Contents. Refuge what do we do?... 4 What is female genital mutilation (FGM)?... 6 Where can it happen?... 8 How FGM might affect your body...

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3 Contents Refuge what do we do? What is female genital mutilation (FGM)? Where can it happen? How FGM might affect your body Periods Pregnancy, childbirth and FGM Deinfibulation Sex, relationships and FGM Psychological consequences Community, family and friends Myths, misunderstandings and excuses made about FGM My children and FGM The law and how it can protect you and your children New protection measures in the UK Female Genital Mutilation Protection Orders (FGMPOs) Duty on professionals to report FGM to the police Who else can I talk to? Specialist NHS FGM clinics Please note, in all case studies, names have been changed to protect identities.

4 Refuge what do we do? Refuge is the country s largest provider of specialist support for women and children experiencing gender-based violence. Our services change lives and save lives. We opened the world s first refuge for abused women and children in West London, in Every day, our national network of services support over 3,300 women and children experiencing domestic violence and other forms of gender-based violence including female genital mutilation (FGM), sexual violence, forced marriage, prostitution, stalking, trafficking and so-called honour -based violence. Refuge has been providing expert specialist support to survivors of FGM in its refuges and outreach services for many years. Alongside these services, we run awareness-raising programmes of work for professionals who support women affected by FGM. We also campiagn for the eradication of FGM, by lobbying the Government and taking the voices of the women and children we support to the policy tables. If you have experienced violence or abuse, Refuge s specialist staff can provide confidential, non-judgmental support. We can help you rebuild your life free from fear. Our webpage contains more information for anyone who has experienced, or may be at risk of, FGM as well as information for concerned friends, family members and professionals. 4

5 Refuge has developed this booklet for women and girls who have experienced FGM, those from practising communities, or those with children at risk of FGM. We want to ensure that you have the best quality information possible to make informed decisions about your health and safety. Refuge understands that women often find it difficult to talk about FGM, even when they have experienced it themselves. For this reason, we recommend you read through this booklet with your key worker. If you choose to read this booklet alone, we hope it provides you with the information you need. Please feel free to approach your key worker with any questions you may have she will be able to support you. 5

6 What is female genital mutilation? Female genital mutilation (FGM), also referred to as 'cutting', generally describes the partial or total removal of the external female genitalia for non-medical reasons. It is a form of abuse designed to constrain and control a woman s sexuality. FGM is against the law. Broadly speaking, there are four types of FGM. However, since FGM is performed differently according to local practice, and women s bodies are all unique, there is much variation between types. The four main types of FGM 1 : Type 1 clitoridectomy partial or total removal of the clitoris Type 2 excision partial or total removal of the clitoris and the labia minora (inner lips that surround the vagina), with or without removal of the labia majora (larger outer lips) Type 3 infibulation the narrowing of the vaginal opening by creating a seal, formed by cutting and repositioning the labia Type 4 (not illustrated) all other harmful procedures to the female genitals, which include pricking, piercing, cutting, scraping and burning 1 Based on information from NHS Choices: 6

7 Labia minora Labia majora Clitoris Uretha opening Vagina Uncut Type 1 Type 2 Type 3 7

8 Where can it happen? FGM is practised by members of some communities from the following areas: Benin Burkina Faso Cameroon CAR Chad Cote d Ivoire Colombia Djibouti DRC Egypt Eritrea Ethiopia Gambia Ghana Guinea Guinea Bissau Indonesia India Iran Iraq Kenya Kurdistan Liberia Malaysia Mali Mauritania Niger Nigeria Oman Pakistan Saudi Arabia Senegal Sierra Leone Somalia Sudan Tanzania Togo Uganda United Arab Emirates Yemen Different communities have different traditions and there is a great deal of diversity in the scale and method of practice from one area to the next. 8

9 In some of the above countries, only a small percentage of communities practise FGM, whilst in others, the vast majority of women have experienced this form of abuse. However, just because a woman or girl is from one of these countries, it does not mean that she has experienced (or that she will experience) FGM. 9

10 How FGM might affect your body FGM can impact on your physical health. Some of the physical consequences can include: Damage to the reproductive system, including infertility The increased likelihood of undergoing later surgery - in some cases, to open the lower vagina if a woman wants to engage in penetrative sexual intercourse, or chooses vaginal childbirth Complications in pregnancy and during labour including increased risk of death of mother and new-born baby Pain during sex and lack of pleasurable sensation Persistent urinary tract infections Difficulty urinating Kidney damage Chronic vaginal and pelvic infections Odour caused by infection, retention of menstrual blood or urine leakage Abnormal periods increased pain and/or prolonged blood flow due to reduced vaginal opening You can find further information about some of these health concerns on the following pages. If you are having difficulties with your physical or psychological health, your key worker can support you to contact your doctor or nearest specialist NHS FGM clinic. 10

