women living here who came from those countries of origin. Thus, the figure is based on two sets of estimates. Yet another study published by the UN Refugee Agency looked at the number of initial applications for asylum from women from FGM-practising countries, to Europe, covering the UK between 2009 and 2011. It found that an average of 2,350 females per year had applied for asylum in the UK. This does not mean all of them were granted asylum or had entered the country, nor that they even had FGM. So the value of these numbers is dubious.

What is certain is that none of these estimates were derived from a bona fide epidemiological study and should never have been accepted and treated by officials, the media or campaigners as if they were. But they were, and they continue to be cited by those pressurising the government to ‘do something’. In reality, there are no accurate data on the number of women in this country who have undergone FGM. Nor is there evidence that FGM is being carried out in the UK on children. Although it is presumed that some British families take their girl children back to where their relatives came from or elsewhere for FGM, the numbers involved are also unknown. These are all good reasons for why accurate epidemiological data should be collected. So, how is the government addressing this need?

Starting in 2014, the Department of Health (DH) mandated that the Health & Social Care Information Centre (HSCIC) collect monthly prevalence data from NHS health professionals working in acute hospital settings, of women who had previously been identified and were being treated for FGM-related or non-FGM-related conditions, as well as newly identified women. This continued to March 2015.

Then in April 2015, prevalence data collection was replaced by an FGM enhanced dataset. Clinicians in England, working in Acute Trusts, Mental Health Trusts and GP Practices now have to record demographic and other data (including patient identifiable data) when a patient with FGM is identified during a consultation for health care of any kind, including the type of FGM she has undergone. The data has to be entered every time the woman or girl seeks care or gives birth to a baby girl (because the baby may be at risk of being subjected to FGM), and every time FGM is identified (by a clinician or self-reported), not just the first time. The data must be sent quarterly to the HSCIC. But this is not the way to do an epidemiological prevalence study. How is it different?

First, its goal is to record data on every woman and girl found to have had FGM. This is neither necessary or cost-effective since the point of epidemiological studies is to obtain representative data on the “group”, not the individuals.

The sort of ‘blanket’ data collection demanded by the DH was not even carried out to identify people living with HIV, for example, even after the extent of the epidemic became clear. Although it was certainly proposed, it caused a great deal of debate and controversy ‒ and was rejected. People living with HIV fought against named data collection as a violation of privacy and medical confidentiality, and as a human rights issue ‒ not only because of the stigma related to being identified as having HIV or AIDS, but also because, in those early days, there was no benefit for patients as no treatment had been developed.

Are not the rights of patients with FGM also being violated when they are identified and recorded as having had FGM? Some activists who have undergone FGM have expressed feelings of being stigmatised and fear of speaking out about it. But unlike with HIV, this fear is because their families are also implicated and might be exposed. Perhaps they do not want themselves and their families to be investigated by the justice system? Or they may be afraid of the racism and condemnation resulting from such exposure?

Secondly, the HSCIC regulations now require that a host of information be recorded, with or without the patient’s permission. The mandatory and required (i.e. if appropriate) non-pregnancy-related data that must be collected include: the woman’s full name, birth date, post code, NHS number, country of birth, country of origin, GP practice, care contact date, details of referring organisation, details of treatment site, existence and type of FGM, details of de-infibulation, pregnancy status indicator, FGM family history, number of daughters under 18, that the woman was advised on the health implications of FGM and on the illegalities of FGM, daughter/s born at this attendance, woman’s age at FGM and country. Optional information includes age and country of origin of the father of any the woman’s daughters aged under 18.

Ironically, despite all of the claims in these regulations that the main purposes of interviewing women who have had FGM is to record information that will be used to help them, there are no questions on the form asking health professionals to confirm that they have given women information on where to find clinical, psychological or social support for FGM if it is needed.

I can understand that recording a woman’s NHS number might be considered necessary to avoid the possibility that, with totally anonymised data, a woman with FGM who attends for health care in more than one place might well be counted more than once. This is a valid concern, considering the flaws in the initial regulations. However, in my opinion, there are serious new concerns here no matter which way one looks at it. The value and purpose of the extent of the information health professionals are now required to record is, epidemiologically speaking, highly questionable, despite HSCIC reassurance that no patient identifiable data (PID) will ever be published. This is because the woman’s personal data may be handed over to the police, social care authorities or the courts if she has girl children who are deemed, during the course of data collection or afterwards, to be at risk of FGM.

This is because FGM is not just a health condition, it is a crime. Consequently, only one of the purposes of data collection by the HSCIC is to determine prevalence and to make information and treatment available to women and girls as victims. Another is to share the information with other governmental authorities, so that they can investigate whether these same women’s daughters are at risk of becoming the next generation’s victims, thereby turning the adult victim into a potential perpetrator or accessory to the same crime she herself was the victim of.

On top of this, even if she does not give her consent to do so, the victim is required to provide health professionals information about herself. On page 48 (of 53 pages), the regulations say: “It is not intended that patient-identifiable data will be shared with other parties. Such activity would require explicit patient consent…. It is intended, however, that the FGM information collected and disseminated using the Clinical Audit Platform will support the publication of patient-anonymised Official Statistics.”

Yet the next paragraph on the same page says: “As the FGM Enhanced Dataset will be underpinned as a result of Department of Health directions, this will require no explicit patient consent to be sought in order to collect this information and subsequently share this with HSCIC. However, each patient where FGM information has been identified by a healthcare organisation, must inform each woman or girl as to how and what will happen to the information being recorded, and further to this, where an objection to this is made each organisation must ensure it understands the fair processing procedures outlining where a woman can contact to make an objection to this information being recorded and sent to the HSCIC.” A long set of instructions on how to handle this follows.

Moreover, it also says that the woman can only register a complaint after the fact, that is, after the data have been recorded, but her complaint will not stop her data being retained and used by the HSCIC. It seems that the Health and Social Care Act 2012 allows health professionals to violate women’s informed consent in this way. This is certainly a violation of privacy and confidentiality that must be challenged.

Pregnant women generally come under a lot of scrutiny. Pregnant women with FGM come under particular scrutiny. The HSCIC requirements say that all existing maternity discharge information sent to GPs and health visitors MUST [their emphasis] also include all relevant FGM information, where appropriate, when FGM or family history of FGM have been identified prior to, during or after the birth of a baby. This is another instance in which personal data will be shared.

