1 00:00:00,420 --> 00:00:15,530 I think it's just sort of. Good morning, everyone, and welcome to the green round today. 2 00:00:15,530 --> 00:00:25,850 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. 3 00:00:25,850 --> 00:00:35,300 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. 4 00:00:35,300 --> 00:00:49,130 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. 5 00:00:49,130 --> 00:00:57,350 Councils are talking about it. School children have been primed about this, and even in our mandatory training, 6 00:00:57,350 --> 00:01:04,760 it has been brought to our attention that this is an issue that we need to think about and tackle. 7 00:01:04,760 --> 00:01:08,820 We also have some members of staff from the safeguarding team. 8 00:01:08,820 --> 00:01:15,710 Six Welcome to to the Grand Round without much due to introduce the first speaker. 9 00:01:15,710 --> 00:01:27,230 Who is Anita making? Anita is one of our consultant, Obstetricians and Gynaecologists in this trust, and she's also the director of Feargal, 10 00:01:27,230 --> 00:01:34,550 which is the International Federation of Obstetricians and Gynaecologists, which is based in London. 11 00:01:34,550 --> 00:01:39,680 She has a master's in public health, and regarding this topic, 12 00:01:39,680 --> 00:01:56,810 she is currently lead of a rose clinic that is run in Oxford for patients who have suffered through this kind of cultural action. 13 00:01:56,810 --> 00:02:03,890 The second person is and Anita will give us the global perspective of of this condition. 14 00:02:03,890 --> 00:02:14,660 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. 15 00:02:14,660 --> 00:02:25,340 She was awarded a Lifetime Award for National Teaching Fellowship by the Higher Education Authority in 2004. 16 00:02:25,340 --> 00:02:36,440 Regarding this topic, her attitudes and beliefs and practises associated with this condition began in 2009 in Kenya, 17 00:02:36,440 --> 00:02:44,540 and then she extended this work to Tanzania, Somaliland, Sierra Leone and Liberia. 18 00:02:44,540 --> 00:02:53,090 But presently, she is working with two NGOs and is connected to the W.H.O. reproductive health desk. 19 00:02:53,090 --> 00:03:04,550 Regarding FGM, so without much time, Anita, okay, so I'm going to talk to you about female genital mutilation or female genital cutting, 20 00:03:04,550 --> 00:03:11,360 and it's going to concentrate on giving you a bit of a global perspective and sort of introducing Katie's 21 00:03:11,360 --> 00:03:16,820 talk where she's white and she will go into detail about the sort of socio cultural aspects of it. 22 00:03:16,820 --> 00:03:26,390 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. 23 00:03:26,390 --> 00:03:28,580 So the definition of FGM, 24 00:03:28,580 --> 00:03:40,410 if she sees any procedure involving the removal of the external genitalia or other injury to the female genital organs for non-medical reasons. 25 00:03:40,410 --> 00:03:46,920 So the W.H.O. classifies FGM into four different types, so first one is type one FGM, 26 00:03:46,920 --> 00:03:51,450 which is partial or total removal of the clitoris and or the précieux. 27 00:03:51,450 --> 00:03:58,590 So just the skin overlying the clitoris also don't when you remove the clitoris as a to reject me. 28 00:03:58,590 --> 00:04:08,250 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. 29 00:04:08,250 --> 00:04:18,660 I think that's a much rarer FGM. Type three involves narrowing of the vaginal orifice with the creation of a covering seal by 30 00:04:18,660 --> 00:04:24,420 removing some of their labia menorah and then actually stitching the remaining parts together. 31 00:04:24,420 --> 00:04:28,950 So this opposition of the labia menorah and or the labour majora. 32 00:04:28,950 --> 00:04:34,620 And you can have excision of the clitoris with that or not. So it involves sort of closing up the vagina. 33 00:04:34,620 --> 00:04:39,910 And Reuters, as well as the removal of some of the anatomy and then type for Israel, 34 00:04:39,910 --> 00:04:45,000 is really any anything else that doesn't fit into types one, two or three. 35 00:04:45,000 --> 00:04:49,860 So any other harmful procedure to the female genital female genitalia for non-medical purposes? 36 00:04:49,860 --> 00:05:01,530 So examples of that might be pricking piercing in sizing, scraping cauterise Asian also recently seen elongation of of labia mineral majora. 37 00:05:01,530 --> 00:05:06,360 So here just some diagrams of what we're talking about. So type one FGM. 38 00:05:06,360 --> 00:05:12,070 You can see the on the top right. The little red area would be removal of often just the prep you. 39 00:05:12,070 --> 00:05:18,770 So sometimes some of the clitoral gland underneath it or all of the clitoral glands. 40 00:05:18,770 --> 00:05:23,510 Type two, hair snow removal again up on the right and the red is the area that's removed, 41 00:05:23,510 --> 00:05:27,380 so removing either just the prep use or some of the clitoris, 42 00:05:27,380 --> 00:05:36,410 but then also some of the labia menorah and the bottom right is how you would see it sort of years down the line. 43 00:05:36,410 --> 00:05:44,540 So as a woman, you would see scarring a sort of anterior superior posture portion of the female genitalia. 44 00:05:44,540 --> 00:05:54,320 And then type three involves removal, usually removal or cutting of sometimes the clitoris, also the labour menorah, but then importantly, 45 00:05:54,320 --> 00:06:01,700 the stitching together of the opposing remaining genitalia so that there is complete, 46 00:06:01,700 --> 00:06:05,520 not complete closure, but almost complete closure of the endroit. 47 00:06:05,520 --> 00:06:17,050 So obliterating the external the urethra on the 8es and narrowing very much the the vaginal entreaties as well. 48 00:06:17,050 --> 00:06:24,460 So as you can imagine, the consequences of FGM or FGC will vary very much depending on which type the lady has undergone, 49 00:06:24,460 --> 00:06:31,880 whether it's a type one, type two, type three or type four. But some of these table shows some of the consequences. 