The re-traumatisation of FGC/M-affected women through invasive and insensitive questioning

Many of the women in the focus groups who had experienced FGC/M said it was something that they wished to forget. As well as the physical and psychological consequences of the experience, it had also damaged relationships within families which had taken time to repair. The majority of participants felt that being asked about their experiences of FGC/M was in itself intrusive and upsetting, with one woman stating: “This is a very private matter. You can’t just ask me what it’s like inside my legs”. Participants objected to being asked about FGC/M when this was considered irrelevant to the health concern. But even where establishing FGC/M status might be pertinent, such as during pregnancy, participants felt that such questioning was often insensitive. That policy required these questions to be asked repeatedly aggravated women, even when they were asked sensitively. One of the issues raised most often in the focus groups was the failure of health practitioners to acknowledge that FGM-safeguarding had already been undertaken and that this information was therefore already available to them:

“When I go to the GP, they ask me again and again, did you do that [FGC/M]? I told the GP, please write down on your computer, I don’t want to do that [FGC/M] and so please don’t ask me any more questions. I hate to hear these kinds of questions.” (Focus Group 1)

Where participants described less distressing experiences with FGM-safeguarding in health settings, encounters had been friendly and open and participants recognised that safeguarding had been performed out of a genuine desire to protect them. This young women recounted a conversation with her GP before a holiday and described the differences between this encounter and others she had experienced:

“She wasn’t saying it in a kinda aggressive way, she was saying it as if it was a normal chat. She goes, ‘I know this is a really silly question to ask’ but she’s like, ‘I’ve gotta ask it’. She just said, ‘There isn’t any chance of you having FGM done [while you’re on holiday]?’ I goes, ‘No, there isn’t’. She goes, ‘That’s fine, then.” If they were a bit more sensitive and they just kinda said, in a polite way, ‘I don’t mean to be rude or insensitive but is there any chance that your daughter could be at risk of FGM? No offence to you or anything’, and the parent says, ‘No’, then…there’s no need to get the police involved.” (Focus Group 6)

However, participants described numerous examples where health professionals had not achieved this:

“Did you have the FGM?” she [midwife] asked. It was like an interview. I was quite shocked… “You have to answer this question,” she told me…She was desperate to fill in this form. I was uncomfortable… It frightened me really.” (Focus Group 1)

Participants also described how these difficult conversations could occur in quite public locations, such as ‘behind curtains, other people could hear…dignity kind of went out of the window’. This reliance on an ‘interview’ style, which followed a ‘form’ or ‘script’, was explained as a consequence of a lack of understanding of FGC/M among health professionals who failed to engage with the knowledge or concerns of their patients: "They don’t know what they are talking about. It’s insulting. You feel embarrassed and attacked". People were embarrassed by the questions, insulted by the fact that health professionals knew so little about an issue they were supposedly educating them about (and indeed, often less than the participants themselves) and attacked by the assumptions about their culture which underpinned these policies and approaches. This apparent lack of care and ‘interview’ style of questioning undermined this participant’s trust and sense of security in her relationship with her midwife, which led her to question her need for antenatal care: “I told her that I didn’t need a midwife like this”.

Approaches to FGM-safeguarding in healthcare were argued to not only ignore but actually risk exacerbating the trauma associated with the experience of FGC/M itself. Our evidence suggests that these traumatising effects are related to:

• the ways in which patients are forced to answer questions about their experiences of FGC/M, even when they explicitly express a wish not to;

• the ways in which victims of FGC/M are forced to (repeatedly) disclose details of their experience to medical staff, approaches which are generally considered inappropriate for victims of (other forms of) child abuse; and

• the insensitive approaches which fail to acknowledge the potential psychological and physical impacts of experience of FGC/M, despite these being the premise on which these policies are deemed necessary.