The pregnancy-related FGM information to be specifically recorded includes: FGM type, confirmation that a de-infibulation procedure took place to facilitate the delivery of a birth, where applicable, and confirmation that no external female genitalia abnormalities were found in girl babies at birth following existing neonatal examinations, confirmation if an interpreter was required during the episode of care, and confirmation that the newborn baby’s healthcare record has been updated to reflect that FGM had been identified in the mother. Additionally, as part of the initial antenatal assessment, every woman MUST [their emphasis] be asked if they have undergone FGM. Where a Health Visitor identifies that there are sisters of a girl with FGM, it is the responsibility of the Health Visitor to inform the GP (pages 12-13). And this is not even the half of it.

The regulations say three times, (pages 8, 11 and 21), that clinical examinations of the woman’s genitalia need only be undertaken “as part of a usual, routine or requested provision of care – there is no intention for every clinician to automatically undertake a clinical examination in order to record the type of FGM”. Thus, there is a presumption that women not requiring examination of their genitalia will “self-report” when asked if they have had FGM. But will all clinicians note this caveat or will we begin to hear stories of women’s genitals being examined no matter what they have attended for?

From the point of view of the woman sitting in front of the doctor or midwife, one might easily imagine that any need for help she may feel would be compromised by the fear ‒ especially if she is pregnant, has girl children under age 18 or has just delivered a girl child ‒ of being investigated, prosecuted and criminalised by the criminal justice system, along with other family members. Will she give all the information asked of her? Will she come back for another appointment?

And what about the health professionals who have to ask women these questions and record their answers in the relevant database? There is an ethical requirement on health professionals not to allow the violation of patient privacy and not to break medical confidentiality, particularly if it is against the woman’s expressed wishes. Yet the HSCIC requirements require just that from health professionals, who must submit the data quarterly and in annual reports.

What if clinicians refuse to collect some or all of the data? The regulations do not say what will happen if they fail to return this information fully and in the required detail, except that “the submission will be rejected”. Will they be required to get the woman back in to obtain more details? Will they be disciplined, as they would if they do not report a suspicion or actual case of FGM in an under-18-year-old? Clinicians already worry about the consequences of not identifying ‒ or mis-managing ‒ women with FGM, and now they also fear prosecution, after what one of their colleagues suffered, in spite of being acquitted.

This is not the first time the Government has attempted to ‘share’ identifiable information from clinical records without patients’ permission. In 2013, they announced they were going to extract ‘identifiable data’ from GP records to be used ‘routinely’ for research by the health service and private entities (which might have included pharmaceutical companies), unless patients asked to opt out. In this instance, there was a public furore and after 700,000 people had opted out, the scheme was ‘indefinitely delayed’. This year, they attempted to do so again on the grounds that they needed to intervene in regard to the care of ‘high cost individuals’.

This time, however, women with FGM are not being given any choices in the matter. It is highly unlikely that they will refuse to provide their personal data in large numbers, as people with HIV did previously, as they do not have the social or political clout, or the public support, to challenge the Government or their health care providers.

Health professionals, on the other hand, do have that power, and just as GPs supported the 700,000 patients’ refusal to allow their data to be shared for unspecified research, so health professionals should stand up in this instance, and refuse to populate the HSCIC database with identifying details about the women involved.

At the end of February 2015, the government reported that 2,603 women and girls who had attended the NHS in the previous six months for health care of some kind had been recorded as having had FGM. Of these, only 44 were under the age of 18. Is it possible to extrapolate from these figures what the estimated prevalence might actually be? Probably it will take a much longer time to accomplish that, depending on how long it takes before the whole population of women and girls with FGM has attended for health care of some kind. Will prosecutions arise from the analysis of those data? Meanwhile, no proper epidemiological study has yet been considered, let alone launched.

Conclusion

I continue to believe, as I did at the FGM trial in January 2015, that this issue is being used politically by people in power, to gain credibility as champions of women only because they can present them as victims of their own culture. Furthermore, when, in reporting the government’s figures, the Guardian quotes Equality Now as saying “this is only the tip of the iceberg”, we can be pretty certain that it is the shock-horror value of FGM that is holding sway here, not concern for the women who have experienced it.

Although the situation is complicated by the criminal aspects of the issues involved, the government clearly needs a rethink ‒ epidemiological data, data for the provision of health care, and information leading to criminal investigation and prosecution should not be conflated in this way.

This blog was written for and appears also on Shifting Sands.

Acquittals in the FGM case in London: justice was done and was seen to be done, but what now?

10/02/2015 Comments Off on Acquittals in the FGM case in London: justice was done and was seen to be done, but what now?

Marge Berer – Editor, Reproductive Health Matters

10th February 2015

This was a case that should never have been allowed to happen. While female genital mutilation (FGM) is a harmful practice and needs to stop, the UK government, politicians from David Cameron on down, and especially the Crown Prosecution Service (CPS), the Director of Public Prosecutions Alison Saunders, the police and the General Medical Council all need to take a giant step backwards and reconsider their position.

The CPS were desperate to find a case with enough evidence that could end in a conviction; the political pressure on them was enormous. By their own admission, however, they spent several years having great difficulty finding a suitable case with enough evidence. They found a case, all right. But on 4 February 2015 at Southwark Crown Court, they had mud on their faces, because the case they had chosen hadn’t got a chance of succeeding, even if they won’t admit it.

It is hard to imagine how women with FGM, in whose name this case was pursued, were in the least helped by it. I sat in the courtroom listening to what was said for over two weeks. I believe it is crucial to share the details with those who weren’t there, to ensure that no one walks away from this thinking ‒ even for a second ‒ that a conviction would have been justified. Everything I report here was given in evidence in court.

