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Original research
‘Putting salt on the wound’: a qualitative study of the impact of FGM-safeguarding in healthcare settings on people with a British Somali heritage living in Bristol, UK
  1. Saffron Karlsen1,
  2. Natasha Carver2,
  3. Magda Mogilnicka3,
  4. Christina Pantazis4
  1. 1Centre for the Study of Ethnicity and Citizenship, University of Bristol, Bristol, United Kingdom
  2. 2School for Policy Studies, University of Bristol, Bristol, United Kingdom
  3. 3School of Sociology, Politics and International Studies, University of Bristol, Bristol, United Kingdom
  4. 4Centre for the Study of Poverty & Social Justice, University of Bristol, Bristol, United Kingdom
  1. Correspondence to Dr Saffron Karlsen; saffron.karlsen{at}


Objectives This research documents the experiences of people with Somali heritage with female genital mutilation (FGM)-safeguarding services in healthcare and whether such services are considered appropriate by the people who encounter them.

Design Six focus groups conducted with ethnic Somalis living in Bristol, during the summer of 2018, divided by gender and whether people had experienced FGM-safeguarding as adults or children.


Participants experienced FGM-safeguarding in primary and secondary care.

Participants 30 people (21 women and 9 men), identified through local organisations or snowball sampling. All participants were of Somali heritage and aged over 18.

Results Government priorities to support those who have experienced female genital cutting/mutilation (FGC/M) are being undermined by their own approaches to protect those considered at risk. Participants argued that approaches to FGM-safeguarding were based on outdated stereotypes and inaccurate evidence which encouraged health and other service providers to see every Somali parent as a potential perpetrator of FGC/M. Female participants described providers in a range of healthcare settings, including Accident and Emergency Departments (A&E), antenatal care and general practice, as ‘fixated’ with FGC/M, who ignored both their health needs and their experience as victims. Participants felt stigmatised and traumatised by their experience. This undermined their trust in health services, producing a reticence to seek care, treatment delays and reliance on alternative sources of care. Associated recommendations include developing more accurate evidence of risk, more appropriate education for healthcare providers and more collaborative approaches to FGM-safeguarding.

Conclusion All the participants involved in this study are committed to the eradication of FGC/M. But the statutory approaches currently adopted to enable this are considered ill-conceived, unnecessarily heavy-handed and ultimately detrimental to this. Recognising these common aims can enable the development of services better able to protect and support those at risk of FGC/M in ways which are culturally competent and sensitive.

  • health policy
  • medical education & training
  • maternal medicine
  • child protection
  • sexual medicine

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  • Contributors SK led the research project and the conception and drafting of this paper. SK, NC, MM and CP each made substantial contributions to the design and drafting of the paper. SK, NC, MM and CP collaborated on the design of the research and developing the application for funding. All authors were involved in generating data via the focus groups and analysis, interpretation and reporting of that data. All authors have provided final approval of the version published and take responsibility for the accuracy and integrity of the work.

  • Funding This study was supported through several grants awarded by the University of Bristol. The study funders were not involved in the study design; the collection, analysis and interpretation of data; the writing of the report or the decision to submit the article for publication. The authors confirm that they all operate independently of these funders.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for the study was obtained from the University of Bristol Ethics Committee (Reference: K260618).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

  • Author note (1) While the term ‘female genital mutilation’ (FGM) is frequently used in policy and practice arenas, it is controversial for at least two reasons. First, it is applied to a wide range of procedures, some of which are not mutilating. Second, it typically excludes other procedures which are genital mutilating, such as forms of cosmetic surgery and male circumcision. For more detailed discussion of this, see Shahvisi and Earp (2019). The term is commonly used in relation to statutory processes relating to FGM-safeguarding. However, scholars prefer the term, female genital cutting (FGC)1

    (2) The WHO definition of FGM includes a range of procedures including: clitoridectomy - the partial removal of the clitoris or prepuce (type 1), excision - the partial removal of the clitoris and labia minora (type 2), infibulation - the narrowing of the vaginal opening (type 3) and any female genital piercing, pricking, incising, cauterising or scraping for non-medical reasons (type 4). Type 4, therefore, includes procedures which might not be associated with long-term tissue damage. FGM mandatory reporting duty in the UK includes female genital piercing, tattooing and other procedures which are medically unnecessary. WHO definitions of type 1 and 2 also mention ‘total’ clitoral removal, but Abdulcadir et al argue that this relies on anatomically incorrect understandings of the nature of the clitoris.11 12

    (3) Bristol has a long traditional of pioneering work towards the development of effective FGM-safeguarding policy. Collaboration between local policymakers, professionals from education, health, social services and the police and members of the local Somali community led to the development of the ‘Bristol Model’ of FGM-safeguarding, which was subsequently incorporated into approaches across the UK.41 42

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