I think it's just sort of. Good morning, everyone, and welcome to the green round today.
Today's our third global surgery. Grand ran for this year and we were very ambitious in organising three speakers for today beat half term.
But you know, one of the speakers very well, which is Chris Larvae, and I think whatever he has to say, he's going to take the entire grand round.
So I've decided to defer his talk for next week. We've chosen this topic of FGM because it's quite a political discussion taking place in parliaments.
Councils are talking about it. School children have been primed about this, and even in our mandatory training,
it has been brought to our attention that this is an issue that we need to think about and tackle.
We also have some members of staff from the safeguarding team.
Six Welcome to to the Grand Round without much due to introduce the first speaker.
Who is Anita making? Anita is one of our consultant, Obstetricians and Gynaecologists in this trust, and she's also the director of Feargal,
which is the International Federation of Obstetricians and Gynaecologists, which is based in London.
She has a master's in public health, and regarding this topic,
she is currently lead of a rose clinic that is run in Oxford for patients who have suffered through this kind of cultural action.
The second person is and Anita will give us the global perspective of of this condition.
The second speaker is Dr Katie Newell Jones. She has a PhD in education, and she's been in education for the past 30 years.
She was awarded a Lifetime Award for National Teaching Fellowship by the Higher Education Authority in 2004.
Regarding this topic, her attitudes and beliefs and practises associated with this condition began in 2009 in Kenya,
and then she extended this work to Tanzania, Somaliland, Sierra Leone and Liberia.
But presently, she is working with two NGOs and is connected to the W.H.O. reproductive health desk.
Regarding FGM, so without much time, Anita, okay, so I'm going to talk to you about female genital mutilation or female genital cutting,
and it's going to concentrate on giving you a bit of a global perspective and sort of introducing Katie's
talk where she's white and she will go into detail about the sort of socio cultural aspects of it.
But I thought it was important to just make sure that we all kind of understand what FGM FGC is and also where we stand at the moment in the UK.
So the definition of FGM,
if she sees any procedure involving the removal of the external genitalia or other injury to the female genital organs for non-medical reasons.
So the W.H.O. classifies FGM into four different types, so first one is type one FGM,
which is partial or total removal of the clitoris and or the précieux.
So just the skin overlying the clitoris also don't when you remove the clitoris as a to reject me.
And FGM type two is a partial or total removal of the clitoris and some of the labia menorah with or without excision of the labia majora.
I think that's a much rarer FGM. Type three involves narrowing of the vaginal orifice with the creation of a covering seal by
removing some of their labia menorah and then actually stitching the remaining parts together.
So this opposition of the labia menorah and or the labour majora.
And you can have excision of the clitoris with that or not. So it involves sort of closing up the vagina.
And Reuters, as well as the removal of some of the anatomy and then type for Israel,
is really any anything else that doesn't fit into types one, two or three.
So any other harmful procedure to the female genital female genitalia for non-medical purposes?
So examples of that might be pricking piercing in sizing, scraping cauterise Asian also recently seen elongation of of labia mineral majora.
So here just some diagrams of what we're talking about. So type one FGM.
You can see the on the top right. The little red area would be removal of often just the prep you.
So sometimes some of the clitoral gland underneath it or all of the clitoral glands.
Type two, hair snow removal again up on the right and the red is the area that's removed,
so removing either just the prep use or some of the clitoris,
but then also some of the labia menorah and the bottom right is how you would see it sort of years down the line.
So as a woman, you would see scarring a sort of anterior superior posture portion of the female genitalia.
And then type three involves removal, usually removal or cutting of sometimes the clitoris, also the labour menorah, but then importantly,
the stitching together of the opposing remaining genitalia so that there is complete,
not complete closure, but almost complete closure of the endroit.
So obliterating the external the urethra on the 8es and narrowing very much the the vaginal entreaties as well.
So as you can imagine, the consequences of FGM or FGC will vary very much depending on which type the lady has undergone,
whether it's a type one, type two, type three or type four. But some of these table shows some of the consequences.
So physically, obviously at the time of the of the surgery, they would have a lot of pain.
The little area is a very vascular structure, so quite a lot of profuse bleeding at the time of the injury.