50 00:06:31,880 --> 00:06:38,410 So physically, obviously at the time of the of the surgery, they would have a lot of pain. 51 00:06:38,410 --> 00:06:45,940 The little area is a very vascular structure, so quite a lot of profuse bleeding at the time of the injury. 52 00:06:45,940 --> 00:06:54,400 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. 53 00:06:54,400 --> 00:07:02,020 And then if they've had a type three search or closure of the interrogators, then they'll have difficulties with menstruation, 54 00:07:02,020 --> 00:07:06,760 sometimes difficulties with passing urine said not describe sort of normal flow. 55 00:07:06,760 --> 00:07:13,180 And then obviously for intercourse and also vaginal birth, they often will require D and fibrillation. 56 00:07:13,180 --> 00:07:19,690 So an opening up of the entreaties, which has been stitched together psychologically. 57 00:07:19,690 --> 00:07:29,350 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, 58 00:07:29,350 --> 00:07:37,720 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. 59 00:07:37,720 --> 00:07:44,860 So they would require DNA fabrication and often describing disparu nia so on intercourse, 60 00:07:44,860 --> 00:07:50,230 superficial pain with the scarring that's left even with type two, I would just type one FGM. 61 00:07:50,230 --> 00:07:55,000 And if the clitoris is removed, then an orgasm you as well would be a consequence. 62 00:07:55,000 --> 00:08:01,330 So who's performing this well again across the globe? Depends where you are. 63 00:08:01,330 --> 00:08:05,320 Who would be involved? But this can go from quite a medicalized practise in some countries. 64 00:08:05,320 --> 00:08:15,580 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, 65 00:08:15,580 --> 00:08:27,100 to traditional birth attendants doing it under sort of less obviously sterile conditions in rural areas or lay women who are within that village. 66 00:08:27,100 --> 00:08:33,760 It would be their responsibility to do the female ceremonies, which include circumcision. 67 00:08:33,760 --> 00:08:38,980 So then we listen to all of this and think, why on earth are people practising this? 68 00:08:38,980 --> 00:08:44,890 Katie will go into the complexities of it in her talk, but in some cultures it's culturally accepted as normal, 69 00:08:44,890 --> 00:08:49,390 and that's what's expected part of a coming of age process. 70 00:08:49,390 --> 00:09:00,940 So part of these women ceremonies in some cultures, there is a belief that it would reduce promiscuity or unfaithfulness before or during marriage. 71 00:09:00,940 --> 00:09:10,420 And also, in some countries, it ensures marital suitability so a lady is not able to be married unless she's been circumcised. 72 00:09:10,420 --> 00:09:18,010 So really important sort of step towards growing up, if you like. 73 00:09:18,010 --> 00:09:27,400 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, 74 00:09:27,400 --> 00:09:37,780 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. 75 00:09:37,780 --> 00:09:45,820 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. 76 00:09:45,820 --> 00:09:51,190 So this is a photo which I took 100 years later when I was in Sierra Leone working for MSF. 77 00:09:51,190 --> 00:09:58,060 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. 78 00:09:58,060 --> 00:10:05,140 So in Sierra Leone? Just thought I'd give you an example. This is where I first came across FGM, FGC. 79 00:10:05,140 --> 00:10:13,000 It's part of a of a ceremony which where girls take part in a secret society. 80 00:10:13,000 --> 00:10:17,890 This is something that their parents decide that they then go to the ladies with the masks on. 81 00:10:17,890 --> 00:10:22,150 They're actually called devil masks, and the ladies are in charge of the whole ceremony, 82 00:10:22,150 --> 00:10:27,520 which will involve a lot more than just the cutting, just the FGM or the FGC. 83 00:10:27,520 --> 00:10:35,050 It will involve trying to explain to the girls what it will be like when they grow up, what menstruation means, 84 00:10:35,050 --> 00:10:41,970 what their duties would be as a wife, what their places in society as a potential future mother. 85 00:10:41,970 --> 00:10:52,120 Was quite a matriarchal society. Sierra Leone. So the girls sometimes would be very excited towards, you know, having the ceremony. 86 00:10:52,120 --> 00:10:58,900 They go in, they disappear off into the forest. The families will give them lots of food to survive several weeks and so on. 87 00:10:58,900 --> 00:11:03,970 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. 88 00:11:03,970 --> 00:11:13,600 And then as part of this big ceremony in Sierra Leone, FGM or FGC will be performed as part of that act. 89 00:11:13,600 --> 00:11:21,550 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, 90 00:11:21,550 --> 00:11:28,090 this was the photo, so that lady was in charge of this group of girls who would vary in age. 91 00:11:28,090 --> 00:11:34,780 So I think since the Civil War, the age at which girls would take part in the ceremony has gone down. 92 00:11:34,780 --> 00:11:39,580 And I think that's been a trend across many sub-Saharan African countries. 93 00:11:39,580 --> 00:11:44,170 It doesn't necessarily mean that they are going to be married immediately after their ceremony, 94 00:11:44,170 --> 00:11:51,820 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. 95 00:11:51,820 --> 00:11:58,690 So globally, about 200 million women have undergone FGM in the world today. 96 00:11:58,690 --> 00:12:02,590 These are estimates from UNICEF and UNFPA, and I must say it is very, 97 00:12:02,590 --> 00:12:09,850 very difficult to get accurate data on FGM and FGC prevalence and practise at the moment. 98 00:12:09,850 --> 00:12:19,330 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. 99 00:12:19,330 --> 00:12:23,620 And that doesn't mean that it's super common in Indonesia, eastern Ethiopia and Egypt. 