Croydon FGM Conference March 2016 - PowerPoint Presentation

Slide1

Croydon FGM Conference

March 2016

Slide2

Elaine ClancyDirector

of Quality & Governance

Slide3

End FGM: Is Europe Watching?

Slide4

Beth Kelly

FGM Project Consultant

Slide5

The Project so far…

Slide6

Progress

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Training

Slide8

#EndFGMCroydon

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Natalie Reseigh

Project Azure, Metropolitan Police Service - The reality of FGM and the police perspective

Slide10

Project Azure

The Metropolitan Police response to Female Genital Mutilation

DC Natalie Reseigh

Partnership Team

Sexual Offences, Exploitation and Child Abuse Command

This presentation contains images and details some may find distressing.

All images contained in this presentation have been retrieved via open source on the internet

Slide11

What is FGM?

"Female genital mutilation

( FGM)

comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non – medical reasons“

The World Health Organisation

Slide12

Pre Conceptions …..

I

sn't it the same as male circumcision?

“If a boy or man underwent the same degree of mutilation as a young woman undergoing the most common form of FGM, he would have the head of his penis and around a third of the shaft removed”

World Health Organisation

Isn't it cultural or religious issue?

There is not one holy book that advocates this practise.

Slide13

Type 1 FGM 

Clitoridectomy: partial or

total removal of the clitoris

(a small, sensitive and

erectile part of the female

genitals) 

 

This practice is extremely painful

and distressing, damages sexually

sensitive skin and is

an infection risk.

The Different FGM Types

Slide14

The Different FGM Types

Type 2 FGM

Excision: partial or total removal of the clitoris and the labia minora,

with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina). 

This practice is extremely painful and distressing, damages sexually sensitive skin and is an infection risk. 

Slide15

The Different FGM Types

Type 3 FGM

Infibulation:

narrowing of the vaginal opening through the creation of a covering seal.

The seal is formed by cutting and sewing over the outer, labia, with or without removal of the clitoris or inner labia. 

This practice is extremely painful and distressing, damages sexually sensitive skin and is an on-going infection risk. 

The closing over of the vagina and the urethra leaves women with a very small opening in which to pass urine and 

menstrual fluid. The opening can be so small that it needs to be cut open to be able to have sexual intercourse.

Cutting is also needed to give birth and can cause complications which harm both mother and baby.

Slide16

The Different FGM Types

Type 4 FGM

Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping, stretching and cauterising the genital area.

This covers everything else that doesn’t fall within 1, 2 and 3

Slide17

The Procedure

NO ANESTHETIC

The Instruments

-

Any crude cutting instrument such as a knife, broken glass, fingernails or razor blade will do,

or the operator may have somehow

acquired medical instruments like a scalpel, forceps or scissors.

- The instruments may be new or may have already been used for other

purposes and/or on other persons.

- Sterilization is seldom known nor performed by these traditional operators.

The Sutures

-

Regular surgical Catgut, Silk or Cotton thread.

- Domestic sewing thread.

- Vegetable or nylon fiber pre-selected by the operator.

Slide18

Health Complications

Death (Type III 10% mortality rate)

Blood Loss

Fractured bones

Infection

Shock

Post traumatic stress disorder

Urinary & menstrual obstruction, no effective outlet

Pain during intercourse

Infertility – Swollen tubes as a result of in effective outlet

Childbirth complications

Slide19

Motives and Functions

Psychosexual

–

Most often cited is the promotion of virginity and fidelity. Infibulation they believe almost guarantees monogamy because of the pain associated. Uncircumcised women are seen as highly sexualised.

Ceremonial -

opening on wedding night.

The husband sometimes forcibly performs penetration and bursts through the scar of the infibulation

Sociological

–

Practitioners see the circumcision rituals as joyful occasions that reinforce community values and ethnic boundaries, and the procedure as an essential element in raising a girl. Social integration. Safeguarding the family honour

Religious

-

Compliance with believed religious requirement. Children becoming too "western"

Aesthetics

–

Genital regarded as ugly & dirty, they believe it should be flat and dry. Its deemed masculine on a girl.