Usually, people who remember having it done will describe difficulty or pain when passing urine because it's all very stinky areas you can imagine.
And then if they've had a type three search or closure of the interrogators, then they'll have difficulties with menstruation,
sometimes difficulties with passing urine said not describe sort of normal flow.
And then obviously for intercourse and also vaginal birth, they often will require D and fibrillation.
So an opening up of the entreaties, which has been stitched together psychologically.
So depending on when the lady undergo underwent FGM or FGC and her memory of the event, then she may indeed suffer from traumatic memories,
PTSD and so on sexually of C sometimes inability to have sexual intercourse at all if they've got a very severe type three FGM.
So they would require DNA fabrication and often describing disparu nia so on intercourse,
superficial pain with the scarring that's left even with type two, I would just type one FGM.
And if the clitoris is removed, then an orgasm you as well would be a consequence.
So who's performing this well again across the globe? Depends where you are.
Who would be involved? But this can go from quite a medicalized practise in some countries.
So doctors, nurses or midwives doing it in hospitals to nurses and midwives doing it in their own practise, sometimes at home or within villages,
to traditional birth attendants doing it under sort of less obviously sterile conditions in rural areas or lay women who are within that village.
It would be their responsibility to do the female ceremonies, which include circumcision.
So then we listen to all of this and think, why on earth are people practising this?
Katie will go into the complexities of it in her talk, but in some cultures it's culturally accepted as normal,
and that's what's expected part of a coming of age process.
So part of these women ceremonies in some cultures, there is a belief that it would reduce promiscuity or unfaithfulness before or during marriage.
And also, in some countries, it ensures marital suitability so a lady is not able to be married unless she's been circumcised.
So really important sort of step towards growing up, if you like.
So this is an interesting picture, which I found on the internet, but it's called Dancing Girls, and it's a picture taken in Sierra Leone in 1910,
and it's a picture of the girls who have undergone their secret society meeting and the ladies on the right and on the left.
Wearing the masks will be the ladies who were in charge of the ceremony. And if you have a look at the one on the left there.
So this is a photo which I took 100 years later when I was in Sierra Leone working for MSF.
You can see the mosque on the right is identical to the mosque on the left here of the picture that was taken in 1910.
So in Sierra Leone? Just thought I'd give you an example. This is where I first came across FGM, FGC.
It's part of a of a ceremony which where girls take part in a secret society.
This is something that their parents decide that they then go to the ladies with the masks on.
They're actually called devil masks, and the ladies are in charge of the whole ceremony,
which will involve a lot more than just the cutting, just the FGM or the FGC.
It will involve trying to explain to the girls what it will be like when they grow up, what menstruation means,
what their duties would be as a wife, what their places in society as a potential future mother.
Was quite a matriarchal society. Sierra Leone. So the girls sometimes would be very excited towards, you know, having the ceremony.
They go in, they disappear off into the forest. The families will give them lots of food to survive several weeks and so on.
And they dance and they sing and they sit around fires and they talk about what is going to be like when they grow up.
And then as part of this big ceremony in Sierra Leone, FGM or FGC will be performed as part of that act.
But when we say, why do we do it so 100 years? Is down the line in Sierra Leone that dressed in the same way and doing the same practise, and again,
this was the photo, so that lady was in charge of this group of girls who would vary in age.
So I think since the Civil War, the age at which girls would take part in the ceremony has gone down.
And I think that's been a trend across many sub-Saharan African countries.
It doesn't necessarily mean that they are going to be married immediately after their ceremony,
but it's part of their initiation into the realisation that they're growing up and that they are are going to leave their original families.
So globally, about 200 million women have undergone FGM in the world today.
These are estimates from UNICEF and UNFPA, and I must say it is very,
very difficult to get accurate data on FGM and FGC prevalence and practise at the moment.
So you need to treat the numbers with a little bit of trepidation so that half of these are actually in Indonesia, Ethiopia and Egypt.
And that doesn't mean that it's super common in Indonesia, eastern Ethiopia and Egypt.
But actually, they've got a large populations and a large proportion of those women have undergone FGM.