100 00:12:23,620 --> 00:12:29,800 But actually, they've got a large populations and a large proportion of those women have undergone FGM. 101 00:12:29,800 --> 00:12:35,710 So it's known to happen across 30 countries Africa, Middle East and Asia, 102 00:12:35,710 --> 00:12:42,170 and there's an estimate that about three million girls are at risk of undergoing the procedure each year. 103 00:12:42,170 --> 00:12:51,050 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, 104 00:12:51,050 --> 00:12:57,650 you know, the centre of the world where there are countries which are involved in practising FGM and FGC. 105 00:12:57,650 --> 00:13:07,220 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, 106 00:13:07,220 --> 00:13:13,920 so you can see this up Africa and some Southeast Asian countries. 107 00:13:13,920 --> 00:13:18,720 So this is probably the most scientifically sound data that I've come across. 108 00:13:18,720 --> 00:13:26,220 It's a systematic review, and it's using demographic get demographic health surveys and mixed data sort of pooling them together 109 00:13:26,220 --> 00:13:32,160 and trying to work out if there are regional trends and what's happening over time with FGM and FGC. 110 00:13:32,160 --> 00:13:37,050 So you can see there, if we look at the right hand column, 111 00:13:37,050 --> 00:13:43,320 we're looking at the overall average annual percentage changes from the first survey that they looked at, 112 00:13:43,320 --> 00:13:48,210 depending on what was available in each of those regions to the last survey that they've looked at. 113 00:13:48,210 --> 00:13:52,260 And so in central Africa, you can see there it's quite a small number of surveys. 114 00:13:52,260 --> 00:14:00,660 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. 115 00:14:00,660 --> 00:14:08,500 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. 116 00:14:08,500 --> 00:14:13,890 East Africa, you can see there 13 studies looking from 1995 to 2014. 117 00:14:13,890 --> 00:14:26,160 So you've got there are fairly good evidence of a decrease minus seven point three percent of average annual trends in circumcision 118 00:14:26,160 --> 00:14:35,010 happening North Africa again nine studies to minus four percent also decreasing trend West Africa good number of study, 119 00:14:35,010 --> 00:14:45,900 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. 120 00:14:45,900 --> 00:14:51,870 And then in western Asia, they're difficult to interpret. There's only three studies and it's actually only covering two countries. 121 00:14:51,870 --> 00:15:01,350 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. 122 00:15:01,350 --> 00:15:06,900 So just a caveat on that because it only actually includes two countries which are Yemen and Iraq. 123 00:15:06,900 --> 00:15:11,580 Whereas the information on Africa is much more widespread in the surveys are much larger, 124 00:15:11,580 --> 00:15:17,790 so probably much more significant, but generally speaking, a decreasing trend. 125 00:15:17,790 --> 00:15:25,830 And in many places and countries with the highest yearly average, they've got their Mali 73 percent, 126 00:15:25,830 --> 00:15:33,600 Eritrea 67, Mauritania 61, Guinea 50, Djibouti 49, Somalia 46 Sudan. 127 00:15:33,600 --> 00:15:39,770 And there's a typo there. If anybody's interested, they can go back and read it. 128 00:15:39,770 --> 00:15:43,730 So why does it matter to us, or why does it matter to UK practise? 129 00:15:43,730 --> 00:15:51,740 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. 130 00:15:51,740 --> 00:15:56,750 What? What are their needs? Are there any needs? What are they and how best to deal with it? 131 00:15:56,750 --> 00:16:01,130 And importantly, it became a very as Kokila was alluding to. 132 00:16:01,130 --> 00:16:10,040 It's become a very politicised subject, and there was a Female Genital Mutilation Act, which came out in 2003, 133 00:16:10,040 --> 00:16:16,640 which said that it was an offence to carry out FGM and that it carries a sentence of up to 14 years. 134 00:16:16,640 --> 00:16:22,370 And so far to date, there's only been one conviction using this act. 135 00:16:22,370 --> 00:16:28,610 But importantly, there's other reasons that people can go to jail other than just if they carry out FGM. 136 00:16:28,610 --> 00:16:37,790 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. 137 00:16:37,790 --> 00:16:44,840 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, 138 00:16:44,840 --> 00:16:51,410 to fail, to protect a British national from having FGM, even when outside the British territory. 139 00:16:51,410 --> 00:16:57,110 So what that means is that if a parent has a British born child and that child goes back to 140 00:16:57,110 --> 00:17:02,330 their home country with their grandparents or stays with their grandparents and undergoes FGM, 141 00:17:02,330 --> 00:17:08,480 when that child comes back to the UK, her parents are liable for what happened to her in the country that she left. 142 00:17:08,480 --> 00:17:15,170 So, you know, it's really quite a punitive law at the moment. 143 00:17:15,170 --> 00:17:19,970 And then I just put at the bottom that the FGM enhanced data set. 144 00:17:19,970 --> 00:17:25,280 Claire Robertson, one of the pitchers and so who is in charge of the safeguarding and so on of the girls? 145 00:17:25,280 --> 00:17:33,440 But just to say that the government does have a data set and women who come through the FGM clinic, um, 146 00:17:33,440 --> 00:17:41,120 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. 147 00:17:41,120 --> 00:17:45,710 But there is a form of collecting data on these women, and this is also a big, 148 00:17:45,710 --> 00:17:56,570 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. 149 00:17:56,570 --> 00:18:03,440 So, so quite quite sort of strict laws and and monitoring of what's going on in the UK at the moment. 