The history: an emergency delivery
An exemplary registrar (Dr D) was called into the labour ward of the Whittington Hospital on 24 November 2012, a busy Saturday morning, to deal with an unbooked emergency delivery. It was the woman’s first baby (the court called her AB). She was 9 cm dilated upon arrival, the umbilical cord was wrapped around the baby’s neck and his heartbeat was falling rapidly. An emergency, instrumental delivery was required. The midwife called for a doctor, and Dr D and a junior doctor came in. AB had to be catheterised to empty her bladder. Neither the junior doctor not Dr D were able to access her urethra. AB had had female genital mutilation (FGM) aged 6 in her home country. She had come to the UK as a refugee and been granted asylum. She married in 2010. However, she had difficulty having sex because of the FGM, as the opening to her vagina was too small to penetrate. She went to her GP for help, and was referred to a specialist FGM surgeon, who deinfibulated her in 2011. She healed without problems, and was then able to have sex without difficulty, and got pregnant not long afterwards. However, it seems that during the healing process, she must have developed some scar tissue on her labia that became a problem during her delivery.

With the baby’s head coming down, Dr D and the junior doctor examined AB and discovered that she had previously had FGM. It was later agreed in court with expert witnesses that scar tissue from the deinfibulation was covering her urethra. To open it, Dr D made an incision of 1.5-2cm, which exposed the urethra, and he successfully emptied her bladder. Because of the size of the baby’s head, an episiotomy was also done. Dr D tried forceps first, which didn’t succeed, and then used a suction cap. The baby was born safe and sound. Everyone agreed that Dr D had saved his life. The episiotomy was bleeding quite a lot and was stitched by the junior doctor under Dr D’s supervision. It was her first perineal repair and took about 20 minutes. She was informed she was needed elsewhere and left. As the scar tissue was also bleeding, even though not very much, he did one figure-8 stitch at the apex of the incision, and the bleeding stopped. He then left to do an emergency c-section.

That one stitch − clinically justified, according to several senior physicians’ expert testimony − became a central focus of the case: Dr D was accused of reinfibulating AB, which is illegal.

Dr D had never seen the genitals of a woman with FGM before. He had never received any training or information on how to deal with FGM at a delivery, let alone an emergency delivery. He had only been at the hospital for about a month. He had come to the UK as a child from a country in which FGM is not practised. Although AB comes from a culture that widely practises FGM, she wanted her labia to be opened surgically in 2011 ‒ to have intercourse and children. Why would she want to be closed up again a year later? There was no evidence that she did. She resumed sexual relations after she healed from the first delivery and had a second baby in 2013 ‒ with no incisions and only a small perineal tear.

While Dr D was doing the c-section, he thought about the stitch he had made in AB. He had no doubts it was clinically necessary, but he wasn’t sure it had been the best stitch to use in the circumstances. After completing the c-section, he sought out his consultant and asked for her views. She confirmed that a stitch was necessary to stop the bleeding, but that she would personally have used a different stitch to ensure that the scar tissue would not reseal. However, she decided that it would be humiliating for AB to be approached by her on the post-natal ward to be examined, and she advised Dr D to let it be. Expert witnesses confirmed that Dr D behaved properly in talking to her after the fact, rather than delaying completing his care of AB to seek advice.

Midwife J did not see AB antenatally nor during the delivery. She was sent to AB’s home six days after AB had left the hospital, to examine the alleged reinfibulation. She gave evidence that she examined AB on her bed (a soft surface and without the aid of the sort of bright lamp that would normally be used to examine a woman with FGM), and she thought AB’s labia were almost completely closed. In contrast, AB described her own genitals at the time as swollen and sore, but not closed. Midwife J did not mention seeing any swelling herself, but because the notes in AB’s green book had been “lost” (torn out, in fact), she was working from memory. Who should be believed if not the “victim”, however? Surely, having her labia stitched together again would have been the last thing AB wanted − she had been “opened” in 2011 by her own choice and considers herself still open today.

The prosecution’s case
Having no idea of what was to come, Dr D was promoted by the hospital in April 2013 to senior registrar. Yet someone must have reported the “incident” to the Trust, because Dr D was unexpectedly subjected to an investigation − and then someone brought the police in. Who? We weren’t told. However, it was public knowledge that the Crown Prosecution Service was looking for cases, and the issue of FGM was all over the news by 2013. The police investigation led to charges in 2014, which led to the trial − two years and two months after the delivery of AB’s first baby.

In the interim, by order of the General Medical Council, who seem to work from the assumption that you are guilty until proven innocent, and then may subject you to their own brand of investigation even if you are proven innocent in court, Dr D was not able to complete his training or work as a doctor for two years. He has, however, thanks to the support of senior hospital staff, participated in research on urogynaecological problems in older women, and he received glowing professional and personal character references from senior medical experts who were witnesses for the defence in court. These witnesses confirmed in court that even though Dr D had had no experience of FGM, he behaved properly in talking to the consultant after the fact, rather than delaying completing his care of AB to seek advice. The prosecution, on the other hand, tried to make it look as if Dr D had behaved wrongly, irresponsibly, ignorantly ‒ for not knowing about FGM, for not having read the hospital’s policy and guidance on the subject, for not knowing which stitch was best to make, and for not interrupting his care of AB to find the consultant and ask for advice before he acted to stop the bleeding.

The prosecution’s case rested on evidence from several midwives and the junior doctor, which was inconsistent and full of gaps due to their witnesses not being able to remember a lot of what happened. With the absence of the green book notes, the lack of memory of details on the midwives’ parts was understandable; after all, they see hundreds of pregnant women every year and can’t possibly keep all the details in their heads. But that made the prosecution’s case incredibly weak.

Creating case law and a legal precedent
The defence requested more than once that the judge dismiss the case without the jury having to deliberate. Alison Saunders, the DPP, was quoted in the Guardian (6 February 2015) as implying that his decision not to do so meant there had been a strong case to answer. I disagree. The judge did decline, but the closing arguments and his instruction to the jury of the legal questions they had to answer to reach a verdict, based on the evidence, made it clear beyond any doubt how weak the evidence was. I believe he recognised, wisely, that had he dismissed the charges without going to the very end, the verdict and the legal precedent set would have been far less powerful in regard to future cases.

Given that it was the first criminal trial on FGM in the UK, he had to be sure that justice was done ‒ and seen to be done. And it was.

One of the most complicated aspects of this trial was that the law against FGM itself was being tested for the first time. In my opinion, the law was found sorely wanting, and more needs to be done to prevent weak cases from being brought against innocent people again, and particularly innocent medical professionals. A courtroom is not the best place to debate the rights and wrongs of complex clinical treatment. As it happened, both defence barristers and the judge dealt with the evidence brilliantly, so it should have been no surprise that the jury took less than half an hour to reach a “not guilty” verdict.