So it's known to happen across 30 countries Africa, Middle East and Asia,
and there's an estimate that about three million girls are at risk of undergoing the procedure each year.
So again, bear with me with the stats, because it's very hard to find good statistics on this, but there's thought to be sort of a band across the,
you know, the centre of the world where there are countries which are involved in practising FGM and FGC.
So in green, never. And then as you go through to the yellow, orange and then red is more than 50 percent of women have undergone FGM,
so you can see this up Africa and some Southeast Asian countries.
So this is probably the most scientifically sound data that I've come across.
It's a systematic review, and it's using demographic get demographic health surveys and mixed data sort of pooling them together
and trying to work out if there are regional trends and what's happening over time with FGM and FGC.
So you can see there, if we look at the right hand column,
we're looking at the overall average annual percentage changes from the first survey that they looked at,
depending on what was available in each of those regions to the last survey that they've looked at.
And so in central Africa, you can see there it's quite a small number of surveys.
So only for survey starting in the first one was 2004, and then they're comparing it up to 2015, and you can see the statistical significance.
Not great. So we don't really know what's going on in central Africa, but likely to be sort of static in terms of any change.
East Africa, you can see there 13 studies looking from 1995 to 2014.
So you've got there are fairly good evidence of a decrease minus seven point three percent of average annual trends in circumcision
happening North Africa again nine studies to minus four percent also decreasing trend West Africa good number of study,
17 studies and also a decreasing trend. So a general understanding that in an Africa, at least it is decreasing in practise so has done over time.
And then in western Asia, they're difficult to interpret. There's only three studies and it's actually only covering two countries.
But it does say there's an increase. And if we look at this graph, which is drawn from that table, you can see the pinky purple line is western Asia.
So just a caveat on that because it only actually includes two countries which are Yemen and Iraq.
Whereas the information on Africa is much more widespread in the surveys are much larger,
so probably much more significant, but generally speaking, a decreasing trend.
And in many places and countries with the highest yearly average, they've got their Mali 73 percent,
Eritrea 67, Mauritania 61, Guinea 50, Djibouti 49, Somalia 46 Sudan.
And there's a typo there. If anybody's interested, they can go back and read it.
So why does it matter to us, or why does it matter to UK practise?
Well, it does matter a lot because of immigration, and a lot of these women may be living in the UK, so it's knowing how to deal with them.
What? What are their needs? Are there any needs? What are they and how best to deal with it?
And importantly, it became a very as Kokila was alluding to.
It's become a very politicised subject, and there was a Female Genital Mutilation Act, which came out in 2003,
which said that it was an offence to carry out FGM and that it carries a sentence of up to 14 years.
And so far to date, there's only been one conviction using this act.
But importantly, there's other reasons that people can go to jail other than just if they carry out FGM.
So offence to assist a girl to mutilate her own genitalia. It's an offence to assist a non-UK person to mutilate overseas a girl's genitalia.
And then lastly, which is what a lot of the parents that come to that clinic in Oxford are worried about is that it's an offence to protect,
to fail, to protect a British national from having FGM, even when outside the British territory.
So what that means is that if a parent has a British born child and that child goes back to
their home country with their grandparents or stays with their grandparents and undergoes FGM,
when that child comes back to the UK, her parents are liable for what happened to her in the country that she left.
So, you know, it's really quite a punitive law at the moment.
And then I just put at the bottom that the FGM enhanced data set.
Claire Robertson, one of the pitchers and so who is in charge of the safeguarding and so on of the girls?
But just to say that the government does have a data set and women who come through the FGM clinic, um,
we asked them whether they're happy to be on there on the enhanced data set, although the government says this isn't deemed and deemed necessary.
But there is a form of collecting data on these women, and this is also a big,
controversial area because a lot of women may not want that kind of information to be wildly discussed, or even though in theory, it's anonymized.
So, so quite quite sort of strict laws and and monitoring of what's going on in the UK at the moment.
And again, just to give you a pointer if you're interested in reading more about this.
So more recently, there was an article in The BMJ by Sarah Crighton,
who does a lot of the FGM work in London talking about how we're tackling FGM at the moment in the UK.
And is it actually the right approach? This very punitive sort of strict management of what happens to a lady with FGM in the UK?