Taken together, these issues were considered to risk inflicting significant damage on the welfare of individuals, particularly those with experience of FGC/M:

“The parents who had it done, they are traumatised. (…) To ask mothers who are traumatised [about FGC/M] over and over and over again. You’re putting salt on that wound, you’re making it fresh again.” (Focus Group 1)

The impact of outdated stereotypes

Participants commented that the evidence underpinning approaches to FGM-safeguarding drew on outdated assumptions about Somali culture and the positive attitudes of people with Somali heritage towards FGC/M:

“The minute you say there is a problem, because [of] who you are, the first thing the GP will look at you, if you mention anything about that [genital] area, any healthcare setting, they feel obliged to ask you [about FGC/M].” (Focus Group 2)

None of the participants in our study claimed that they supported FGC/M and they all agreed that it was a practice that children should be protected from. Participants in all groups were adamant that these attitudes to FGC/M were common among British Somalis and were frustrated that this was not acknowledged in FGM-safeguarding policy: "Young mothers, born here, do not have FGM". It was argued that these attitudes had been encouraged by migration to Britain, to a ‘different [FGC/M] environment’. People also described the significant impact of Bristol Somali-led anti-FGC/M initiatives on awareness of the nature and problems of FGC/M in Britain. Participants reflected that attitudes to FGC/M were changing in Somalia/Somaliland, such that even these statistics were problematic: “A hundred years ago, this country had a different culture from today. Are the people still living in the same way? They modernised. So, in Somalia, we too modernised”. Participants argued that they were 'trying to find our identity as British Somalis, and we don’t want FGM to be part of that'. But approaches to FGM-safeguarding were believed to directly undermine these aims:

“Even though, as a community, we want to move away from this practice [FGC/M], again, to be slapped across the face with it…even if communities stop practicing it, they will still be stigmatised and labelled by it, and it kind of undermines the progress that we’ve made” (Focus Group 3)

These persistent stereotypes encouraged health practitioners to treat their patients with suspicion, misinterpreting behaviour considered normal (both for Somalis and others) as indicative of potential FGC/M risk: “[My daughter] was one of those shy kids, she wouldn’t take her clothes off in front of anybody. And the nurse kept saying to her “Do you want your mum to leave?” Approaches to FGM-safeguarding encouraged a sense of Somali parents as incompetent and prone to criminal activity: “my mum got taken for an idiot or that she was unworthy of being trusted as a parent”. Parents described how they felt forced to prove their innocence in response to the unsubstantiated negative reactions of healthcare providers. Parents were asked repeatedly about their plans to arrange FGC/M for their daughters. This was interpreted as an attempt by health practitioners to ‘catch people out’ and admit their dishonest and criminal intentions. Not surprisingly, this was considered extremely disrespectful:

“And my mum was like, “No… no-one in my family’s had it done, I don’t know where you got this information from” and she [Nurse] kept on badgering my mum, as if she was trying to get information. Like, I know when someone tries to be manipulative, as a professional, it’s very easy, she kept asking my mum… It was very patronising, and my mum was getting frustrated because… you know, when you see your child’s in pain and no-one’s helping them, so the more frustrated my mum got, the more angry and the more guilty it made her look…Everything got brushed aside. It was just fixated on making my mum look guilty.” (Focus Group 6)

A failure to acknowledge potential changes in attitudes towards FGC/M among affected groups can exaggerate a perceived risk and encourage practitioners to view their patients with suspicion, undermining the provision of sensitive and culturally competent care. This directly contributed to participants’ loss of trust in their health providers and sense of exclusion from wider society.