But what would have happened if Dr D had been found guilty? In deciding to bring this particular case, as opposed to bringing a case against someone who had actually done an infibulation, particularly on a child, I have to ask whether DPP Alison Saunders lost sight of the fact that the criminal law against FGM expressly mentions the importance of not creating barriers that would prevent necessary surgery, including during labour and delivery, which are specifically mentioned in the law in this regard. Yet the creation of barriers was likely to have been one of the main consequences of this trial had Dr D been found guilty.

Why was it these two men who were on trial?
In my opinion, it is not an accident that the first two people in the UK to be tried for FGM were people of colour and immigrants from Asia and Africa, albeit the doctor was educated, middle class and a health professional.

It is mainly African and to a lesser extent Asian women in the UK who have had FGM themselves. As activists in the cause of stopping FGM, they and others have been campaigning with passion, commitment, integrity and the best of intentions to have FGM recognised as a harmful practice ‒ here, as elsewhere. Nonetheless, I believe this issue has been used politically by people in power, particularly senior Tories, who are seeking to gain credibility as champions of women but only because they can present them as victims of their own cultures.

I am concerned that anti-immigrant politics is their motivation, and is why FGM is in the headlines 40 years after campaigns against the practice first began. Bona fide doctors and their patients, and their patients’ partners and families − most from Africa or Asia − are being demonised, investigated and prosecuted not only for the “crime” of FGM but also the “crime” of sex selective abortion. The connection is visible in the Serious Crime bill currently before Parliament, where all these “crimes” are clustered together to be further criminalised. Pick up any newspaper, any report from Parliament, any statement by a vote-seeking politician or the Director of Public Prosecutions, to see words such as “evil”, “abhorrent” and “barbaric” applied to the practices of people of colour, who are implicated for having brought them to these shores as immigrants.

The responsibility of the hospital
No one suggested putting the hospital on trial, though it may yet come to that. It might easily be said that Dr D was a scapegoat for the hospital’s many failings in this case, and Dr D’s barrister and the judge were articulate about this point on the last day of the trial. AB had had three antenatal visits and had acknowledged having had FGM as a child at the first visit (where she also said clearly that she had been “opened”). Yet AB was not referred to a specialist FGM midwife, as she should have been, which would have avoided everything that happened subsequently. No one ensured that she had an interpreter at any of her antenatal or post-natal visits, and there was no time to find an interpreter during the delivery. Nor did she have a birthing plan. She arrived at the hospital at the last minute, an ambulance having refused to take her there when called several hours earlier. So it was convenient to focus only on Dr D.

However, it would be as much of a mistake now to lay blame on the hospital and the midwives as it was to lay blame on Dr D. Clinicians make mistakes, things are missed out in their training. In an NHS starved of cash by a government trying to bring the whole system to its knees (and also trying to close this particular hospital), they would have little spare time to find and digest the endless policy and guidance documents that now exist in the middle of seeing patients, let alone while handling emergencies, as happened in this case.

Turning a clinical judgement call into a criminal act: the consequences for medical professionals
Maternal deaths are rare in Britain, and one of the most important reasons why has been the historic role of confidential enquiries into every maternal death. The purpose of those enquiries is neither to punish nor to identify who did something wrong, but to identify, analyse and learn from what happened, including any mistakes made and how they could have been avoided or addressed differently. Because Dr D and almost all the witnesses in this trial were medical people, something akin to such an enquiry took place − in the Crown Court. But it was not confidential, it was not anonymous, and it was wholly intended to blame and to punish. In my opinion, this is the crux of the injustice of this case, and I believe it would be a serious error on the part of the medical profession to sit back and allow what happened there to happen again.

I hope it is clear that the legal issues in this case as regards Dr D were in fact clinical ones, and I hope from my description of the evidence that it is clear the law had not been broken. The law against FGM says that FGM, including infibulation (or reinfibulation), is illegal unless it is done on the grounds of the woman’s health and/or in relation to labour and birth. The case against Dr D rose and fell on the question of whether the single suture he did was necessary for AB’s health and was done in relation to labour and birth ‒ or whether it was clinically unnecessary and intended to reinfibulate her.

The violation of AB’s privacy and bodily integrity
I believe this prosecution was a gross violation of the privacy of a woman who had had FGM as a child, which was done in the name of protecting her. Not stating her name and not bringing her into court to give evidence were to protect her privacy. Her privacy was actually violated, however, because her most “private parts” were the main subject of attention throughout the trial, where she was talked about as if she were a piece of meat being dissected, with an unrelenting focus on the most minute aspects of her genitalia. In the end, although this might have been necessary, it almost felt like voyeurism.

Now what?
The intended outcome of this trial was to open a door to further prosecutions, and indeed a new one was announced on 6 February. The CPS and the police are apparently not stopping to reconsider their position, nor apparently are FGM activists. I hope against hope that the medical profession does. The conviction of Dr D would have threatened the entire medical community, who are increasingly being subjected to criticism, opprobrium ‒ and the threat of criminal sanctions − by demagogic politicians, aided by sting operations against doctors carried out by media such as the Daily Telegraph. Several years ago, the Telegraph succeeded in demonising three South Asian doctors over their alleged willingness to authorise fictitious abortions on the grounds of sex selection. None of the doctors was criminally prosecuted by the DPP, who decided it was not in the public interest, but abortion providers have felt threatened, which was in fact always the intention.

I believe an analysis of the wording of the 2003 law against FGM is needed and would reveal major flaws. I believe this case raises questions about whether there should be a criminal law against FGM at all, and if so, what it should be covering. So if someone should be criminalised, who should it be? Do we really want to put grandparents and mothers and aunties in jail? Do we really want small children to be picked up by the police at the airport and taken into care? And little girls’ genitals examined in school? Should everyone getting into an airplane be treated as a suspected FGM criminal, in addition to being seen as a potential terrorist? The conclusion of most of the experts on this issue internationally has been that criminalisation is not the answer. These are questions I plan to take up next.

Lastly, and I think it cannot be said often enough, serious consideration is needed on the part of Parliamentarians, the Ministry of Justice, the police and the legal profession, as well as the medical profession and medical bodies like the Royal College of Obstetric and Gynaecology and especially the General Medical Council, of the negative and destructive consequences of criminalising medical care to do with women’s bodies and sexuality ‒ especially when it is linked to ethnic and racial profiling ‒ which is the bottom line of the many the ethical issues involved in this case.