And that has been there quite a bit of back and forth about whether actually the evidence that we have supports,
whether we have sufficient evidence about FGM statistics in the UK to be doing what we're doing and whether we have evidence
that what we're doing at the moment is actually beneficial to these women or whether we may be making things worse.
So generally, what happens in Oxford?
So Brenda Kelly, who is unfortunately not here and found that the Oxford Rose Clinic here at the J.R.R and I'm running it at the moment.
So it's a monthly clinic, it's multidisciplinary.
So we have a specialist obstetrician and gynaecologist.
She be myself or Brenda, psychosexual counsellor, stroke general practitioner and also a clinical psychologist.
And the clinic is set up to deal with health issues associated with FGM for pregnant women, but also for non-pregnant women.
So we try and see the pregnant women more urgently because as you can imagine,
if they've had FGM type three and it's an issue for delivery, then we need to split the ladies before they they go into labour.
But we do. We do see a lot actually of non-pregnant women who either just want to find out what they have or what it what it means to them,
or if they actually have consequences from it and need some support with that.
So it's an opportunity to educate and hopefully we try to instil a sort of measured and appropriate response to each and every case because it varies.
As I've tried to give you an idea of what's happening sort of across the globe,
you can imagine sitting in a clinic, getting people from all over the world.
Actually, one person's experience, for example, in Indonesia, might be very different from another a Sudanese lady.
So lady with the type one from Indonesia to a type three from Sudan will be a very different experience and need a very different management approach.
So we have also prenatal and fibrillation, as I said, for the pregnant ladies.
So this isn't to test.
I mean, I'm sure Brenda is looking into the numbers, but this is just based on my experience of of of the ladies that we've been seeing.
So the reason that they're referred.
Well, the main source of referral to the Rose Clinic are midwives who see ladies antenatal when they do their booking appointment.
One of the questions that they have to ask the woman is Have you suffered from FGM or FGC?
And if they say yes, then they automatically get referred to the Rose Clinic and that standard so vast majority.
A lot of women are referred through that route, or that can be self referrals or GP's, obviously, if women have had issues.
So as you could expect, the DNA rate is quite high, about 30 to 40 percent.
I would say something like that in terms of DNA, and this may be several fold,
but I think the punitive nature of legislation in the UK definitely contributes to this.
Women do not want to come and tell us, you know, come to a clinic to talk about FGM and see if they don't have a problem with it.
And they've heard that it's something that the government is collecting statistics on, then they don't want to come to clinics.
So our DNA rate is quite high. I'd say the vast majority of women who come do not perceive it as a problem.
So the vast majority that we see a type one and type two, and they often have no memory of the incident because it was done as a child.
So before the age of force in some countries, actually as babies and they don't have any sequelae from it, they they don't really see it as an issue.
It's something that happened to them as part of their culture.
But it's not a problem at all to say that type one and type two FGM can often be missed.
So often, people will have had reasons to have other examinations prior to coming to the clinic.
So, for example, for a smear and so on, and no one will ever have commented on the fact that they have FGM because it can be quite subtle.
The scarring can be quite subtle, particularly if it's just a type one or if it's a mild type two.
So sometimes you have women coming and saying, Well, no one's ever mentioned this to me before.
You know, why is it not become an issue?
And they might have been seen by multiple multiple health practitioners who haven't necessarily picked up on it, even though they've had examinations.
So continuing about the women, says the proportion of women who will report an orgasmic and dyspareunia,
particularly prior to their first birth to their first maturation.
They often describe that improving after the first birth, and there are a small proportion who obviously do remember the incident.
So particularly when the FGM or FGC is performed later on as an adolescent or as an older girl,
they'll remember every single detail of that event, and they can describe it to you.
Like, it happened yesterday. I've seen ladies in their fifties and sixties describing what happened to them as a
child aged six or seven because the whole event was so traumatic and so horrific.
So there are extremes of how of people's experience of it,
and these women were very glad to have support in terms of a clinical psychologist that can help them deal with that.
Other women do not want to actually remember anything about what happened because they buried that in the past and they've got on with their lives,
and they actually don't want to be questioned deeply about something that happened that long ago, which they've put behind them.