Loss of trust in health services

There was a strong sense from across the focus groups that the health needs of Somali families were being overlooked in efforts to collect data on FGC/M: "Before they cared about your health and how the child was feeling. Now it’s just FGM". This sense of the de-prioritisation of a patient’s health needs was evident in a range of healthcare settings, including in general practice and midwifery care, as well as acute A&E services. Even those with potentially serious symptoms could have their health needs overlooked in efforts to conduct FGM-safeguarding:

“Instead of the nurse trying to figure out why I was in such pain – you know, the usual procedures, bloods, blood pressure, all of that – she [the A&E Nurse] skipped all those steps and directly, she was like to my mum, ‘Have you done FGM to your daughter?’… I think it’s quite dangerous when…if a nurse or a doctor hasn’t been given enough training or [has] enough awareness on the topic to the point where they might misdiagnose the patient” (Focus Group 6)

Participants described how the Somali community—through their own educational initiatives—had become more aware of the health implications of living with FGC/M. But, even here, the focus of health providers on FGM-safeguarding and data collection meant that the health needs of women could be ignored:

“Now there is a fear [that] she [the woman with FGC/M] will lose the child, she will have health problems, complications. [Somali] People are now more aware of the [long-term] health issues [of FGC/M]. How do we get our service providers here to understand this?” (Focus Group 4)

Such evidence further highlights the limitations of assumptions regarding the educational potential of such health provider engagement.

Participants described ways in which experiences of FGM-safeguarding had directly contributed to a loss of 'confidence in the health service'. Inappropriate or insensitive healthcare generated an on-going concern among families:

“We are just very worried now. I’ve got a daughter who is nearly 12, if anything should happen to her, to her privates, if she gets an infection, the first thing that comes in my mind is this situation [FGM-safeguarding]. […] It’s very stressful, it keeps coming back. The first thing that comes in my mind is that the doctor will ask you this question.” (Focus Group 1)

There is a tangible fear relating to parents’ awareness of their inability to protect their children from a system perceived to be designed to harm people. This service disengagement led some participants to rely more heavily on unregulated or unorthodox medical and non-medical alternatives, while others described engaging with health services with more reluctance and at a later stage: potentially risking their health and increasing the need for more intensive medical responses. Importantly, participants reflected that the problem with FGM-safeguarding in healthcare, and more generally, was as much one of legislated policy as its implementation. Health practitioners were often argued to have no choice, that they were just ‘doing their job’: “they feel obliged to ask you [about FGC/M] because they don’t want to get in trouble”. But while this encouraged a little sympathy for health providers, it also discouraged hope for future improvement.

Policy recommendations

Participants in several focus groups recognised the positive intentions of FGM-safeguarding and all acknowledged the need to protect children at risk. However, approaches adopted to achieve this were believed to be unjustifiably aggressive and counter-productive, to the extent that ‘Safeguarding policies [had] exacerbated and exaggerated the situation’ rather than resolving it: “I think the safeguarding policy is fantastic, [but] you have to take precautions because…the end goal is to stop this happening, but if we are to stop this happening, we need to think about the process. If we are offending people, and to a certain extent, violating people [we will be unsuccessful]” (Focus Group 6). The introduction of FGM-safeguarding was seen to have directly contributed to a loss of empathy in the provision of healthcare to not only individual Somali families, but the entire Somali population:

“People are more result-orientated than [interested in] looking at the feeling and perspective of the community and parents who are involved, or even the young child who is involved. Being result-focussed, it is more difficult to be empathetic with someone.” (Focus Group 4)

Participants argued that there were problems with the evidence underpinning these policies as well as with their implementation. People were concerned that the statistics collected as part of the FGM Enhanced Dataset, which focus on women who had experienced FGC/M as children when living outside the UK, could be ‘misuse(d)’ to inflate perceptions of the scale of the FGC/M risk posed to young girls living in the UK. Participants also considered it unhelpful that the statistics collected included those for ‘piercing’, ‘cosmetic (surgery)’ and ‘different (less invasive) categories (of FGC/M)’, which were less relevant for addressing what they considered to be the most pressing ‘FGM issue’. This amalgamation could also be used by the media and others to exaggerate the prevalence of FGC/M and further stigmatise the Somali population without justification. In order to get ‘more accurate and precise statistics… that are not so biassed’, there was a need to ‘hear the views of the young people who were born in the West’.