11 Periods Some women experience pain during their monthly period as a result of FGM. If blood is unable to escape easily through the vaginal opening because it is closed, the uterus may try to push the blood out which might result in pain and discomfort. If this is a problem you experience, speak to a healthcare professional who will be able to talk you through your options. Pregnancy, childbirth and FGM If you are pregnant and have had FGM, it is important that you tell your doctor or midwife so they can ensure you are able to give birth as safely and comfortably as possible. Unless you are having a caesarean section delivery, your vagina must be able to open in order to allow you to give birth. For some women the 11

12 How FGM might affect your body (continued) scar tissue they have as a result of having experienced FGM can make this difficult. Having a reduced vaginal opening may also cause complications during birth and create additional risks for you and your baby. Whilst it is possible to have a vaginal birth after having experienced FGM, you may need to have an episiotomy. This is where a cut is made between your vagina and anus to help the baby come out. This is a very common procedure - around one in seven births require an episiotomy. For some women, a process called deinfibulation may be necessary this means that a doctor or midwife will re-open the vagina to allow the baby to pass through. The next page gives more information on deinfibulation and how it works. The first time I encountered FGM was about 10 years ago with a service-user from Ethiopia. I remember she was pregnant and we were not aware of her FGM until she went to hospital. She had type 3 FGM and had problems giving birth. She had to have a caesarean. Now we ask women about FGM so that they can be prepared. Mary, a Refuge staff member 12

13 Try to let a health care professional know as early as possible if you are pregnant and have experienced FGM. They can talk you through your options. If you are pregnant and are unsure of where to go for medical advice, ask your Refuge key worker, who can support you to access the most appropriate health service near to you. Deinfibulation Deinfibulation describes a surgical procedure, aimed at opening a vagina that has been closed during FGM. Women can choose to be deinfibulated at any time in their life. For some women, their choice is determined by particular life events for example, if they have recently married or become pregnant. Some women simply choose to be opened, whilst others choose not to be. It is important to remember your body belongs to you and no-one has the right to tell you what you should, or should not, do to it. Deinfibulation is your choice. If you do choose deinfibulation, the health care professional performing the operation (usually a midwife or a doctor) will talk you through all of your options before the procedure takes place. You can choose whether you would prefer to be under local or general anaesthetic whilst it happens. A friend can attend with you and, if you have a local anaesthetic, she may be able to stay with you whilst the procedure is completed. Some women find deinfibulation very empowering, whilst others may be reminded of when they experienced FGM. If the person who accompanies you has also undergone FGM, she may find the experience difficult too. Please share any concerns you may have with the health care professionals present. 13

14 Sex, relationships and FGM Many women who have experienced FGM find sex difficult. This can be for physical and/or psychological reasons. Every woman s experience of sex after FGM is different. Some women who have experienced FGM have a positive experience of sex. Others may experience a lack of sensation, low libido (not feeling the urge to have sex), or find sex very painful. Whatever your experience, you are not alone and Refuge is here to support you. It is important to remember that sex must be your choice. If you are unable or unwilling to have sex, your partner must respect that decision. If you are being pressured or forced to have sex please speak to your key worker, or if you are in immediate danger of sexual assault dial 999. If you decide that you do want to have a sexual relationship, but are experiencing difficulties as a result of FGM, there are treatments that might help. For example, if your vagina is not open enough for you to have penetrative sex, deinfibulation may help visit page 13 for more information about this procedure. If you would like to explore your options, contact your doctor who can speak to you in confidence. Some women may develop vaginismus an involuntary tightening of the muscles around the vagina whenever penetration is attempted. The cause, in women who have experienced FGM or other forms of abuse and violence, can be emotional, physical or a combination of both. You might like to discuss ways to address vaginismus with a 14