Slide20

Survivors - In their own words

The parents cut the daughters, because they fear the girls could become too westernised.  'I felt my flesh, my genitals, being cut away. I heard the sound of the dull blade sawing back and forth through my skin.

'It's like somebody is slicing through the meat of your thigh, or cutting off your arm, except this is the most sensitive part of your body. I passed out.

'When I woke up… the worst part of it had just begun. The Killer Woman had piled next to her a stack of thorns from the acacia tree. She used them to puncture holes in my skin, then poke a strong white thread through the holes to sew me up.'

-

Waris Dirie, model and campaigner

 

Another survivor suffered the most extreme form of FGM in that her vagina was sewn up after she was cut. She was left with a hole no bigger than a matchstick that left her with a host of health problems and rendered her infertile.

I

recalled the moment I was cut. She said: ‘Your whole body is in pain, the scream that you scream, meant I lost my voice for a couple of days.

'The moment your genitals are cut, a part of your soul dies.’

- Leyla Hussein

Slide21

The cutters perspective

uncut girls 'are told they smell like a dog'.

There is also financial considerations. The family of a girl who is not cut cannot expect to a dowry for her hand in marriage.

'The cut girls would get money and a lot of cows for their dowry. Girls who are not cut do not get many cows, in fact they would not get a dowry.'

 

A cutter from Kenya said: 'I was taught by the old people – my elders, my mother and my grandmother. I started to learn when I was about 12 and it took about four years to learn. After that I continued to practice. The cutter is more important than a midwife.

A cutter told MailOnline: 'We use a sharp instrument like a knife or a razor blade. I put millet flour over the organs so that is not slippery so I can hold it. And the flour helps to stop the bleeding.'

Slide22

The cutters perspective

The clitoris is put on the ground to be carried away by Safari ants, as part of the tradition.

'A neighbour might ask a mother if her daughter has fed the ants, as a way of asking if the girl has been circumcised.' 

Cutter women are paid less than £13 [2,000 Kenyan Shillings or $20.20] to carry out the life-changing procedure.

Both cutter women admit that FGM victims can suffer terrible complications from the crude surgery.

But perversely if a girl dies following the procedure her mother is blamed.

'If the girl becomes sick it is the failure of the mother because she should be at home looking after her daughter. I know two girls from this village who have died [after FGM].

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A Kenyan Cultural leaders perspective

Giving an insight into the pressure families are put under, a cultural leader of Kenya's Kisi tribe, said that ending the barbaric practice will turn Africans into 'slaves' of the West.

He said: 'Circumcision is carried out by families who have left Africa to maintain their culture. Some [African families who have moved abroad] have been told to forbid their girls from getting cut. 

'But these girls have no discipline and show no respect towards their relatives. The families become isolated in their own community, they become lost from their own culture and traditions. 

'In Africa culture is everything. If you are out of the culture you are lost from the community. Not being circumcised is a cultural taboo. Someone who is without their culture is a slave to another culture.'

Slide24

Prevalence

In more than 28 countries in Africa and parts of the Middle East.

FGM is reported amongst Bohra Muslims in

India, Pakistan and East Africa, Malaysia

and Indonesia.

Due to migration its happening in Australia, Europe and here in the UK.

In communities where FGM is the social norm, its practised by Muslims, Christians and followers of indigenous religions which suggests that the practice is more cultural than a religious practice.

Slide25

Who is at risk?

2 million girls around the world every year are mutilated

Mainly African and Middle Eastern countries and alarmingly now in the immigrant

population of Europe, America and Australia

Approximately 24,000 girls in the UK and 6,500 girls in London are at risk of FGM every year

Slide26

FGM is a safeguarding issue

FGM IS CHILD ABUSE!!

FGM is a gender based violence, it violates a number of human rights principles, including equality and non discrimination on the basis of sex.

