Dear editor, We write in response to the article in the July 2020 edition of the British Journal of Midwifery: ‘A review of the law surrounding female genital mutilation protection orders’ (Home et al, 2020). This paper reviewed the introduction of the Female Genital Mutilation Protection Order (FGMPO) and its effectiveness as a protective measure since its inception in 2015, under the Serious Crime Act 2015.
The authors identified what was already known about this specific subject, as well as its relevance to regulated healthcare professionals. Home et al (2020) critically discussed the evident data inconsistency regarding FGM cases recorded by health services in England between April 2015 and September 2019, including those related to FGMPOs, the latter documenting a very low number of applications compared with FGM cases registered.
The authors' focus on the lack of evidence and clarity around the effectiveness of FGMPOs in safeguarding girls at risk of FGM is a significant point that needs to be cautiously considered, to bring light to the often contradictory position of an FGMPO being or not being granted in practice. Indeed, such absence of transparency further confuses the role of regulated health professionals working directly with clients exposed to, or at risk of FGM, who are expected to contribute to decisions around the granting of an FGMPO.
Amongst their recommendations, the authors made a case for creating a national FGM Commissioner post, whose functions would include:
- Raising awareness of the availability of FGM Protection Orders
- Promoting access to these orders
- Evaluating FGM law
- Leading public health FGM prevention strategies (primary, secondary and tertiary prevention).
In taking this position, Home et al (2020) argue that based on the scarcity of consistent evidence demonstrated in their paper, successful implementation of the FGMPO will at best be compromised. With regard to their findings, the authors' recommendation of appointing a national FGM Commissioner is totally relevant, highly needed and should be supported. However, we would further argue that the description of such a role goes beyond the functions enumerated by Home et al (2020). The authors arguably missed the opportunity to elaborate on potential issues related to the FGMPO's requirement for mandatory medical examination (MME). This similarly is a crucial point, particularly for regulated health professionals working directly with children and young girls subjected to MME, either within a statutory or a non-statutory setting. While guidance providing advice on good practice for FGM medical examination (National FGM Centre, 2019) is available, there is insufficient evidence exploring health professionals' responsibilities and limitations when an MME on girls aged under 18 years old is requested.
Clear boundaries should be established, and a standard guideline developed, as the role of health professionals involved in the MME of this young population could quickly become challenging and perplexing. Legal demands attached to MMEs are sometimes in conflict with the Nursing and Midwifery Council ‘s (NMC, 2018) requirements of protecting and caring for vulnerable people, not always prioritising the client's emotional wellbeing. For example, when producing an FGM expert medical/therapeutic report required by the Family Court of Justice, time constraint might be a negative factor when emotionally supporting the young girl and her family ahead of the MME. Such pressure may often lead to conflict between the different actors involved, each party considering their respective targeted outcomes as a priority. A thorough review of existing healthcare policy with regard to the responsibility of regulated health professionals involved in MMEs of children and young girls is therefore needed and this could sit under the remit of a national FGM Commissioner, ensuring clarity and consistency in clinical practice.
Further responsibility under the role of an FGM Commissioner could include a comprehensive evaluation of FGM specialist services provided by non-statutory agencies, often involved in decision-making around FGMPOs being or not being granted, including FGMPOs' requirement around MME. These organisations play an important role as part of the multi-agency partnership. Drawing on a comprehensive report evaluating FGM programmes introduced across Greater Manchester (McAndrew and Ayodeji, 2019), evidence of challenges is highlighted in regard of the ‘coming together’ of third sector and statutory agencies. Power-imbalance was amongst cited difficulties to enhance collaborative work. While UK national standards and quality assurance processes on FGM (Her Majesty's Government, 2016; Department of Health, 2015) promote an effective connection between agencies, little is known about how productive such collaboration is. The multi-agency approach on FGM is an important methodology in meeting the priority needs of families affected by FGM, as well as the standard requirement established by the Department of Health. It is important to have someone overseeing what is going on at national level, to ensure continuity, consistency and the dissemination of good practice.
It is important to emphasise that with an appointed national FGM Commissioner, the health and wellbeing of girls granted or requiring FGMPOs for their safeguarding, in conjunction with the tailored care package they should receive from regulated health professionals working within statutory and non-statutory agencies, could be carefully monitored. This would provide standardisation at national level, while fulfilling the scope of the NMC's (2018) person-centred care provision and safeguarding requirements.
In light of the evidence provided by Home et al (2020), we would support the call for a national FGM Commissioner as an important step in ensuring good practice in the prevention, detection, investigation and prosecution of FGM crimes, as well as in the identification of victims. Similar posts have been developed within the last few years for anti-slavery, domestic abuse, children and disaster. Considering the cruel nature of FGM, a crime perpetrated against vulnerable young girls and women, we would suggest that this request for an Independent FGM Commissioner in England be given serious consideration.