Irish doctors getting to grips with female genital mutilation

10 years ago, examples of female genital mutilation in Ireland were rare. Not so anymore, writes Caroline O’Doherty

GPs are always keen to reassure the reluctant that there’s nothing they can bring to the surgery that hasn’t been seen before — but there is one condition that can leave both doctor and patient at sea.

Female genital mutilation (FGM) is something few western doctors have encountered so when it comes through their door, it can test all their medical and interpersonal skills.

Dr Caitriona Henchion, medical director of the Irish Family Planning Association, understands their difficulties. “Up to 10 or 15 years ago, the chances of anybody in Ireland seeing this was extremely rare so it’s not something that would have been included in our medical education.”

The Irish Family Planning Association last year opened the country’s first free, dedicated clinic for women dealing with the after-effects of FGM and, while the numbers attending so far have been small, some have needed significant treatment.

“There are various types of FGM. Sometimes only part of the clitoris and labia is removed. The type that causes the most complications is the stitching closed of the vaginal opening and particulaly where that closing is very severe. Those are the women most likely to come to see us.”

An arrangement is in place with the Rotunda Hospital in Dublin whereby women are fast-tracked to a female gynaecologist who performs corrective surgery free of charge. The results can be very good from a medical point of view but surgery can only do so much to erase the damage.

“You can rectify the vaginal opening so that the women can have comfortable sex and have normal deliveries but you can’t put back a clitoris or labia. We can’t replace what has been taken away.”

Our free #FGM treatment service is accessible via a drop-in clinic each Wed or by calling/texting 085 8771342 http://t.co/PcSCo77Aba #EndFGM

— IFPA (@IrishFPA) February 6, 2015

What has been taken away is more than just physical. FGM is usually performed to keep a girl “clean” for her future husband, and sometimes re-performed after childbirth to keep her faithful. It is a powerful way of taking away a girl’s independence, dignity, and sense of worth.

“It’s a barbaric act that doesn’t have any place in modern society,” says Mike Mansfield of development agency Plan Ireland.

“We’re very clear in Plan that it is mutilation — not cutting or circumcision as it’s sometimes termed — so for us, we call it FGM, not FGC.”

The challenge for the organisation is getting that message out to communities where FGM is a deeply entrenched tradition in a manner that nurtures understanding rather than breeds resentment.

“We have to be respectful and non-judgmental and, at the same time, give girls the realities behind the myths of FGM and tell them how it is going to impact on them — that you’re twice as likely to die in childbirth, for example,” he says.

“We have to do a lot of work with the cutters who have all undergone the practice themselves and for whom cutting can be a very lucrative source of income.

“We can’t just go in and say stop doing it. We have to give them the tools and training to provide another way of earning. We also work with governments. FGM is outlawed in 21 African countries — including some where the instance of FGM is highest — but there is a big difference between it being illegal and that law actually being enforced. There have been successes. If you look at Senegal, there has been a huge decrease in numbers there and in Mali and in Ethiopia, it is decreasing. Some communities are declaring themselves FGM-free and that creates a momentum for change.”

Spoke in #seanad to mark tomorrow's international day of zero tolerance on FGM & to commend work being done by @AkiDwA & @IrishFPA #EndFGM

— Ivana Bacik (@ivanabacik) February 5, 2015

The World Health Organisation estimates about 140m women worldwide have undergone FGM, with prevalence rates in some countries, such as Guinea, Somalia, and Egypt, as high as 97%-99%.

Based on those figures, it is estimated 3,700 women here have undergone FGM so the numbers coming to the Irish Family Planning Association clinic represent only a very small fraction.

Dr Henchion says healthcare professionals should not wait until the issue presents itself as a medical emergency or a crisis because of impending marriage or childbirth as many women will silently suffer repeated infections and other problems, and store up trouble for the future.

She says: “We tend to shy away from asking a patient where are you originally from because you’d be afraid that they would think you had views on their race and might discriminate against them. But one of the simplest ways to enable a conversation about FGM to begin in a GP’s surgery is for the GP to ask directly where a woman is from and to have in their own mind the prevalence rate for that country and to explain then that there are some conditions we know are more common in certain countries and we’d like to talk about them for the sake of the patient’s health.”

Ireland outlawed FGM in 2012 as well as reinfibulation or the reclosing of a vagina that has been opened for childbirth, and it was also made an offence to take a child out of Ireland for FGM.

Dr Henchion says being able to cite a clear-cut law is important for doctors who may otherwise be pulled into a debate over respect for a patient’s cultural beliefs.

If there is a risk of the law driving the practice underground, there is as yet no evidence of it.

“There are no reports of it, no general uneasy feeling that it is happening. That is not to say that there haven’t been isolated cases because a lot of the time people will not go to a healthcare professional unless something went disastrously wrong,” says Dr Henchion.

“But that’s why it’s important that as healthcare professionals we do start talking more about it. This is not something we want to treat — it’s something we want to prevent.”

Details about the FGM clinic are at www.ifpa.ie or on 085 8771342.

Akidwa, the network of migrant women in Ireland, have a guide to FGM for healthcare professionals. Yesterday, the International Day of Zero Tolerance For FGM, launched another guide for education professionals.

Both are on www.akidwa.ie