It is Violence against women and girls and is child abuse……

It highlights the subordinate role of a woman

Section 11 Children's Act 2004 - makes it everyone responsibility to act and share information to safeguard a child

Section 47 Children's Act 1989 – Is a Joint investigation between Police and Children's Social Care

Slide27

The Law

Prohibition of Female Circumcision Act 1985

Penalty – 5 years imprisonment

Female Genital Mutilation Act 2003

Penalty – 14 years imprisonment

Slide28

FGM Act 2003

Offence to commit FGM [S1]

Offence to assist a girl to commit FGM on herself [S2]

Offence for someone in the UK to arrange or assist FGM outside of UK even if carried out by a person who isn’t a UK national or resident [S3]

NO AGE LIMIT - ‘Girl = woman’

Defence = If it is a surgical operation

necessary for physical / mental health

Mental health does not include belief that FGM is required as a matter of custom or ritual

Consent is not a defence

Slide29

New This year

Extension of extra-territorial liability to "habitual" UK residents

Lifelong victim anonymity

Parents's and guardians' liability for failing to protect a child from FGM

(Serious Crime Act 2015)

Slide30

New this year

Civil Protection Orders for FGM

Mandatory reporting for relevant professionals

Slide31

Barriers

Children are unlikely to ‘tell on their parents'/

too young to remember

Many from parents not known to agencies

Once in a lifetime event

Honour Based Violence

Community Acceptance / Marriage

Language / Immigration status -

In Somaliland the women refer to their procedure by two names, the

Sunna

and the

Pharaonic

. In Sierra Leone its known as

Bondo

In Liberia its known as

Sande.

Unaware of the law

Lack of understanding of health implications

Slide32

Indicators FGM may be about to take place

Family from an affected community;

Mother or siblings have had FGM

Extended holiday, particularly to a practicing country;

Child is going to “become a woman” or have a “special celebration”;

Child may begin to display a behavioural change……

Indicators - FGM has already happened

Girl may spend long periods of time away from the classroom associated with bladder or menstrual problems;

The child requiring to be excused from physical exercise;

Prolonged absences from school plus a noticeable behaviour change…..

Slide33

MPS Response

1. Project Azure

Dedicated SPOCS on each CAIT team and across 9 priority boroughs

Supported Dept. Of Health with conferences across the UK

LSCB training events for harmful practises

Training for Police/UKBF/Health/Education

Operation Limelight

Hosted FGM Conference and harmful practises events

NSPCC Helpline / Protocol with CPS

Produced a guidance for schools

Slide34

Where do you stand?

Thank you for listening…

Any questions?

projectazure@met.police.uk

020 7161 2888

Slide35

Lucy Njomo

My

Story

Registered

as International charity in February 2008 

Helping

to educate and campaign against FGM 

Provides

a community support group focusing on FGM

Slide36

Emma Scutt FGM

Survivors Artwork

An illustration created for an FGM event at Waltham Forest Town Hall

Alimatu Dimonekene, Hibo Wardere, Leyla Hussein, Stella Creasy MP and me pictured at the original exhibition, at St Barnabas Church June 2015 

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11:30 – 11:50

Refreshment break

Slide38

NSPCC Ending FGM

Slide39

FGM Conference

Croydon University Hospital

Perineal clinic

Ranee Thakar (Consultant); Adeyemi Johnson(Midwife)

Slide40

Gynaecological

complications

Sexual dysfunction with

anorgasmia

Pain

& tenderness

in

scar tissue

Lacerations/haematomas/genital

swelling

Infertility - failed

intercourse, pelvic infection and obstructed

menstruation

Difficulty in gynae. Exams/cervical screening

Slide41

Long Term Implications (particularly type 3)

V

aginal

closure

b/c scarring

Impair

menstrual

flow & Painful menstruation

Sexual dysfunction;

bacterial vaginosis (

Berg 2014

)

Urinary

flow

obstruction - poor

flow, pain,

UTIs,

Chronic vaginal/pelvic infections/ local irritation

Cysts and keloid scar formation

Psychological damage/depression

Slide42

Obstetric complications

Difficult

vaginal examinations

and inhibits identification

of complications e.g. mal presentations

Difficulty

in applying

and obtaining FSE; FBS and catheterising

of the bladder

Prolonged labour/maternal deaths

Perineal tears/ Postpartum haemorrhage

Increased

risk of

c/section/instrumental deliveries

extended

maternal hospital

stay

High

standard of obstetric care minimises risk

Infant

resuscitation

& stillbirth/early

neonatal

death

Banks et al 2006;