So there's a big variation on a the effect it's had on them when they had it and what kind of care they need.
And some women find the terminology upsetting, upsetting,
so calling it mutilation rather than cutting because they don't feel that they have been mutilated.
Other women who had terrible experience feel very much that they've been mutilated,
and that was something that was done against their will that they remember as horrific.
So it's quite varied again. And then just to explain so depending on where you are in the world, your experience would be different.
But we see Indonesian ladies who have who would have had the procedure done in hospital immediately after birth by doctors under anaesthetic.
And it's done as a boy is circumcised at birth, so a girl would be circumcised as well.
And that's just removal of the prep use. So the skin covering the clitoris.
And so they particularly find the term mutilation quite bizarre and believe it
to just be part of the sort of normal way of being and would happen if they,
if they were in Indonesia, would happen to their children if they were back in Indonesia.
So most women who are seen, if they have no sequelae sequelae do report that they wouldn't continue the practise on their daughters.
But some of them very honestly say, Actually, if I was back in my country, my daughter would be circumcised.
Not particularly because I think it's a good thing to do, but because my entire culture,
environment, my, you know, my parents, my aunts and so on would expect that to happen.
And so if we were back, there probably would.
But I, you know, if I'm here in the UK, I don't feel it's a necessity in extreme that she needs needs to have this done in order to get married.
So very varied, very varied group of women with a varied, um uh, various issues, some of which are trivial and some of which are incredibly serious.
So that's the end of my talk. It was more really just so that we all had the same understanding of what have FGM and FGC is and introducing Katie,
who said she already been introduced by Kokila, but she's going to come and tell us about her very broad experience across the globe with FGM and FGC.
Thank you. Thank you. And it's great to be invited to speak here.
Can everybody hear me? OK, if I don't, I tend to wander a little bit.
OK? My name's Kate Jones. I'm not a surgeon.
I've been working in health settings for plus years, and I've been working more along the lines of social interactions.
Why practises happen and what can we do to stop them?
Great to see Tony here. Tony Jeffries, who who after many conversations in different places, said, Why don't I come along and talk?
So I've worked in quite a number of countries, including in Somaliland, and quite a lot of my work has been in Somaliland very recently.
And so that's the country that I'm going to focus on this morning.
So this is really where where I've been working at the moment.
So since 2015, I've been involved in Somaliland and with ActionAid and also a small local organisation called Somaliland Family Health Association.
And I've been carrying out research. So, you know, the research has been a combination of qualitative and quantitative.
And as you'll see, we've got a total overall of about 4000 people who have been interviewed in these two pieces of research,
both baseline and mid-term reviews, which are happening at the moment. We're just finishing off of a final of those midterms at the moment.
Somaliland has also been looking at national indicators for FGC to be thinking about this whole issue, as Anita said, What do we measure?
How do we measure? Because it's not easy and especially once in a country you have a law which there isn't in Somaliland,
you start pulling into communities and asking people whether they're cuts or whether they're going to cut their daughters.
And people know that that's illegal, and it's quite difficult to get honest responses to that.
So they're looking at national and international indicators.
And then we've also been running. I've been facilitating knowledge sharing workshops for the last couple of years in Somaliland,
working with all the organisations who are working to end FGC and also government ministries and community leaders.
So that's a little bit of where I am and where I'm coming from.
So where is Somaliland? It's that sat beside me.
So it's part of Somalia. It's an independent state.
It declared its independence in 1991. Now, Somalia is one of the countries with the highest rate of FGC.
So 98 99 percent of women and girls are cut in some description or another.
And 80 percent and these are D.H.S. And mix figures.
80 percent of those women have had the most severe cuts, W.H.O. type three, as I need to show you with all its ramifications.
So mid-term reviews, if we started cutting through so mid-term reviews, if she's just these,
these last couple of years, we're talking about the overall prevalence still being 98 99 percent.
So in most communities, most people, most men, most women, those children don't know someone who is hasn't been cut.
So if you can imagine being in a in a culture where everyone is cutting.