150 00:18:03,440 --> 00:18:07,670 And again, just to give you a pointer if you're interested in reading more about this. 151 00:18:07,670 --> 00:18:11,840 So more recently, there was an article in The BMJ by Sarah Crighton, 152 00:18:11,840 --> 00:18:18,410 who does a lot of the FGM work in London talking about how we're tackling FGM at the moment in the UK. 153 00:18:18,410 --> 00:18:30,530 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? 154 00:18:30,530 --> 00:18:38,660 And that has been there quite a bit of back and forth about whether actually the evidence that we have supports, 155 00:18:38,660 --> 00:18:46,370 whether we have sufficient evidence about FGM statistics in the UK to be doing what we're doing and whether we have evidence 156 00:18:46,370 --> 00:18:52,760 that what we're doing at the moment is actually beneficial to these women or whether we may be making things worse. 157 00:18:52,760 --> 00:18:54,410 So generally, what happens in Oxford? 158 00:18:54,410 --> 00:19:02,510 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. 159 00:19:02,510 --> 00:19:06,890 So it's a monthly clinic, it's multidisciplinary. 160 00:19:06,890 --> 00:19:09,410 So we have a specialist obstetrician and gynaecologist. 161 00:19:09,410 --> 00:19:18,110 She be myself or Brenda, psychosexual counsellor, stroke general practitioner and also a clinical psychologist. 162 00:19:18,110 --> 00:19:24,920 And the clinic is set up to deal with health issues associated with FGM for pregnant women, but also for non-pregnant women. 163 00:19:24,920 --> 00:19:28,550 So we try and see the pregnant women more urgently because as you can imagine, 164 00:19:28,550 --> 00:19:36,860 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. 165 00:19:36,860 --> 00:19:44,090 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, 166 00:19:44,090 --> 00:19:50,120 or if they actually have consequences from it and need some support with that. 167 00:19:50,120 --> 00:19:58,910 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. 168 00:19:58,910 --> 00:20:03,200 As I've tried to give you an idea of what's happening sort of across the globe, 169 00:20:03,200 --> 00:20:06,470 you can imagine sitting in a clinic, getting people from all over the world. 170 00:20:06,470 --> 00:20:11,780 Actually, one person's experience, for example, in Indonesia, might be very different from another a Sudanese lady. 171 00:20:11,780 --> 00:20:20,420 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. 172 00:20:20,420 --> 00:20:26,780 So we have also prenatal and fibrillation, as I said, for the pregnant ladies. 173 00:20:26,780 --> 00:20:29,150 So this isn't to test. 174 00:20:29,150 --> 00:20:36,230 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. 175 00:20:36,230 --> 00:20:38,920 So the reason that they're referred. 176 00:20:38,920 --> 00:20:46,220 Well, the main source of referral to the Rose Clinic are midwives who see ladies antenatal when they do their booking appointment. 177 00:20:46,220 --> 00:20:51,010 One of the questions that they have to ask the woman is Have you suffered from FGM or FGC? 178 00:20:51,010 --> 00:20:57,190 And if they say yes, then they automatically get referred to the Rose Clinic and that standard so vast majority. 179 00:20:57,190 --> 00:21:04,300 A lot of women are referred through that route, or that can be self referrals or GP's, obviously, if women have had issues. 180 00:21:04,300 --> 00:21:08,920 So as you could expect, the DNA rate is quite high, about 30 to 40 percent. 181 00:21:08,920 --> 00:21:14,320 I would say something like that in terms of DNA, and this may be several fold, 182 00:21:14,320 --> 00:21:18,760 but I think the punitive nature of legislation in the UK definitely contributes to this. 183 00:21:18,760 --> 00:21:26,590 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. 184 00:21:26,590 --> 00:21:32,560 And they've heard that it's something that the government is collecting statistics on, then they don't want to come to clinics. 185 00:21:32,560 --> 00:21:39,460 So our DNA rate is quite high. I'd say the vast majority of women who come do not perceive it as a problem. 186 00:21:39,460 --> 00:21:47,290 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. 187 00:21:47,290 --> 00:21:57,490 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. 188 00:21:57,490 --> 00:21:59,620 It's something that happened to them as part of their culture. 189 00:21:59,620 --> 00:22:06,730 But it's not a problem at all to say that type one and type two FGM can often be missed. 190 00:22:06,730 --> 00:22:12,070 So often, people will have had reasons to have other examinations prior to coming to the clinic. 191 00:22:12,070 --> 00:22:19,960 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. 192 00:22:19,960 --> 00:22:25,930 The scarring can be quite subtle, particularly if it's just a type one or if it's a mild type two. 193 00:22:25,930 --> 00:22:30,580 So sometimes you have women coming and saying, Well, no one's ever mentioned this to me before. 194 00:22:30,580 --> 00:22:32,320 You know, why is it not become an issue? 195 00:22:32,320 --> 00:22:39,490 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. 196 00:22:39,490 --> 00:22:45,580 So continuing about the women, says the proportion of women who will report an orgasmic and dyspareunia, 197 00:22:45,580 --> 00:22:49,060 particularly prior to their first birth to their first maturation. 198 00:22:49,060 --> 00:22:56,350 They often describe that improving after the first birth, and there are a small proportion who obviously do remember the incident. 199 00:22:56,350 --> 00:23:03,040 So particularly when the FGM or FGC is performed later on as an adolescent or as an older girl, 200 00:23:03,040 --> 00:23:07,390 they'll remember every single detail of that event, and they can describe it to you. 201 00:23:07,390 --> 00:23:12,130 Like, it happened yesterday. I've seen ladies in their fifties and sixties describing what happened to them as a 202 00:23:12,130 --> 00:23:16,660 child aged six or seven because the whole event was so traumatic and so horrific. 