Vangen et al 2002, Chibber et al 2011, Raouf et al 2011; Berg et al 2014)

Slide43

Perineal clinic

Full history, assessment of

external

genetalia

Type

of FGM,

abnormalities

,

urethra; infections

Documented of findings in pregnancy notes

Illegality

of FGM discussed

and documented

Psychosexual

counselling/Referrals/Treatment

Deinfibulation – antenatal/not pregnant

- de-infibulation

is offered or performed;

- Consented for de-infibulation

- After procedure review

- Urinary/vaginal/menstrual/sexual issues

- Partner counselling

Slide44

FGM PATHWAY (ANTENATAL)

Woman seen by midwife at booking/pregnancy.

Ask all women if they have had FGM/cutting/circumcision

Female

interpreter ( not a family member)

Record the ‘No’ response in pregnancy notes electronic databases

Record in pregnancy notes/computer

DATIX

Illegality of FGM

Data reporting

Safeguarding

Perineal clinic

YES

NO

Slide45

FGM PATHWAY

(LABOUR)

Caesarean Section is NOT indicated due to FGM

Normal care is required during the 1st stage of labour

FGM Type 3 (Infibulated)

All women with FGM Type 1 & 2 or who have had de-infibulation performed antenatally

- treat as ‘normal care’ in labour

- comment on genetalia

- if a female child comment in baby’s red book following baby check

Slide46

FGM Type 3 (Infibulated

)- Labour

–

Deinfibulation in 1

st stage labour to expose urethra/VEs

Active labour

– Deinfibulation in 2

nd

stage

Deinfibulation by trained practitioner/analgesia/aseptic

+/ mediolateral episiotomy

Not permissible

to reinfibulate following birth

Immediate care

- adequate pain relief

perineal care

Discharge summary to include delivery history

Perineal clinic

referral

Illegality of FGM discussed

DATIX

Safeguarding children

Comment on child’s

external genetalia in red book

Post natal perineal review

Slide47

Non- Pregnant woman/girl

with FGM

Patient identified as having had FGM

Record in clinical notes that she has FGM,

Type where possible

Patient’s details. The women should be referred to the perineal clinic and social services

Women/girl referred to the perineal clinic

Referral to Social services

Perineal clinic

FGM type

Complications

Treatment

Deinfibulation

Referral

Police

(<18years)

Inform GP/Relevant

services

Slide48

Training at CUH

Raise awareness amongst Health

professionals

about FGM

Discuss

the health/ psychological and emotional consequences and offer the family

support

Deal with FGM in a sensitive & professional manner

, & do

not exhibit signs of horror or revulsion

when

treating

individuals

with FGM

.

Identify and classify FGM and record and treat comorbidities

Discuss the UK law i.e.: it is a criminal offence

to perform FGM

What is the family’s view and view of the extended family

?

Discuss the specialist services for any health or psychological

needs

Discuss the obligation to refer to social services

Female

genital cosmetic surgery (FGCS) may be prohibited unless it is necessary for the patient’s physical or mental health.

Slide49

Questions to ask women regarding FGM

Speciality/department where FGM identified: Patient hospital No: DOB

1. Date FGM identified

2. Have you had female circumcision/surgery/cutting to genital area?

YES (if yes what type)

3. Types of FGM : 1 ( ) 2 ( ) 3( ) 4 ( ) unknown ( )

4. Do you suffer from any complications as a result of this procedure?

5.

For Type 3

– Have you been deinfibulated?

6.

If Yes

: Non-pregnant Antenatally In Labour

7. Have you been vaginally examined by a Doctor/midwife or nurse?

8. Have any members of you/your husband’s family been cut/circumcised?

9.

If yes

- Who

10. If you have a female child, would you feel under pressure to continue this practice from any relatives?

11. Are you & husband aware that it is illegal in the UK to practice any form of female circumcision/cutting/pricking to genital area?

12. Are you aware that it is also illegal to send a female child abroad to have this done and in both cases are liable for prosecution?

You Husband/Partner

Slide50

Group Activity – The Croydon Pledge

Nominate a spokesperson and a scribe from your table.