While some participants acknowledged the contribution of Somali people to the development of FGM-safeguarding approaches in Bristol (although attitudes regarding the longer-term success of this collaboration varied), others felt that the engagement of policy-makers and practitioners with Somali people in Bristol had been less than comprehensive. Recommendations for improving services therefore emphasised the need for more inclusive approaches, involving different FGC/M-affected groups, in the development and implementation of safeguarding services, with ‘a proper consultation’ to develop ‘policies which we are part of’.

A constant theme among participants was the significant need to improve the education received by professionals involved in the provision of statutory FGM-safeguarding. Education was required to ensure that staff could identify and describe forms of FGC/M, and better support those who had experienced it. ‘FGM Standards for Training Healthcare Professionals’ were published in 2018,45 and built on the earlier safeguarding curriculum. Training on FGC/M type is included for some, but not all, staff. Participants also described a need for more awareness of the potentially traumatic effects of FGM-safeguarding itself:

“You gotta think about the child, as well. Imagine having to go into a hospital or doctor and get examined. Just imagine how uncomfortable you’re feeling when someone’s like searching your private parts. That’s almost like a violation to you because that’s your private parts… …we have to be very considerate of the situation.” (Focus Group 6)

While current guidelines expect those conducting genital examinations of children to be considerate of appropriate approaches, it is unclear whether this will be sufficient to address this. Professionals also needed training to ensure that information gathered on people’s FGC/M experience, was gathered sensitively, to avoid it being experienced as an ‘interrogation’:

“It’s a relevant thing to ask [but] it’s a very sensitive thing to ask so the wording around it and how you actually approach a parent…it needs to be sorted out otherwise I feel like a lot of Somali parents are going to … take it as an offence, instead of a general question. When you are questioning a mother about ‘are you going to send your child over there to get FGM done?’, it can come across as a threat against her culture, against her parenting. It’s like asking any parent, ‘Are you going to starve your child?’, [the reaction is] ‘Are you mocking my parenting? Why would I do that?’ That’s why I think a lot of people are very defensive.” (Focus Group 6)

More general training to provide sensitive care and enable health providers to ‘be sensitive to that person’s culture’ was required. More specifically, recognising ‘the historical [pre-migration FGC/M] context’ and how that might have changed over time would also enable them ‘not to automatically assume that you’re guilty of this crime’. Participants argued that not only were Somali people not supportive of FGC/M, but they now understood many of the health implications of aspects of the practice. This identified need was not recognised by health providers, and is not acknowledged in training guidelines.

Participants were particularly frustrated with the ways in which a failure to acknowledge these cultural changes encouraged mothers’ experiences of FGC/M to be used as indicators of risk for their children, which unfairly framed them as potential criminals rather than victims and drew attention away from their healthcare needs. Participants felt that acknowledging that not only Somali cultures were associated with FGC/M would help address the particular ways in which those with Somali heritage were ‘targeted’. A Public Health England FGM training video which ‘shows that it’s not just one ethnic’ group was highlighted as making a positive contribution to this realisation. Developing knowledge of these ‘facts’ was considered important for restoring a ‘belief in the system’.

A more collaborative approach in healthcare, and more generally, would enable more successful interventions within families and cultural changes that could eventually lead to the elimination of FGC/M. This improved communication should also extend to establishing more effective means of responding to negative treatment: "I think my mum did try and put in a complaint [to the NHS]) but then she left it after a while because she said, “it’s not worth it if somebody’s going to be uneducated. There’s nothing I can do about it”". More sensitive approaches were argued to have the potential to engage families around FGC/M while minimising the harm associated with current practices, including the sense of fear, stigmatisation, criminalisation and (re)traumatisation which is evident in current approaches:

“If I was approached in a correct manner, I would obviously cooperate, but if I was approached in a manner where I felt targeted, harassed, I couldn’t cooperate at all.” (Focus Group 6)