203 00:23:16,660 --> 00:23:21,610 So there are extremes of how of people's experience of it, 204 00:23:21,610 --> 00:23:30,320 and these women were very glad to have support in terms of a clinical psychologist that can help them deal with that. 205 00:23:30,320 --> 00:23:36,820 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, 206 00:23:36,820 --> 00:23:42,850 and they actually don't want to be questioned deeply about something that happened that long ago, which they've put behind them. 207 00:23:42,850 --> 00:23:50,620 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. 208 00:23:50,620 --> 00:23:54,100 And some women find the terminology upsetting, upsetting, 209 00:23:54,100 --> 00:23:59,080 so calling it mutilation rather than cutting because they don't feel that they have been mutilated. 210 00:23:59,080 --> 00:24:02,890 Other women who had terrible experience feel very much that they've been mutilated, 211 00:24:02,890 --> 00:24:08,140 and that was something that was done against their will that they remember as horrific. 212 00:24:08,140 --> 00:24:14,590 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. 213 00:24:14,590 --> 00:24:25,540 But we see Indonesian ladies who have who would have had the procedure done in hospital immediately after birth by doctors under anaesthetic. 214 00:24:25,540 --> 00:24:30,070 And it's done as a boy is circumcised at birth, so a girl would be circumcised as well. 215 00:24:30,070 --> 00:24:34,330 And that's just removal of the prep use. So the skin covering the clitoris. 216 00:24:34,330 --> 00:24:39,100 And so they particularly find the term mutilation quite bizarre and believe it 217 00:24:39,100 --> 00:24:45,940 to just be part of the sort of normal way of being and would happen if they, 218 00:24:45,940 --> 00:24:49,900 if they were in Indonesia, would happen to their children if they were back in Indonesia. 219 00:24:49,900 --> 00:24:58,300 So most women who are seen, if they have no sequelae sequelae do report that they wouldn't continue the practise on their daughters. 220 00:24:58,300 --> 00:25:03,520 But some of them very honestly say, Actually, if I was back in my country, my daughter would be circumcised. 221 00:25:03,520 --> 00:25:09,220 Not particularly because I think it's a good thing to do, but because my entire culture, 222 00:25:09,220 --> 00:25:14,110 environment, my, you know, my parents, my aunts and so on would expect that to happen. 223 00:25:14,110 --> 00:25:16,630 And so if we were back, there probably would. 224 00:25:16,630 --> 00:25:24,040 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. 225 00:25:24,040 --> 00:25:36,640 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. 226 00:25:36,640 --> 00:25:46,650 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, 227 00:25:46,650 --> 00:25:57,930 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. 228 00:25:57,930 --> 00:26:04,080 Thank you. Thank you. And it's great to be invited to speak here. 229 00:26:04,080 --> 00:26:08,400 Can everybody hear me? OK, if I don't, I tend to wander a little bit. 230 00:26:08,400 --> 00:26:13,020 OK? My name's Kate Jones. I'm not a surgeon. 231 00:26:13,020 --> 00:26:25,230 I've been working in health settings for plus years, and I've been working more along the lines of social interactions. 232 00:26:25,230 --> 00:26:31,170 Why practises happen and what can we do to stop them? 233 00:26:31,170 --> 00:26:42,270 Great to see Tony here. Tony Jeffries, who who after many conversations in different places, said, Why don't I come along and talk? 234 00:26:42,270 --> 00:26:53,610 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. 235 00:26:53,610 --> 00:26:58,980 And so that's the country that I'm going to focus on this morning. 236 00:26:58,980 --> 00:27:02,640 So this is really where where I've been working at the moment. 237 00:27:02,640 --> 00:27:15,330 So since 2015, I've been involved in Somaliland and with ActionAid and also a small local organisation called Somaliland Family Health Association. 238 00:27:15,330 --> 00:27:24,450 And I've been carrying out research. So, you know, the research has been a combination of qualitative and quantitative. 239 00:27:24,450 --> 00:27:35,370 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, 240 00:27:35,370 --> 00:27:44,670 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. 241 00:27:44,670 --> 00:27:56,040 Somaliland has also been looking at national indicators for FGC to be thinking about this whole issue, as Anita said, What do we measure? 242 00:27:56,040 --> 00:28:04,770 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, 243 00:28:04,770 --> 00:28:10,020 you start pulling into communities and asking people whether they're cuts or whether they're going to cut their daughters. 244 00:28:10,020 --> 00:28:14,430 And people know that that's illegal, and it's quite difficult to get honest responses to that. 245 00:28:14,430 --> 00:28:19,290 So they're looking at national and international indicators. 246 00:28:19,290 --> 00:28:28,170 And then we've also been running. I've been facilitating knowledge sharing workshops for the last couple of years in Somaliland, 247 00:28:28,170 --> 00:28:36,730 working with all the organisations who are working to end FGC and also government ministries and community leaders. 248 00:28:36,730 --> 00:28:42,180 So that's a little bit of where I am and where I'm coming from. 249 00:28:42,180 --> 00:28:47,220 So where is Somaliland? It's that sat beside me. 250 00:28:47,220 --> 00:28:51,180 So it's part of Somalia. It's an independent state. 251 00:28:51,180 --> 00:29:01,470 It declared its independence in 1991. Now, Somalia is one of the countries with the highest rate of FGC. 252 00:29:01,470 --> 00:29:09,570 So 98 99 percent of women and girls are cut in some description or another. 253 00:29:09,570 --> 00:29:14,070 And 80 percent and these are D.H.S. And mix figures. 254 00:29:14,070 --> 00:29:25,470 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. 