 

As a group you need to have a discussion about what you can do following the event today to ensure that you are considering children/adults who are affected by FGM or are at risk of FGM in your service area AND responding to their needs.

 

In addition, we would like you to discuss what activities you think could be built into Croydon’s approach to addressing FGM – prevention /support? What can your service contribute to these activities?

 

We would like you to come up with 3 key elements of good practice that you think are essential to

the

development

of high quality services that children and adults affected by FGM would feel happy to use.

 

Please write the 3 key elements in the thought bubble on the papers given and they will be collected and added to the Croydon FGM pledge.

 

EXAMPLE

:

Slide51

Siaka Charles

A Male Perspective

Slide52

Croydon College Students – Young people, FGM and the FGM Society

Slide53

at Croydon College

Slide54

Legacy of Achievement

For three years Croydon College students have led a campaign to raise awareness about FGM and to work towards its eradication.

Slide55

Legacy of Achievement

The first Croydon College FGM Society organised a major conference which

took place

in summer 2014. They invited organisations

such as

UNICEF, Amnesty

International

, NSPCC, Integrate Bristol and Forward as well as representatives from Croydon borough.

The aim of the

event

was to encourage international charities, national organisations and students to engage in a forum where a strategy on efforts to strengthen the Female Genital Mutilation Act 2003 could be developed.

Slide56

Following the discussions, a Charter was agreed for Croydon borough.

As a result of the conference, members of the College FGM Society were recognised for their outstanding achievements by Forward.

Legacy of Achievement

Slide57

The second FGM Society took forward this work, and was trained by Forward as Peer Advocates. This ensured that they were equipped to lead classes, raising awareness of the key issues surrounding FGM.

The group also encouraged students across the college to participate in the Home Secretary’s consultation on the introduction of mandatory reporting for FGM.

Legacy of Achievement

Slide58

The second FGM Society met the Cabinet Councillor for Communities and the Deputy Cabinet Councillor to present their proposals to create a Safe Haven for families and FGM survivors in Croydon.

Their vision for a Safe Haven was to provide a multi-agency facility, offering information and support.

Legacy of Achievement

Slide59

What we are doing now

Taking the legacy forward, the current FGM Society also trained as Peer Advocates and have been leading class sessions to raise awareness of FGM.

They have met with Beth Kelly, the FGM project Consultant in Croydon, on several occasions to look at how they can support borough strategic drivers. They will be leading student workshops as part of Safer College week in the summer term.

Slide60

The FGM

Society 2014/15

Slide61

The future

Croydon College is the only Rights Respecting FE College in the UK. For this reason it is imperative that we uphold our responsibility to protect the human rights and civil liberties of

our community.

Slide62

FGM and Safeguarding

Dr Shade

Alu

Designated Doctor for Child Protection

Slide63

The Shock of The New

What we mean by safeguarding does and should change – the system’s capacity to absorb new work is the issue as well as the contested nature of statutory intervention in new safeguarding

Slide64

Key principles

The safety and welfare of the child is

paramount

All agencies to act in the interests of the right of the child, as stated in the United Nations Convention (1989

)

It is acknowledged that some families see FGM as an act of love rather than cruelty. However, FGM causes significant harm both in the short and long term and constitutes physical and emotional abuse to children

.

Slide65

Continued

All decisions or plans for the child/

ren

should be based on good quality assessments and be sensitive to issues of race, culture, gender, religion and sexuality, and avoid stigmatising the child or the practising community as far as possible

Accessible, acceptable and sensitive health, education, police, children's social care and voluntary sector services must underpin the procedures

All agencies should work in partnership with members of local communities, to empower individuals and groups to develop support networks and education programmes

Slide66

“The importance of a coordinated strategy, predicated on open and respectful cooperation between all the safeguarding agencies involved, simply cannot be overstated.

An ongoing dialogue in which each party respects, and I make no apology for repeating the word respect, the contribution of the other, is most likely to achieve good and informed decision making”.

Lord Justice Hayden

Slide67

Slide68

Summary and Q&A

Slide69

‘Integrate Bristol – FGM Song’

Slide70

Thank you – Please now join us at the networking Lunch