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Read RHM journal papers on FGM here.

Read our previous blogs on FGM here and here

Reflections on the recent arrest in London of two people for female genital mutilation (FGM)

14/04/2014 Comments Off on Reflections on the recent arrest in London of two people for female genital mutilation (FGM)

Marge Berer, RHM Editor

Last month an obstetrician-gynaecologist and the husband of a patient at the Whittington Hospital in London were charged with the crime of female genital mutilation (FGM) because of a procedure carried out on a woman, following childbirth, who had previously experienced FGM.

This is the first prosecution for FGM in the UK since it was criminalised in 1985 and the law further amended in 2003. This fact may suggest that the Crown Prosecution Service (CPS) have been too circumspect before now in bringing a prosecution. On the other hand, do they think the current case is watertight, given that the woman will have needed some kind of repair following delivery of her baby? Part of the problem is that the lack of previous prosecutions and recent highly emotional and effective campaigning by a new generation of anti-FGM activists may have put pressure on them to bring the only case they felt had a chance of success, even one which may not stand up to legal or clinical scrutiny further down the line.

The decision to make the arrests was celebrated by veteran anti-FGM campaigner Efua Dorkenoo, who was reported on the website of the International Federation of Gynecologists and Obstetricians to have “welcomed news of the first prosecution relating to the procedure in the UK”. At the same time, an article by Sarah Ditum in the New Statesman on 24 March, asked why the first prosecution took 30 years since the law was first passed. Neither woman addressed the details of the actual case, which were unknown, nor whether it was the right place to start.

However, a letter from a group of distinguished, senior obstetrician-gynaecologists, published in the Guardian soon after the arrests, said that for pregnant women whose external genitals had been cut and stitched together, leaving only a small hole for urination and menstruation, defibulation (that is, opening the stitching), is required for them to give birth, and then after the birth, some form of repair is also required. The Crown Prosecution Service are well aware of this, and that the law exempts such repair from prosecution. Indeed, its website with legal guidance on FGM states:

“No offence is committed by a registered medical practitioner who performs a surgical operation necessary for a girl’s physical or mental health… but only if the operation is on a girl who is in any stage of labour, or has just given birth, and is for purposes connected with the labour or birth.”

While it is also “an offence under the Act for any medical professional (or anyone, for that matter) to reinfibulate or close a woman after she has been defibulated during labour for childbirth” this is diffferent from needing to repair the tissue itself. According to this, obstetricians and midwives should have nothing to fear from providing necessary treatment to a woman who has been deinfibulated before or during labour and needs some kind of suturing afterwards. The signatories to the Guardian letter believe that this prosecution, which may be about this very kind of repair, will create a climate of fear for obstetricians and tie their hands when it comes to providing necessary (and sometimes life-saving) care to women who have had FGM in the past.

This case may hinge on whether the procedure carried out was in fact necessary clinical care or actually went further, in particular, by reinfibulating the woman (i.e. sewing her labia together again, effectively reinstating the FGM, which is against the law). This uncertainty suggests that the guidelines (or their interpretation by the CPS) may not sufficiently distinguish between suturing intended to result in reinfibulation, and suturing to prevent bleeding and accelerate healing for a woman whose infibulated vulva has been cut open to make childbirth possible.

The last thing we need in the UK is to obstruct the very medical professionals who have the skills to help pregnant women with the more severe forms of FGM to have their babies safely without resorting to a caesarean section.

For answers, we must await further details of the case. In the meantime, the conflicting reactions of people who are in fact united in their concern for women’s health and their opposition to FGM itself, serve to demonstrate what a blunt instrument the law may be when dealing with a practice such as FGM.

Action against FGM has been taking place in almost every country where it is practised for up to 20-30 years now. According to a comprehensive review by UNICEF, published in 2013, signs of change – reduced prevalence, more local opposition, especially among younger people, less damaging forms of FGM being used, including symbolic pricks and nicks in the clitoris − are finally appearing in a growing number of countries. But change has been slow because girls and women who do not have FGM have simply not been marriageable. Prosecution has rarely been tried in spite of laws against FGM in many places, both in Africa and Europe, because it is believed by many that far from stopping the practice, this would only push it underground. A recent RHM article from Tanzania (1) corroborates this, reporting on the claim by several ethnic groups that FGM has had to be continued in spite of the law to prevent a new form of genital infection, not for its own sake.

Prosecution or doing nothing are not the only two options. Calling for mandatory information in sex education classes is a bit difficult when sex education itself is not mandatory, thanks to government fears of conservative criticism. How to educate ourselves more needs to be debated and discussed, and needs to reflect the knowledge and expertise of those within the communities where FGM is practised. For example, the call from activists from those communities to designate FGM as “child abuse” instead of a cultural practice was extremely powerful.

Those activists believe that prosecution is a necessary part of the package of actions to stop FGM. However, it is important that prosecutions do not push the practice further underground or inadvertently have a negative impact on those health professionals whose practice supports women with FGM to come through childbirth safely, or to restore genital health and sexual pleasure in spite of the previous mutilation (2).

Post Script (16th April 2014)

This case was heard at Westminster Magistrate’s Court on 15th April 2014 and was referred to Southwark Crown Court to be heard on the 2nd May.

(1) Ali C, Strømb A. ‘It is important to know that before, there was no lawalawa.’ Working to stop female genital mutilation in Tanzania. Reproductive Health Matters 2012; 20 (40):69-75 Doi: 10.1016/S0968-8080(12)40664-4).1.

(2) Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012 Jul 14;380(9837):134-41. doi: 10.1016/S0140-6736(12)60400-0. Epub 2012 Jun 12.

A selection of RHM articles on FGM, labial surgery and cosmetic surgery:

The limited effectiveness of legislation against female genital mutilation and the role of community beliefs in Upper East Region, Ghana

Female genital mutilation/cutting and issues of sexuality in Egypt

Views of women and men in Bobo-Dioulasso, Burkina Faso, on three forms of female genital modification

Labia reduction for non-therapeutic reasons vs. female genital mutilation: contradictions in law and practice in Britain

Genitals and ethnicity: the politics of genital modifications

Cosmetic surgery, body image and sexuality

These topics have been covered extensively in RHM. All RHM papers older than one year are now free to download from RHM-Elsevier.