255 00:29:25,470 --> 00:29:31,800 So mid-term reviews, if we started cutting through so mid-term reviews, if she's just these, 256 00:29:31,800 --> 00:29:38,790 these last couple of years, we're talking about the overall prevalence still being 98 99 percent. 257 00:29:38,790 --> 00:29:48,060 So in most communities, most people, most men, most women, those children don't know someone who is hasn't been cut. 258 00:29:48,060 --> 00:29:56,640 So if you can imagine being in a in a culture where everyone is cutting. 259 00:29:56,640 --> 00:30:03,990 And one of the things which is really quite scary for me was that when we after several years of interventions, 260 00:30:03,990 --> 00:30:16,440 the young women ages 12 to 24, the same rate, it was about 97 98 percent of 12 to 24 year olds are cut. 261 00:30:16,440 --> 00:30:24,660 Now there's a change so that they're the type of cuts is less, but they're still being cut. 262 00:30:24,660 --> 00:30:34,710 So we've got 92 percent of women interviewed and undertook to cut in with stitches still in the mid-term review. 263 00:30:34,710 --> 00:30:39,080 However, only half of them 51 percent of their daughters. 264 00:30:39,080 --> 00:30:49,580 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. 265 00:30:49,580 --> 00:30:53,450 So you've got to stop here. 266 00:30:53,450 --> 00:31:04,580 We there's a whole load of different types and the different terms, Somaliland being an Islamic country. 267 00:31:04,580 --> 00:31:11,750 And we've got to kind of zero tolerance. Nothing happening over here. 268 00:31:11,750 --> 00:31:24,820 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. 269 00:31:24,820 --> 00:31:31,970 We've got the intermediate top two, top three and the top four, which is coming in, which is a pray. 270 00:31:31,970 --> 00:31:35,810 There's been a lot of change, so that's the range of what we've got. 271 00:31:35,810 --> 00:31:39,050 OK. And Anthony, 272 00:31:39,050 --> 00:31:50,270 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, 273 00:31:50,270 --> 00:32:07,100 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. 274 00:32:07,100 --> 00:32:15,470 So it is something which happens because it happens and because it's it's working within the community now. 275 00:32:15,470 --> 00:32:24,140 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. 276 00:32:24,140 --> 00:32:30,230 We go into a community and we think, Oh, let's tell people what all the complications are for cutting. 277 00:32:30,230 --> 00:32:36,200 And if I tell people that if they cuts, then their daughters may have fistula, they may have this and they have that, 278 00:32:36,200 --> 00:32:44,000 they're going to have monthly kidney infections, et cetera, then if they know that they'll stop cutting. 279 00:32:44,000 --> 00:32:52,070 And that is very much from an individualistic approach to be thinking that if I do that, then stop cutting. 280 00:32:52,070 --> 00:32:56,390 If we look at it as a social norm, then that's rather different. 281 00:32:56,390 --> 00:33:01,250 So in order to be a social norm, there are these three conditions. 282 00:33:01,250 --> 00:33:18,500 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. 283 00:33:18,500 --> 00:33:23,540 If you are cut, you are of a higher status, you're marriageable. 284 00:33:23,540 --> 00:33:29,870 You have celebration, you have new clothes your family can celebrate. 285 00:33:29,870 --> 00:33:37,880 So it's very much valued by the community. So if you decide not to cut your daughter, you're going against that. 286 00:33:37,880 --> 00:33:45,030 It's also over on this side. It attracts sanctions and benefits, so people often think, Oh, 287 00:33:45,030 --> 00:33:51,050 there is this disadvantages to being cut that can't possibly be advantages to being cut. 288 00:33:51,050 --> 00:33:54,440 Well, actually, there's loads of advantages to being cut, 289 00:33:54,440 --> 00:34:02,540 even if you're being cut by the most severe cuts because you're socially acceptable, you marriageable, et cetera. 290 00:34:02,540 --> 00:34:04,580 OK in Somalia. 291 00:34:04,580 --> 00:34:13,710 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. 292 00:34:13,710 --> 00:34:23,690 Now her family has a camel camel tribe, and they and she sells the milk. 293 00:34:23,690 --> 00:34:33,710 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. 294 00:34:33,710 --> 00:34:39,320 So in terms of sanctions, that's a massive thing for the family. 295 00:34:39,320 --> 00:34:48,530 So there's a mother she's trying to decide, is she going to take an individual decision not to cut her daughter? 296 00:34:48,530 --> 00:34:53,180 And if she does, what's that going to have on the whole of the extended family? 297 00:34:53,180 --> 00:34:56,120 So sanctions and benefits? 298 00:34:56,120 --> 00:35:06,200 And finally, the third one interdependency, I cut my daughter because somebody else cuts their daughter and he expects his daughter to be cut. 299 00:35:06,200 --> 00:35:12,800 And so, so perhaps their daughter. And we will have social norms within our. 300 00:35:12,800 --> 00:35:21,920 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, 301 00:35:21,920 --> 00:35:26,900 then generally speaking, you get on a tube train or bus, you don't talk to strangers. 302 00:35:26,900 --> 00:35:31,910 You keep your eyes down. You don't talk to people in the UK. 303 00:35:31,910 --> 00:35:38,710 And that's our social norm. If you start chatting away to people, people start thinking, you're a bit loopy now some. 304 00:35:38,710 --> 00:35:44,890 Or else. And those of you who come from different cultures, you wouldn't think of going on public transport, 305 00:35:44,890 --> 00:35:48,520 and I'm just from Kenya just recently wouldn't think of going and getting on it 306 00:35:48,520 --> 00:35:53,180 and attached to a bus without saying hi to a couple of other people on that. 307 00:35:53,180 --> 00:36:00,640 So social norms are part of what keeps us going. These social norms are keeping that practise in place. 308 00:36:00,640 --> 00:36:08,530 So if we think we can change by just saying, here are the health complications now, stop it. 309 00:36:08,530 --> 00:36:16,390 We've actually got to think of a whole load of other things around in order to stop this game in Somalia. 