Week 4

Question 1

Terminology

Answer 1

FGM- violation human rights, clear distraction from male circumcision, emphasis harmfulness of act
Female circumcision- used in FGM affected countries, WHO states should be avoided felt to be misleading suggests similarity to male circumcision
Femal gential cutting, excision, genital cutting

Question 2

What is female genital mutilation FGM

Answer 2

Female genitalia deliberately cut/injured without medical reason
4 main types: 7 further subtypes
Amount genital tissues cut increases type 1-3
Type 1- clitoris removed
Type 2- clitoris and labia minora removed
Type 3- infibulation most extensive most stitched up
Type 4- burning, pricking, piercing
Type 3 may require surgical intervention deinfibulation

Question 3

FGM type 1

Answer 3

Clitoridectomy- partial or total removal of the clitoris and or the prepuce (clitoral hood)

Question 4

FGM type 2

Answer 4

Excision- partial or total removal of the clitoris and the labia minora with or without excision of the labia majora

Question 5

FGM type 3

Answer 5

Infibulation- narrowing (stitching) of the vaginal orifice with creation of a covering seal by cutting and apositioning the labia minor and/or the labia majora with or without excision of the clitoris

Question 6

FGM type 4

Answer 6

All other harmful procedures to female genitalia for non medical purposes for example: stretching , pricking, burning, piercing, incising, scraping, cauterisation, introduction of corrosive herbs

Question 7

FGM is a global issue

Answer 7

200 million women and girls- 5% of the global female population
1 in 10 likely to have experienced type 3
4.3 million women and girls at risk of FGM in 2023
68 million at risk by 2030
1.4 billion dollars global annual health care cost: £100 million UK annual NHS costs
Predominantly in African countries but practice exists in over 20 other countries across Eastern Europe, Latin America, the Middle East and south Eastern Asia, FGM diaspora live across the world

Question 8

FGM stats in England

Answer 8

Increased identified amongst migrants from FGM affected communities
80% identified in maternity services
2011 estimates 137000 women and girls living with consequences, evidence survivors in almost all local authorities
FGMED 2015-2019 40030 healthcare attendances related to FGM, 20470 previously unidentified cases

Question 9

Impacts of FGM

Answer 9

No health benefits
Immediate life long consequences, health, obstetrics, sexual frequency, psychological, economic impacts
Risk adverse outcomes increases with more extensive FGM
9 in 10 type 3 survivors report complications
Loss of life and decrease in QOL
Evidence impact on men

Question 10

Immediate impacts of FGM

Answer 10

Haemorrhage
Pain and shock
Urinary retention
Infections
Trauma adjacent tissues
Transmission HIV, Hep B
Bone fractures
Death

Question 11

Shorter term impacts of FGM

Answer 11

Delayed wound healing

Question 12

Longer term impacts

Answer 12

Recurrent UTI
Haematocolpus
Dysuria
Dyspareunia
Morbidity and mortality in childbirth and pregnancy
PID/infertility
PTSD
Psychosexual and social trauma
Death

Question 13

How is FGM performed

Answer 13

“Circumsisers” variety of instruments (razors, scissors, knives, broken glass, sharpened stones) no anaesthetic

Question 14

Why is FGM practised

Answer 14

Considered necessary part of raising girl- prepare adulthood and marriage
Psychosexual
Socioeconomic
Hygiene, aesthetics, femininity
Marriageability
Religion

Question 15

FGM safeguarding risk assessments

Answer 15

A child/women may be at risk of FGM:
-girls mother has undergone FGM
-other female family members have had FGM
-father/partner comes from an FGM affected community
-parents say that they or a relative will be taking the girl abroad for a prolonged period
-girl withdrawn from PSHE lessons or from learning about FGM
-woman/family believe FGM is important to their culture/religious identity
A child/woman might have undergone FGM:
-girl/woman asks for help
-girl/woman tells professionals they have undergone FGM
-parent/family member disclosed that girl has undergone FGM
-difficulty walking, sitting or standing or looks uncomfortable (especially if new presentation)
-girl/woman spends much longer using the toilet due to difficulties urinating
-presents with frequent urinary, menstrual or stomach issues
-prolonged absences from school/work
-reluctant to undergo medical examinations

Question 16

HCP response to FGM

Answer 16

Provision of sensitive services:
-survivors of FGM are most likely to be identified through maternity services but may present throughout NHS
-all pregnant women should be asked about FGM
-health professionals must be able to sensitively enquire about FGM
-once FGM is identified they should respond to the complex medical needs and refer appropriately
Safeguarding girls at risk:
-health professionals have a legal duty to protect girls from FGM
-if a health professional identifies FGM, this must be documented in the medical notes
-if a child has had or is thought to be at risk of FGM a referral must be made to social services
-mandatory duty to report

Question 17

FGM legalisation

Answer 17

In place in at least 68 countries
Including UK, Australia, republic Ireland, USA, South Africa and Sweden
FGM illegal in 23/28 of the most FGM prevalent countries in Africa

Question 18

FGM and the law

Answer 18

FGM has been illegal in the UK since 1985
-used to be prohibition of female circumcision act 1985 (5 years imprisonment)
-female genital mutilation acts 2003 (14 years imprisonment)
And serious crime act 2015