And one of the things which is really quite scary for me was that when we after several years of interventions,
the young women ages 12 to 24, the same rate, it was about 97 98 percent of 12 to 24 year olds are cut.
Now there's a change so that they're the type of cuts is less, but they're still being cut.
So we've got 92 percent of women interviewed and undertook to cut in with stitches still in the mid-term review.
However, only half of them 51 percent of their daughters.
Have that so you can see a big shift from 92 to only half of the has been cut, so got this change in the type of cut.
So you've got to stop here.
We there's a whole load of different types and the different terms, Somaliland being an Islamic country.
And we've got to kind of zero tolerance. Nothing happening over here.
You've got type one, which freed a lot of these recent interventions was what was happening and the called the sooner sooner being Islamic Courts.
We've got the intermediate top two, top three and the top four, which is coming in, which is a pray.
There's been a lot of change, so that's the range of what we've got.
OK. And Anthony,
you've also got a range of the type of instruments that are being used from your traditional cutters to your table as to what your nurses,
doctors and midwives might be using. So, um, I come from a body of thinking, which is that thinks of FGC as being a social norm in a community.
So it is something which happens because it happens and because it's it's working within the community now.
Why it's important to think of it as a social norm is that we often as external people, but also health people or whatever.
We go into a community and we think, Oh, let's tell people what all the complications are for cutting.
And if I tell people that if they cuts, then their daughters may have fistula, they may have this and they have that,
they're going to have monthly kidney infections, et cetera, then if they know that they'll stop cutting.
And that is very much from an individualistic approach to be thinking that if I do that, then stop cutting.
If we look at it as a social norm, then that's rather different.
So in order to be a social norm, there are these three conditions.
One is that it's valued by a community. And as Anita was saying, and as we've we've seen in many, many ways, cutting is valued is expected of people.
If you are cut, you are of a higher status, you're marriageable.
You have celebration, you have new clothes your family can celebrate.
So it's very much valued by the community. So if you decide not to cut your daughter, you're going against that.
It's also over on this side. It attracts sanctions and benefits, so people often think, Oh,
there is this disadvantages to being cut that can't possibly be advantages to being cut.
Well, actually, there's loads of advantages to being cut,
even if you're being cut by the most severe cuts because you're socially acceptable, you marriageable, et cetera.
OK in Somalia.
And just recently when I came, when I was last there, I met a young woman who was trying to decide whether or not she was going to cut her daughter.
Now her family has a camel camel tribe, and they and she sells the milk.
That's what her. That's the income from the family. Now, the local community are saying, if you don't cut your daughter, we won't buy your camel milk.
So in terms of sanctions, that's a massive thing for the family.
So there's a mother she's trying to decide, is she going to take an individual decision not to cut her daughter?
And if she does, what's that going to have on the whole of the extended family?
So sanctions and benefits?
And finally, the third one interdependency, I cut my daughter because somebody else cuts their daughter and he expects his daughter to be cut.
And so, so perhaps their daughter. And we will have social norms within our.
We're not within our community. If we we have a lot of eating social norms, we have a lot of if you catch public transport in the UK,
then generally speaking, you get on a tube train or bus, you don't talk to strangers.
You keep your eyes down. You don't talk to people in the UK.
And that's our social norm. If you start chatting away to people, people start thinking, you're a bit loopy now some.
Or else. And those of you who come from different cultures, you wouldn't think of going on public transport,
and I'm just from Kenya just recently wouldn't think of going and getting on it
and attached to a bus without saying hi to a couple of other people on that.
So social norms are part of what keeps us going. These social norms are keeping that practise in place.
So if we think we can change by just saying, here are the health complications now, stop it.
We've actually got to think of a whole load of other things around in order to stop this game in Somalia.
So down the bottom here, Becky celebration in my life.
Just like Anita's picture, when I'm cut, I'll be purified ready for marriage.
And it's a fantastic thing. And that is a lot of what young people, when they're looking forward to it, they might know that it's going to hurt.
They might know there might be complications, but it is something which they're looking forward to.
Not all, not all, by all means, but may. If I'm not a man, you are.
That's a positive benefit of being cut down the bottom there.
You've got a negative one, so you've got the being called names not being allowed to marry, et cetera, et cetera.