310 00:36:16,390 --> 00:36:20,680 So down the bottom here, Becky celebration in my life. 311 00:36:20,680 --> 00:36:26,050 Just like Anita's picture, when I'm cut, I'll be purified ready for marriage. 312 00:36:26,050 --> 00:36:38,500 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. 313 00:36:38,500 --> 00:36:43,360 They might know there might be complications, but it is something which they're looking forward to. 314 00:36:43,360 --> 00:36:49,210 Not all, not all, by all means, but may. If I'm not a man, you are. 315 00:36:49,210 --> 00:36:52,870 That's a positive benefit of being cut down the bottom there. 316 00:36:52,870 --> 00:37:00,640 You've got a negative one, so you've got the being called names not being allowed to marry, et cetera, et cetera. 317 00:37:00,640 --> 00:37:05,680 So all of these issues around there. 318 00:37:05,680 --> 00:37:10,420 So it's not an easy decision to decide whether or not to cut what we've looked 319 00:37:10,420 --> 00:37:16,930 at in the research in Somaliland have been all this whole lot of things. 320 00:37:16,930 --> 00:37:24,460 I'm going to concentrate on medicalisation. I'm also going to talk about decision making dilemmas as well. 321 00:37:24,460 --> 00:37:37,420 So so I'm going to concentrate on just on medicalisation because here we are in the global health group. 322 00:37:37,420 --> 00:37:45,850 So medicalisation here. 323 00:37:45,850 --> 00:37:53,800 What we've got is there's an increase in Somaliland in the medicalisation of cutting. 324 00:37:53,800 --> 00:38:00,280 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. 325 00:38:00,280 --> 00:38:06,580 But hang on. It is changing. So here we are, right down the bottom. 326 00:38:06,580 --> 00:38:11,200 So we've got the blue is the baseline. The so that was the section. 327 00:38:11,200 --> 00:38:21,820 So 2018 and the NCR was the data was collected in 2018 and then some of it. 328 00:38:21,820 --> 00:38:28,510 So we've got women overall, women back up by a health professional. 329 00:38:28,510 --> 00:38:38,290 Yes, it's low. It's less than 10 percent. However, if we look at women under 25, we've got that group. 330 00:38:38,290 --> 00:38:46,630 There's actually a doubling more or less of the proportion who are being cut by a health professional. 331 00:38:46,630 --> 00:38:54,820 When we ask those people, What about your daughters? What are you who cut your daughters? 332 00:38:54,820 --> 00:38:56,760 You can see a massive change. 333 00:38:56,760 --> 00:39:06,370 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, 334 00:39:06,370 --> 00:39:15,070 I remember it was still 98 99 percent for the daughters being up, they were being cut by a health professional. 335 00:39:15,070 --> 00:39:20,150 Now this is quite shocking. OK. And look at that change. 336 00:39:20,150 --> 00:39:30,550 Right? And this is the first time that this sort of data has been revealed in Somaliland, and it's influencing the debate. 337 00:39:30,550 --> 00:39:38,830 It's influencing policy is influencing the Ministry of Health once again on this issue. 338 00:39:38,830 --> 00:39:41,080 So that was the ActionAid one. 339 00:39:41,080 --> 00:39:52,900 This is the this is so for the Somaliland Family Health Association, and this is again for their mid-term review review. 340 00:39:52,900 --> 00:39:59,050 I mean, it's a different communities with different regions of the company and from other digits. 341 00:39:59,050 --> 00:40:08,020 So here we've got the interviewee, her daughter and her future daughters. 342 00:40:08,020 --> 00:40:15,790 OK, now you will see a slight. And this is for the mid-term review, the mid-term review alone. 343 00:40:15,790 --> 00:40:20,920 So we're actually up at those those higher, those higher figures. 344 00:40:20,920 --> 00:40:26,140 Now the reason why this is 19 percent rather than just, say, 345 00:40:26,140 --> 00:40:32,920 eight or nine as the last straw for this piece of research focussed more on younger people. 346 00:40:32,920 --> 00:40:38,590 So we've got slightly higher figures. But again, you look at that between the interview, we heard all. 347 00:40:38,590 --> 00:40:42,220 And future daughters. And now we're over the tipping point. 348 00:40:42,220 --> 00:40:47,770 We're just 71 percent of people intending to have their daughters cut by health professionals. 349 00:40:47,770 --> 00:41:00,880 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. 350 00:41:00,880 --> 00:41:08,840 The pilot will be in Guinea, in West Africa, in Kenya and also in Somaliland. 351 00:41:08,840 --> 00:41:19,960 And that'll be looking at training of health workers to reduce medicalisation, so positive perceptions. 352 00:41:19,960 --> 00:41:30,310 And this goes back again to our social norms. So in a rural community over in Sana'a, only the Seabreeze. 353 00:41:30,310 --> 00:41:35,950 And so this is when they were asked, Who does the cutting? I ask them, Who does the cutting in your country? 354 00:41:35,950 --> 00:41:42,310 It's severe is in traditional cuts as we don't have anyone else, and it would be much better if we did. 355 00:41:42,310 --> 00:41:45,850 OK, so this is what our community is saying. 356 00:41:45,850 --> 00:41:57,910 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. 357 00:41:57,910 --> 00:42:09,180 Now she doesn't come anymore. Instead, we gather all girls together and we take them to the Mk8 and we have them cut. 358 00:42:09,180 --> 00:42:18,270 So these are communities, communities and communities, and they're saying this proudly, absolutely proudly that this is what they do. 359 00:42:18,270 --> 00:42:24,720 This is what they do in order to, in their opinion, keep their girls safer. 360 00:42:24,720 --> 00:42:34,530 OK, so here a community facilitator, a wonderful young woman and her nephew. 361 00:42:34,530 --> 00:42:42,720 And this was last September, and she is one of the community facilitators on FGC project. 