FGM: condemn globally, act locally

21/12/2012 Comments Off on FGM: condemn globally, act locally

Lisa Hallgarten, Reproductive Health Matters

We should all celebrate the news that on Thursday 20th December 2012, the United Nation’s General Assembly unanimously passed a resolution banning the practice of Female Genital Mutilation (FGM). Resolutions to eliminate FGM are important. When they are passed in a global forum, they may pre-empt the claims of cultural relativism which try to prevent us talking critically across nations and cultures about FGM and other dangerous or unethical practices.

However, the process of eliminating FGM can only happen when initiatives are developed at local level and informed by the specific beliefs, practices, unmet needs and politics of the areas where it is prevalent. This is perfectly illustrated by an article in the new Reproductive Health Matters (1)  which reports on beliefs in some ethnic groups in Tanzania in which FGM is still practised, over 40 years after it was made illegal.

The article reports on findings from nine years of work combatting FGM in 45 villages  in Tanzania. FGM has, historically, been widely practiced in 12 ethnic groups living in seven of Tanzania’s 24 regions: the Gogo, the Rangi and the Sandawi of Dodoma, the Nyaturu of Singida, the Chagga of Kilimanjaro, the Waarusha of Arusha, the Luguru of Morogoro, the Maasai, the Iraqw, the Barbaig and the Hazabe of Manyara, and the Kurya of Mara region.

Until the late 1960s FGM was carried out on girls between eight and twelve years old. It was an essential part of community rituals and celebrated openly. In 1968 FGM was criminalised, but far from ending the practice, criminalisation led to FGM going underground. Most significantly it led to the development of a narrative that explains and promotes the practice and gives it a new legitimacy. The new narrative identifies FGM as both a preventive against, and cure for urinary tract and genital infections known locally as lawalawa.

Lawalawa affects young infants and children – resulting mainly from lack of clean water and poor hygiene practices – so by the 1970s it was being said that ‘circumcising babies was necessary in order to cure a mystic spell (lawalawa) placed on them by the ancestors.’  In this way FGM became increasingly removed from the public space and detached from the original ritual purpose and meaning of the practice. “It seems that (they) invented lawalawa to legitimate FGM, even though the performance had to lose some of its meaning.” The authors conclude that steps must be taken to educate people about and address the real causes of lawalawa, and also effectively to disseminate information about medical care that is available to treat infections.

This may be a very particular cultural context, but the paper has a universal message. All ritual and cultural practices are perceived by the community in which they take place as serving a purpose. Wherever it happens in the world FGM is justified in different and specific terms. This paper illustrates that fundamentally changing attitudes across the community and from within the community is the only way to move towards the elimination of FGM.

I’m all for global condemnation and local engagement.

(1) Ali C, Strømb A. ‘It is important to know that before, there was  no lawalawa.’ Working to stop female genital mutilation in Tanzania. Reproductive Health Matters 2012; 20 (40):69-75

Journal and conference announcements bombarding my email addresses: what’s an author to do?

10/06/2017 Comments Off on Journal and conference announcements bombarding my email addresses: what’s an author to do?

When open access journals first came onto the scene, I was really worried about the various ways they would change the journal publication landscape and practice. More importantly than anything else, I felt it was unfair and inequitable to charge authors to have their papers published so that I, as a reader, could get access to them free. On the other hand, I have grown to like the idea a great deal, in that I began to feel entitled to access to articles and annoyed when I couldn’t get them. And there are some journals, I have no idea how many, that waive the open access fee for a certain number of global south authors so as not to exclude them from publishing. But I remain concerned that this will only be available to a few and that all the work that was done to open the door to publication to them will be undone as more seek a waiver.

To address the threat to equity of access for global south and individual authors, the compromise we negotiated with Elsevier for RHM when I was still the editor was a decent one – articles were behind a subscription paywall for one year, and then became open access. The journal paid for publication and for subscriptions for its global south readers, who were the great majority of readers, while authors did not have to pay. This meant both that authors who could not afford the open access fees would not be discriminated against nor would they lose the opportunity to publish, while readers too got access, including those who could not or would not pay the subscription, even if it took a year. But this was an unusual deal and as far as I know, it has not been much replicated.

What I did not expect, but what has taken place to an alarming extent, is that open access has become big business. Apparently bogus journals are seeking to fleece unsuspecting authors of their money by offering to publish their work. If what comes into my inbox and my spam box is any indication, such journals have been launched by the cartload. I am being bombarded on an almost daily basis with requests to publish with one journal or another by submitting a paper. Some of these emails are addressed to me personally and mention a paper I have published previously as the source of their knowledge of me. Others are generic. Still others invite me to review a paper or attend a conference or to serve on a committee for a conference, and some try to sell me scientific equipment of one kind or another. I presume my address is being shared widely to make this happen. Apart from titles that have something to do with women’s sexual and reproductive health, or more commonly obstetrics & gynaecology, the rest, while mostly in the health and medical field, are totally inappropriate for me, as their subject is one I know nothing about. What I find most shocking, however, is that some of them are written in absolutely appalling English. Who they think they are kidding, I don’t know.

In September 2016, I began to collect these emails in a folder, planning to write a blog about them as a scam. I never got around to it until now, so they have piled up since then. They are in my inbox at both my email addresses and in the junk mailbox of both my email addresses. There are hundreds of them. I decided to list them here to show how absurd this has become, or should I say appalling. Many have written more than once, and some, when I do not reply, write again and push me to respond.

Here are several examples:

  1. Dear Dr. Marge Berer,

How are you? I hope you are healthy and happy. The Merry Christmas Grand Celebration is very keen, for the rewarding start of this special event, I need one praiseworthy manuscript. I realize that best fit manuscript is your transcript only. Hence, I feel honored to invite you for your manuscript submission and I am confident that my expectations on your works will help me to rejoice this event.

 

I hope to cheer this occasion with your legendary article.  Await your reply.