So all of these issues around there.
So it's not an easy decision to decide whether or not to cut what we've looked
at in the research in Somaliland have been all this whole lot of things.
I'm going to concentrate on medicalisation. I'm also going to talk about decision making dilemmas as well.
So so I'm going to concentrate on just on medicalisation because here we are in the global health group.
So medicalisation here.
What we've got is there's an increase in Somaliland in the medicalisation of cutting.
OK. So when I first went in and people said, Oh, it's it's so small, we don't even need to talk about it.
But hang on. It is changing. So here we are, right down the bottom.
So we've got the blue is the baseline. The so that was the section.
So 2018 and the NCR was the data was collected in 2018 and then some of it.
So we've got women overall, women back up by a health professional.
Yes, it's low. It's less than 10 percent. However, if we look at women under 25, we've got that group.
There's actually a doubling more or less of the proportion who are being cut by a health professional.
When we ask those people, What about your daughters? What are you who cut your daughters?
You can see a massive change.
So all of the women in the mid-term review, we've got 44 percent of them saying that when they thought this was more cut,
I remember it was still 98 99 percent for the daughters being up, they were being cut by a health professional.
Now this is quite shocking. OK. And look at that change.
Right? And this is the first time that this sort of data has been revealed in Somaliland, and it's influencing the debate.
It's influencing policy is influencing the Ministry of Health once again on this issue.
So that was the ActionAid one.
This is the this is so for the Somaliland Family Health Association, and this is again for their mid-term review review.
I mean, it's a different communities with different regions of the company and from other digits.
So here we've got the interviewee, her daughter and her future daughters.
OK, now you will see a slight. And this is for the mid-term review, the mid-term review alone.
So we're actually up at those those higher, those higher figures.
Now the reason why this is 19 percent rather than just, say,
eight or nine as the last straw for this piece of research focussed more on younger people.
So we've got slightly higher figures. But again, you look at that between the interview, we heard all.
And future daughters. And now we're over the tipping point.
We're just 71 percent of people intending to have their daughters cut by health professionals.
So this is a serious issue. And W.H.O. are now involved in some training in three countries that I've been working with them on.
The pilot will be in Guinea, in West Africa, in Kenya and also in Somaliland.
And that'll be looking at training of health workers to reduce medicalisation, so positive perceptions.
And this goes back again to our social norms. So in a rural community over in Sana'a, only the Seabreeze.
And so this is when they were asked, Who does the cutting? I ask them, Who does the cutting in your country?
It's severe is in traditional cuts as we don't have anyone else, and it would be much better if we did.
OK, so this is what our community is saying.
And down the bottom again, this is a semi rural community over on the West and again until a few years ago, traditional cutter used to come.
Now she doesn't come anymore. Instead, we gather all girls together and we take them to the Mk8 and we have them cut.
So these are communities, communities and communities, and they're saying this proudly, absolutely proudly that this is what they do.
This is what they do in order to, in their opinion, keep their girls safer.
OK, so here a community facilitator, a wonderful young woman and her nephew.
And this was last September, and she is one of the community facilitators on FGC project.
So she is campaigning for the end of cutting OK.
And she says this. So I would say just after the summer holidays,
and she was starting to take her three nieces to a traditional cuppa and then a friend phoned her and said, Don't do that, go to the MSI hedge.
And interesting things there she went, and I said to her, did you have to make an appointment?
No, I just went along and she was so proud. The girls who put the plane straight away went to school the next day.
They had to type two with two stitches.
So there will have been serious. Most likely to be serious complications as the years go on.
So one of the other things, which is a misconception in Somaliland,
is that putting it where it's only pricking or snipping only types one and three are generally speaking not regarded as being FGM.
FGM is considered to be that's quite severe, very severe removal of every single type through.
So again, this sort of trend and kind of posing to you now, you know, what are you thinking now about this as medicalisation?
Is this a good move? Is this a good move?
Because when they get into an NCAA champion being done there, there's an aesthetic, there's a skilled midwife and there's often antibiotic as well.
Is that better? Is that what we want? So here we are.
A nurse interviewed. So this was in a government hospital, in a rural communities, and so here she goes.