15 health care professional, who can prescribe you vaginal dilators in various sizes. These are tools that you can use in your own home to help your vagina gradually get used to opening if this is what you want. For sex to be comfortable, most women, whether they have had FGM or not, need a caring, empathetic and supportive partner. Women also need to be suitably aroused before attempting penetration or any other form of sexual intercourse. If you are not aroused your vagina may feel tight and dry and penetration may be painful. Lubricant (a liquid or gel that reduces friction between the penis and vagina) can be very helpful in aiding penetration. For some women, sex is more difficult because of the emotional rather than the physical impacts of FGM. Medical professionals can prescribe a range of different psychological therapies depending on your specific needs and circumstances and you can also approach your key worker about this too. Remember - a fulfilling sexual relationship is possible after FGM. When I had sex with the man they forced me to marry it hurt. But when I met my daughter s father, we fell in love. It hurt at first, but I loved him so much, I began to enjoy it. Before I didn t think that would be possible. Mamakoh, a Refuge service-user 15

16 Psychological consequences FGM can have a range of psychological impacts, including: Self-harm Addiction use of drugs or alcohol to try to escape thoughts and feelings associated with FGM Anxiety, anger and panic attacks Flashbacks and nightmares Low self-esteem Depression It is both normal and understandable to experience many of the above after FGM. If you are experiencing any negative consequences as a result of FGM, please remember that you are not to blame and you are not alone. If you need to talk about your feelings, your key worker is here to support you. She can help you access counselling or other emotional support. You can also approach your doctor, or turn to page 23, to find out about additional support. 16

17 Community, family and friends Supportive family and friends understand that it is your right to choose what happens to your body. We also know from our work with women and children that some families are not supportive. If your family forced you to undergo FGM, or you were persuaded to undergo FGM, because of social pressure from your community, you may feel scared and betrayed. Remember - you are not alone and you are not to blame. It is very common to feel like this. It might be that someone you love or trust has hurt you and that can be very confusing. Sometimes it is not safe for women (or their children) to have contact with their family or friends and we understand that that can be very upsetting. If you are experiencing any of these concerns, or feel isolated, your key worker can help you to access groups and activities to help you meet new friends. If you would like to try and safely reconnect with family members or friends, speak to your key worker and she will support you. 17

18 Myths, misunderstandings and excuses made for FGM FGM is carried out in order to control female sexuality, but many people - including your family and friends - may make excuses to justify it. Myth: FGM helps women to be or to keep clean. Vaginal secretions are the body s way of keeping the vagina clean. FGM can disrupt and prevent these secretions and can cause infection. Myth: FGM is a religious obligation. FGM is not a requirement of any religion. This unlawful practice predates the Bible and the Qur'an. Leaders from all world faiths have spoken out against FGM because it is not a religious requirement. You can continue to be part of your faith even if you reject and oppose this harmful traditional practice. Myth: FGM is part of our culture; it is a tradition and cannot be changed. Cultures are broadly defined by the ideas, customs and social behaviour of a particular people or society - they evolve over time. FGM is a dangerous tradition, not a culture. It is a crime, and we are all responsible for stopping it. 18

19 Scarification (cutting or branding designs onto the skin) used to be part of our culture in Sierra Leone but that culture changed. The culture of FGM will change too. This will not happen to my child. Fatu, a Refuge service-user 19

20 My children and FGM If you are experiencing pressure from your family for your daughter to undergo FGM, you should be aware that FGM is a form of child abuse and it is against the law in the UK. If you have parental responsibility for a child you can be prosecuted for failing to protect a girl from FGM. The maximum sentence for this crime is seven years imprisonment, a fine, or both. There are many organisations that can help you to protect your child from undergoing FGM. If your child is judged to be at risk it may be necessary for social services to be involved in supporting you to protect your child. Your key worker can provide you with support and advocacy through this process. If your child has already undergone FGM, Refuge can support her to get the help she needs. Your key worker will have information on services near to you if she requires additional medical or psychological support. Refuge may also be able to refer your child for counselling to help her work through the emotional consequences of FGM. 20

21 The law and how it can protect you and your children FGM is illegal in the UK. It is also illegal to take a British national, permanent, or habitual resident abroad for FGM, or to help someone trying to do this. A person is guilty of an offence of FGM if s/he alters, or injures, the whole, or any part, of a girl's labia majora (the outer folds of skin surrounding the external genitalia), the labia minora (the inner folds of skin surrounding the external genitalia), or the clitoris for non-medical reasons. The maximum sentence for carrying out, or facilitating FGM is 14 years in prison. Anonymity Alleged victims of FGM are entitled to lifelong anonymity under the law. This means the law prohibits the publication of any information which would be likely to lead members of the public to identify an alleged victim of FGM. This includes publication on social media channels such as Facebook and Twitter as well as in newspapers and on television. 21