Best Regards, B…G… Journal of Gynecology and Women’s Health (JGWH) 14/12/16

2. Distinguished Dr. Marge Berer,

I recently came across your work titled “The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?”. As far as I understood, it has been written at the -. Following this, the editorial team of Omniscriptum Publishing Group reaches out to you with a free of charge publishing offer.  Briefly speaking, we invite you to publish this work as an independent printed book which will be listed by major libraries and online bookstores. Could you please let us know your thoughts regarding this opportunity? If you would like we can discuss the next steps. I would be happy to answer any questions. 3.

3. …It would be appreciated, if you submit on or before 26thMarch, 2017. If you submit, we will process and publish within 21 days followed by rapid peer review process…

4. Dear Colleague,

Happy International Women’s Day. It’s always been a pleasure and privilege to work with so many female researchers. On the occasion of Women’s Day, Clinical Obstetrics, Gynecology and Reproductive Medicine (COGRM) is providing special concession on the publication fee until 24th March, 2017. Articles submitted before the mentioned date will be published (if accepted after peer-review process) with processing fee of USD 300 instead of USD 890. COGRM follows rapid peer review from the experts throughout the world, which helps us to publish an article within 7-10 days of submission.

***

Here is a list of all the supposed journals and conferences I have heard from so far (with the number of times an email has been received, e.g. x 4):

Reproductive Immunology x 4

SM Tropical Medicine Journal

SM Journal of Community Medicine

Annals of Community Medicine and Practice

GNWH Nursinghealthcare

Journal of Neonatal Biology

Austin Journal of Obstetrics and Gynecology x 2

Journal of Gynecology and Obstetrics x 2

Global Journal of Medical Research

NWH Nursinghealthcare

Trauma and Emergency Care

SM Group

Journal of Forensic Psychology

Global Women’s Health x 2

HSOA Journal of Reproductive Medicine, Gynaecology & Obstetrics

Pediatric Nursing

Dermatology 2017

General Practice 2016

Journal of Family Medicine

Journal of Psychology & Psychotherapy

Andrology & Gynecology: Current Research

Sexual Medicine: Annals of Clinical Case Reports

2016 5th EEM International Conference on Hospitality, Leisure, Sport, Tourism & Education

Family Nursing 2017

Breast Cancer 2017

Journal of Gynecology & Neonatal Biology

Science can be Beautiful

Journal of Nursing & Women’s Healthcare

Protein Lab

Reproductive Immunology: Open Access x 3

Editorial@current-whr-journals

Hospital Management 2016

Proteo-Genix

Journal of Women’s Health, Issues and Care x 2

Journal of Community and Public Health Nursing x 2

Mental Health 2017 x 2

Nursing Education 2017

Apps Store Now India Development Company

Journal of Modern Physics

Pharmacy Express

Family Practice Special Issue

WordPress Magento

Mathews Journal of Gynecology & Obstetrics x 2

Applied Psychology 2017

Call for Participation to the 2nd International Conference on Medicine and Natural Sciences, Albania

5th International Congress of Gynaecology and Obstetrics

Translational Reproductive Biology And Clinical Reproductive Endocrinology

Journal of Gynecology and Women’s Health

International Journal of Reproductive BioMedicine

Journal of Environmental Protection x 2

Forensic Science and Criminology x 2

Journal of Pregnancy and Child Health x 3

Journal of Gynecology and Women’s Health x 5

EC Gynaecology Journal x 2

Journal of Sexual and Reproductive Medicine

Journal of Reproduction and Infertility

Functional Food Centre (repeatedly)

Health x 2

Special Issue: “Current Research on Safety and Environment”/ The selected papers will be submitted to the Elsevier: “Journal of Chemical Health and Safety” x 6

Journal of Pregnancy & Child Health x 2

Acta Psychopathologica x 2

Journal of Fertilization: In Vitro

Obstetrics & Gynecology International Journal x 3

Gynecology and Womens Health Research x 3

Midwifery Congress 2017 x 2

Pregnancy & Child Health

Journal of Traumatic Stress Disorders & Treatment x 3

Diana – ProteoGenix

Reproductive Medicine 2017 x 4

Public Health 2017

Internal Medicine Review

Gynecology and Obstetrics Research – Open Journal x 2

Trauma and Critical Care 2017

Open Access Journal of Urology & Nephrology (OAJUN)

25th World Congress on Controversies in Obstetrics, Gynecology & Infertility (COGI)

International Conference on Obesity and Diabetes

Reproductive System & Sexual Disorders International Journal

The 4th International Congress of Forensics & Police Tech Expo-2017

Journal of Women’s Healthcare and Wellness

Women’s Health & Gynecology

Women’s Health Bulletin

Primary Healthcare

Women’s Health – Open Journal

Global Biotechnology Congress 2017

Austin Public Health

JSM Sexual Medicine

EC Gynaecology x 3

Global Conference on Nursing and Healthcare

Annals of Clinical Case Reports

Scientia Ricerca

SOJ Gynecology, Obstetrics & Women’s Health

services@sciedunews.net

Thinkers Hub Conferences

Journal of Reproductive Endocrinology & Infertility x 3

Surgical Nursing

Peer Reviewed Academia Sciences

Reproduction

The Scientific Pages of Anthropology

Nursing Conference

Journal of Psychology & Psychotherapy

Journal of Drug Abuse

Pregnancy & Child Health Journal x 2

Forensic Science-2017 x 3

Sociology and Anthropology

World Nursing and Healthcare conference

Clinical Obstetrics, Gynecology and Reproductive Medicine

Reproductive Immunology: Open Access

Innovate Nursing 2017

Journal of Women’s Health and Gynecology x 6

Journal of Community and Public Health Nursing

Plastic Surgery: Clinics in Surgery

Journal of AIDS & Clinical Research x 2

Drug Discovery & Therapy World Congress 2017

Nursing 2017

Journal of Addiction Research & Therapy

Juniper Online Journal of Public Health

Journal of Forensic Toxicology & Pharmacology

Sanaz – ProteoGenix

Protein Profiling

NEW Cyagen and Vectorbuilder Newsletter x 2

Reproductive Medicine_Com

HIV Scientific meeting

Agriculture & Food, 5th International Conference 2017 x 2

Reproductive System & Sexual Disorders International Journal x 4

Journal of General Practice

Breast Pathology 2017 x 2

Women’s Health (Sage) x 3

Journal of Nursing

World Conference on Science, Technology & Medicine x 2

Surgical Nursing 2017

Nurse Practitioner 2017

Stockholm Nursing Conference

Healthcare Asiapacific 2017

Open Access Journal of Urology & Nephrology x 2

Maternity Complications and Women’s Health Journal x 3

Archives of Medicine x 2

Journal of Family Medicine & Community Health x 2

Embryology 2017

Annals of Men’s Health and Wellness x 2

Journal of Women’s Health Care

Andrology and Gynecology Reports

Nutritionists

Andrology-Open Access

Pharma-2017 x 2

Dr. Sanchita Roy (editor09@sdjournals.net)