I was sadly cut before the community changed from the four on it.
That's type three to the surface type of cutting. She suffered all her life.
She's got no children and no grandchildren. And here she is.
She uses A. Anaesthetic for the two stitches.
Not for just the pain of it. It's more healthy to do it here.
It's a septic sterile. OK.
When I asked her how she felt about doing this, she said I feel a lot of happiness because she is doing something to her,
the next generation of girls, which is less harmful in her opinion, than happened to her down on the bottom.
She actually said to me, I need more training on this, I need more training to do it better should she get that training.
The Ministry of Religious Affairs in Somaliland believes she should.
They want to see the cutting just just performance of the sonar, a snip or prick introduced into the midwifery curriculum.
Anita, when she introduces this morning,
said definition of FGC is intervention with girls genitalia where there is no medical reason should it be in the midwifery curriculum.
Dean fibrillation definitely should, but should cutting. So can you see here?
Is she a heroine or is she a better?
And once a law comes in, which isn't going to happen for a long while, I don't think in Somaliland, then what's going to happen then?
So here we are again. Right? So this is now February this year and interviewing health professionals.
And remember, this is all this is new data for Somaliland. This is.
And so here what we've got here is all the health professionals that were interviewed in the mid-term review.
28 percent of them, 28 percent of them have been approached by someone asking them to cut their daughter.
OK. On the other side, how many of them, 22 percent of them said, Yes, I've cut.
I have performed some kind of a.
And then the fifth that's really, really kind of concerns me is of those three quarters of those have actually cut with stitches.
So they have performed type two or type three.
This is how we have a draught plan to medicalisation strategy that's that's been developed by A.H. at the moment.
And it is enormously contested. Here is the anti medicalisation strategy trying to stop people doing it with stitches.
Or not? Is it trying to do it safely? So there's a whole load of issues around here.
Yeah. OK, you just off the top there from the surveys again, from the research.
70 percent of health specialists intend to cut their own daughter's 70 percent, and all of those would use a health specialist.
OK? 80 percent of health specialists would expect their sons to marry a cut girl.
All the advantages of that I need to mention about last. So these are your health professionals that you're working with there,
and they are subject to those social norms that we've talked about in their communities.
One of a midwife again.
So, so she she you know, she has to open girls again for marriage.
She campaigns for what she calls zero tolerance. However, when I when I asked her at the end, I said, This is a kind of contradiction here.
You're campaigning for zero tolerance, but yet you're you're performing it.
And she says one spot I have to do as a midwife and the other is what I hope for in my community in the future.
So this again, health professionals and parents, but we're talking just about health professionals here having decision making dilemmas.
It's all well and good for us to say this. Here's the medical evidence that you shouldn't do this.
Actually, they're part of the community, and so they have all the social pressures as well.
And in a rural community, that's quite significant. So in summary, them medicalisation it's happening is increasing and it's highly contested.
Some people in the Ministry of Education support medicalisation because they say we're not going to get abandonment, total abandonment,
at least if girls just go and just go on to have the sooner done in a in an age,
they will be better schools, a school schoolroom if we interrupted less.
So education is important. Let's medicalised cutting that it won't interrupt people's education so much.
Medicalisation, obviously, a great show and a lot of internationals, it's opposed publicly by most of the Ministries Ministry of Religious Affairs.
It supports it and they want to see training of health professionals.
It's supported by some within Ministry of Education and Health.
And this point here, as you've seen from the cross, is actively sought by most community members.
And so really thinking about harm reduction to A. Medicalisation won't necessarily lead to that abandonment, everything.
So really, that's what I want to leave you.
Health professionals facing decision making dilemmas that have brought about through their own social norm to the communities.
And so it's not that easy to make decisions just based on health complications, as we we might imagine it to be.
There's a whole load of other things going on that. It sure, as I say, during some interventions that are starting in Somaliland shortly.
And so far,
their health clinics are doing some amazing work with their midwives and nurses to counsel people rather than fall into the trap of doing the country.
And that's really where we are at the moment.
Causation, nurses, training midwives, and that is part of the big public debate that's going on in Somaliland.
I wonder which side of that you might sit. Thank you.