22 New protection measures in the UK Female Genital Mutilation Protection Orders (FGMPOs) Female Genital Mutilation Protection Orders (FGMPOs) currently apply in England, Wales and Northern Ireland. A FGMPO is an injunction imposed by the high court, or family courts to protect a girl who may be at risk of FGM, or a girl on whom FGM has been inflicted and who could be at risk of further harm. Either the victim or a relevant third party may apply to the court for a FGM protection order. Relevant third parties can include local authority departments such as social services. The order may contain prohibitions, restrictions or requirements that the court considers appropriate. Breach of an order will be a criminal offence with a maximum sentence of five years imprisonment, or as a civil breach, with a maximum sentence of two years imprisonment. Duty on professionals to report FGM to the police When this duty comes into force healthcare professionals, teachers and social care workers in England and Wales must inform the police when, in the course of their work, they discover that an act of FGM appears to have been carried out on a girl who is under the age of 18. This applies when the victim discloses the offence to the professional, or where the professional has observed the physical signs of FGM. No commencement date has yet been set for this measure (as of August 2015). 22

23 Who else can I talk to? National support and information: Your Refuge key worker, or local service manager, is available for you to talk to whether you require emotional support, or more practical information about your options. If you feel that you would benefit from counselling then your key worker may be able to help you find specialist local services. Alternatively, you can discuss accessing psychological therapies with your doctor. The Freephone 24-Hour National Domestic Violence Helpline: The Helpline, run in partnership between Refuge and Women s Aid, can signpost and refer you to specialist support services: Refuge: Visit the Refuge website for more support and information around FGM: NSPCC: Call the 24-hour NSPCC FGM helpline: or fgmhelp@nspcc.org.uk Foreign and Commonwealth Office: If a girl or woman is believed to be at risk of FGM and has already been taken abroad, you should phone: Forward: A women s organisation that provides information on services and one-to-one support: , extension 1 or support@forwarduk.org.uk If you need access to local support, please speak to your Refuge key worker. 23

24 Specialist NHS FGM clinics Please note that some FGM clinics may require a referral from your doctor. Most clinics support all women, but some may only assist pregnant women. Please contact clinics to find out their requirements*. Clinic Location University College London Hospitals Female Genital Mutilation (FGM) Clinic Elizabeth Garrett Anderson Wing Clinic 3, Lower Ground floor, 235 Euston Road, London, NW1 2BU Contact Clinic Location African Well Women's Clinic Antenatal Clinic, Central Middlesex Hospital Acton Lane, Park Royal, London, NW10 7NS Contact Midwives office / 7177 Clinic Contact Chelsea and Westminster FGM Service enquires caw-tr.fgmwestlondon@nhs.net Clinic Whittington Hospital - Women's Health department Location The Whittington Hospital, Magdala Avenue, London, N19 5NF Contact Switchboard Clinic Guys & St Thomas Hospital FGM Clinic Location London, SE1 7EH Contact * Information correct as of August

25 Clinic Location Tower Hamlets Contraception and Sexual Health (TH CASH) FGM service Mile End Hospital, Bancroft Road, London, E1 4DG Contact or Clinic Northwick Park and Central Middlesex Hospital FGM clinic Location Antennal clinic, Watford Road, Harrow, Middlesex, HA1 3UJ Contact Clinic Location Contact Nottingham University Hospital Antenatal Clinic Hucknall Road, Nottingham, NG5 1PB / Carol.mccormick@nuh.nhs.uk Clinic Bristol Minority Ethnic Women s & Girls Clinic Location Charlotte Keel Health Centre, Seymour Road, Easton, Bristol, BS5 OUA Contact Clinic Location Contact Bristol Community Rose Clinic at Lawrence Hill Health Centre Lawrence Hill Health Centre, Hassell Drive, Lawrence Hill, Bristol, BS2 0AN / bristolrose.clinic@nhs.net Clinic Location Princess of Wales Women's Unit Labour Ward. Birmingham Heartlands Hospital Bordesley Green East, Birmingham, B9 5SS Contact or Clinic Liverpool Women's NHS Foundation Trust Location Crown Street, Liverpool, Merseyside, L8 7SS Contact Switchboard: / Fax:

26 I hadn t considered my FGM until my key worker helped me to increase my knowledge and referred me to a specialist doctor. Through Refuge, I ve been able to escape my situation and have been supported to get my life back on track. Julie, a Refuge service-user

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