Dr. Sarmila Das (editor02@sdjournals.net)

AIDS Clinical Research & STDs

Journal of Forensic Psychology x 2

Annual Summit on Sexual & Reproductive Health, Oncology & Medicine x 2

Dr. Kateryna Bielka, M.D. kateryna.bielka@journals.ke-i.org x 2

Acta Psychopathologica

International Journal of Surgery Research and Practice

Journal of Psychology and Brain Studies

Social Sciences 2017

Pediatrics-2017

Forensic Research 2017

Family Medicine 2017 x 2

Journal of Psychiatry

Obesity Summit

Ms Aloka Jana (editor04@ikkppress.org)

Journal of Medical Implants and Surgery

Journal of Research and Development

Neonatal Nursing 2017

Journal of Forensic Research

International Conference on Women’s Health, Gynecology & Obstetrics x 2

Midwifery Congress

Journal of Basic and Clinical Reproductive Scienc

Women’s Health Research

Lipids 2017

Sexual and Reproductive Health 2017

Euro Primary Care 2017 x 2

Journal of Gynecology and Women’s Health

Generic-Biosimilars 2017

Austin Journal of Civil & Legal Sciences

Avid Science

Medical & Clinical Reviews

Euro Midwifery-2017 x 3

Journal of Surgery

Public Health Congress

Forensic Congress 2017

Journal of Endocrinology and Diabetes

Insights in Reproductive Medicine

Gynecology 2017

Journal of Sexual & Reproductive Medicine

Journal IJCAR

InTechOpen invites you to write a chapter for a new Open Access book project “Family Planning,” edited by Dr. Zouhair O. Amarin.

Journal of Basic and Clinical Reproductive Science

GB HealthWatch

Journal of Genital System & Disorders

Clinical Practice (Therapy)

Advances in Journalism and Communication

Journal of Family Medicine and Disease Prevention

Oral Presentations for Scientists

****

Whew!!! I have no idea what to do about this, but it feels like a permanent invasion of my territory and a form of e-trash being dumped on me. I have no idea who to complain to, nor how to stop them coming but will share this blog with the European Association of Science Editors to see if they have some advice or want to let others know this is happening.

Disappointing decision on HPV vaccination for boys (UK)

12/11/2014 Comments Off on Disappointing decision on HPV vaccination for boys (UK)

Marge Berer, RHM Editor

The Joint Committee on Vaccination and Immunisation (JCVI) advises the UK Department of Health on its vaccination programme and has been considering the question of whether to vaccinate boys against the Human Papillomavirus (HPV). Today it published its interim recommendations, which do not address a universal programme of vaccination for boys as well as girls.

Background

The UK currently has a programme of HPV vaccination for girls to prevent cervical cancer which is most commonly caused by infection with HPV.  Because it is important to vaccinate before they become sexually active and come into contact with the virus, the vaccination is offered to all girls aged 12-13 years  old.

In addition to cervical cancer, HPV is a factor in many other cancers including anal cancer, penile cancer, mouth cancer and oropharyngeal cancer, all of which affect men as well as women. People living with HIV are at higher risk of all these cancers. Under the current regime, there is no HPV vaccination programme for boys. Assuming men in the UK only have sex with women who have been vaccinated, they should be protected from HPV. However it is safe to assume that men in the UK may also have sex with:

  • women who missed out on vaccination because of their age (vaccination for girls was only introduced in 2008) or parental withdrawal from the scheme,
  • women from countries where there is no vaccination programme,
  • and other men

Recognising the range and seriousness of diseases that can be prevented, the Australian government introduced HPV vaccination for teenage boys in 2013. HPV action, a UK coalition of 35 health-related organisations, has been lobbying for the same ‘gender-neutral’ vaccination in the UK.

The interim decision of the JCVI, published today, is to advise that “a programme for the vaccination of MSM aged 16 to 40 years of age should be implemented in GUM and HIV clinics in the UK using the quadrivalent HPV vaccine, subject to the programme being provided at a cost-effective price”. This suggestion is shortsighted beyond comprehension.

The whole point of talking about the sexual health needs of MSM (men who have sex with men) as opposed to homosexual or gay men in the first place is because men who have sex with men don’t all only ever have sex with other men. As both men and boys, they also sometimes have sex with women. Given that universal vaccination of girls to prevent human papillomavirus (HPV) and genital warts has been accepted as a public health priority globally, surely universal vaccination of boys is equally a priority – since boys and men are at risk of an equally serious range of cancers and other diseases from HPV (especially if they have HIV), and they have genital warts as often as girls and women.

How could anyone have suggested, let alone seriously considered, vaccinating only MSM in the male population in the first place. What did they expect to do as regards adolescent boys – walk into schools and say “Which boys are having sex with other boys here? Raise your hands − and please come to the school clinic now.”??  Or even more absurd, how can they advise waiting until a boy or man attends an STI clinic in order to recognise they are at risk of HPV, and offer them a vaccination after the fact, when it may be too late! It also seems transgender people aren’t on the radar at all, in spite of findings from 15 countries in the Lancet Infectious Diseases in 20131 that 19% of transgender women have HIV(1), and transgender men also have a high HIV prevalence, which puts them at increased risk of HPV infection and HPV-related diseases.

Moreover, studies have shown that a female-specific vaccination approach would be only 60–75% as efficient at reducing HPV prevalence in women as a gender-neutral vaccination(2).

The only sensible policy is universal vaccination, from the same age as girls of 13, and with the same catch-up provisions for those who are older.

References

(1) Baral SD et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis, 13: 214-22, 2013.

(2) Kubba T. Human papillomavirus vaccination in the UK: what about boys? RHM 16(32) 97-103

All RHM papers and research round ups on HPV are available to download here

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