Question 19

Combination of 2003 and 2005 FGM acts offences

Answer 19

FGM
Assisting a girl to mutilate her own genitalia
Assisting a non uk person to mutilate overseas a girls genitalia
Failing to protect a girl from risk of genital mutilation
Penalties 14 years in prison and/or fine

Question 20

Combination of 2015 and 2020 FGM acts

Answer 20

Extend extra territorial jurisdiction for FGM
Lifelong anonymity for victims of FGM
Create a new offence of failure to protect a girl from FGM
Introduce FGM protection orders
Introduce a mandatory reporting duty requiring regulated health, social and education professional to report known cases of FGM in under 18s to police
Confers on the Secretary of State a power to issue statutory guidance on FGM

Question 21

Mandatory recording and reporting (England and wales only)

Answer 21

Mandatory recording- is in regard to adult women and is a matter for health professionals such as GPs
As a result of the serious crime act 2015, mandatory reporting is required under section 5B of the FGM act 2003
- it concerns children under 18 and is a matter for all regulated professions (health, social care, education)

Question 22

Mandatory reporting ‘known’ cases

Answer 22

All regulated health, social and education professionals have to report direct to the police any child under 18 where:
-as a result of examination FGM has been visually identified
-they disclose that they have had FGM
You are not required to ‘verify’ that FGM has occurred in order for the duty to apply and a report to be made
The duty is personal. I.e the professional who identifies FGM/receives the disclosure must make the report- it cannot be transferred

Question 23

Mandatory reporting does not apply to

Answer 23

An adult woman (18+) discloses that she has had FGM
You think a girl might have had FGM but she has not disclosed and you have not seen any signs/symptoms
If you know it has already been reported by a regulated professional in your organisation
In these cases you need to follow local safeguarding procedures

Question 24

What do you need to do as a medical student

Answer 24

Not mandated to report
Discuss with whoever is responsible for your clinical placement seek advice from local safeguarding team

Question 25

Post partum legal position UK

Answer 25

No suturing to be performed that will re-infibulate
-women/their families may request this (some travel home to be reinfibulated and will present again in maternity services)
-discuss legislation, educate, inform
-treat with dignity and sensitively
Where deinfibulated, raw edges to be sutured as may heal back together
Document normal genitalia in the new born record sheet element of the delivery noted at birth and in child health book following neonatal examination
Refer to multi agency team

Question 26

Maternal death

Answer 26

The death of a women while pregnant or within 42 days of termination of pregnancy irrespective of duration and site of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes - ICD10

Question 27

Maternal mortality in the UK

Answer 27

Reduced rapidly
Instead of per 1000 its per 100000
More education, more births in hospital, no illegal abortions, complications screened, c sections, post partum care, sterilisation, antibiotics, living standards, decreased birth rate

Question 28

Direct and indirect maternal deaths

Answer 28

Direct: resulting from obstetric complications of pregnant state (pregnancy, labour, puerperium ) form interventions, omissions, incorrect treatment or from chain events resulting from any of the above
Indirect: resulting from previous existing disease or disease that developed during pregnancy and which was not the result of direct obstetric causes but which was aggravated by the physiological effects of pregnancy

Question 29

Maternal mortality rate

Answer 29

Number of direct and indirect maternal deaths per 100000 maternities

Question 30

Maternity

Answer 30

A maternity is considered to be a pregnancy that results in a livebirth at any gestation or stillbirth form 24 weeks gestation by law require notification

Question 31

Why might maternal mortality increased

Answer 31

Relative to white women maternal mortality among women from black ethnic origin backgrounds is almost 4 times higher and its almost 2 times higher among women with Asian ethnic backgrounds
Maternal mortality in women in the 20% most deprived areas in UK is more than 2 as higher as among women in more affluent areas this disparity not reducing
More half women giving birth in UK are now overweight or obese being obese doubles risk maternal mortality
Age at childbirth continues to rise in UK. Maternal mortality in women aged 40+ is around 3x greater than those aged 20-24
Many maternal deaths are from medical or mental health conditions made worse by pregnancy women with multiple adversity and multiple morbidities continue to be over represented. The main elements of multiple severe disadvantage were mental health diagnosis, substance misuse and domestic abuse

Question 32

International comparisons maternal mortality

Answer 32

In developing regions 95% deaths a
Based on maternal mortality ratio MMR- denominator is livebirths
Very high in sub Saharan Africa Lower in Australia, New Zealand, Europe high in developing countries
Developed regions- indirect causes and direct causes, Lower in haemorrhage and sepsis
Northern America increased 2000 to 2020: obesity rates, racism disparity, sub populations healthcare, more accurate data recording
In developing regions: different hygiene standards, difference access to care, less resources, standard living, education different, births at home, stigma, religion, spirituality

Question 33

Maternal morbidity

Answer 33

Major morbidities: sepsis, haemorrhage caused by same factors that cause death more commonly do so in developing world
In developing world little data collection so incidence and prevalence estimates not possible
Minor morbidities: rarely life threatening can affect QOL, adverse effects. Some can be long lasting. Backache, headache, fatigue, haemorrhoids, faecal incontinence, constipation, urinary stress incontinence, perineal pain, dyspareunia, depression
Some may be unrelated to pregnancy or birth arising because of extra demands of childcare or background morbidity