362 00:42:42,720 --> 00:42:49,410 So she is campaigning for the end of cutting OK. 363 00:42:49,410 --> 00:42:56,700 And she says this. So I would say just after the summer holidays, 364 00:42:56,700 --> 00:43:08,950 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. 365 00:43:08,950 --> 00:43:13,450 And interesting things there she went, and I said to her, did you have to make an appointment? 366 00:43:13,450 --> 00:43:23,440 No, I just went along and she was so proud. The girls who put the plane straight away went to school the next day. 367 00:43:23,440 --> 00:43:29,020 They had to type two with two stitches. 368 00:43:29,020 --> 00:43:37,050 So there will have been serious. Most likely to be serious complications as the years go on. 369 00:43:37,050 --> 00:43:42,420 So one of the other things, which is a misconception in Somaliland, 370 00:43:42,420 --> 00:43:54,450 is that putting it where it's only pricking or snipping only types one and three are generally speaking not regarded as being FGM. 371 00:43:54,450 --> 00:44:03,510 FGM is considered to be that's quite severe, very severe removal of every single type through. 372 00:44:03,510 --> 00:44:12,630 So again, this sort of trend and kind of posing to you now, you know, what are you thinking now about this as medicalisation? 373 00:44:12,630 --> 00:44:17,340 Is this a good move? Is this a good move? 374 00:44:17,340 --> 00:44:34,890 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. 375 00:44:34,890 --> 00:44:41,350 Is that better? Is that what we want? So here we are. 376 00:44:41,350 --> 00:44:51,100 A nurse interviewed. So this was in a government hospital, in a rural communities, and so here she goes. 377 00:44:51,100 --> 00:44:54,490 I was sadly cut before the community changed from the four on it. 378 00:44:54,490 --> 00:45:00,850 That's type three to the surface type of cutting. She suffered all her life. 379 00:45:00,850 --> 00:45:07,200 She's got no children and no grandchildren. And here she is. 380 00:45:07,200 --> 00:45:11,520 She uses A. Anaesthetic for the two stitches. 381 00:45:11,520 --> 00:45:17,700 Not for just the pain of it. It's more healthy to do it here. 382 00:45:17,700 --> 00:45:23,440 It's a septic sterile. OK. 383 00:45:23,440 --> 00:45:35,230 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, 384 00:45:35,230 --> 00:45:47,080 the next generation of girls, which is less harmful in her opinion, than happened to her down on the bottom. 385 00:45:47,080 --> 00:45:56,830 She actually said to me, I need more training on this, I need more training to do it better should she get that training. 386 00:45:56,830 --> 00:46:02,860 The Ministry of Religious Affairs in Somaliland believes she should. 387 00:46:02,860 --> 00:46:15,550 They want to see the cutting just just performance of the sonar, a snip or prick introduced into the midwifery curriculum. 388 00:46:15,550 --> 00:46:18,850 Anita, when she introduces this morning, 389 00:46:18,850 --> 00:46:33,700 said definition of FGC is intervention with girls genitalia where there is no medical reason should it be in the midwifery curriculum. 390 00:46:33,700 --> 00:46:38,620 Dean fibrillation definitely should, but should cutting. So can you see here? 391 00:46:38,620 --> 00:46:45,320 Is she a heroine or is she a better? 392 00:46:45,320 --> 00:46:55,880 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? 393 00:46:55,880 --> 00:47:05,180 So here we are again. Right? So this is now February this year and interviewing health professionals. 394 00:47:05,180 --> 00:47:10,760 And remember, this is all this is new data for Somaliland. This is. 395 00:47:10,760 --> 00:47:18,630 And so here what we've got here is all the health professionals that were interviewed in the mid-term review. 396 00:47:18,630 --> 00:47:27,050 28 percent of them, 28 percent of them have been approached by someone asking them to cut their daughter. 397 00:47:27,050 --> 00:47:34,190 OK. On the other side, how many of them, 22 percent of them said, Yes, I've cut. 398 00:47:34,190 --> 00:47:40,190 I have performed some kind of a. 399 00:47:40,190 --> 00:47:53,190 And then the fifth that's really, really kind of concerns me is of those three quarters of those have actually cut with stitches. 400 00:47:53,190 --> 00:47:58,520 So they have performed type two or type three. 401 00:47:58,520 --> 00:48:09,430 This is how we have a draught plan to medicalisation strategy that's that's been developed by A.H. at the moment. 402 00:48:09,430 --> 00:48:19,560 And it is enormously contested. Here is the anti medicalisation strategy trying to stop people doing it with stitches. 403 00:48:19,560 --> 00:48:31,630 Or not? Is it trying to do it safely? So there's a whole load of issues around here. 404 00:48:31,630 --> 00:48:38,800 Yeah. OK, you just off the top there from the surveys again, from the research. 405 00:48:38,800 --> 00:48:50,200 70 percent of health specialists intend to cut their own daughter's 70 percent, and all of those would use a health specialist. 406 00:48:50,200 --> 00:48:58,960 OK? 80 percent of health specialists would expect their sons to marry a cut girl. 407 00:48:58,960 --> 00:49:08,130 All the advantages of that I need to mention about last. So these are your health professionals that you're working with there, 408 00:49:08,130 --> 00:49:17,450 and they are subject to those social norms that we've talked about in their communities. 409 00:49:17,450 --> 00:49:25,620 One of a midwife again. 410 00:49:25,620 --> 00:49:34,020 So, so she she you know, she has to open girls again for marriage. 411 00:49:34,020 --> 00:49:44,740 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. 412 00:49:44,740 --> 00:49:49,120 You're campaigning for zero tolerance, but yet you're you're performing it. 413 00:49:49,120 --> 00:49:56,310 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. 414 00:49:56,310 --> 00:50:07,380 So this again, health professionals and parents, but we're talking just about health professionals here having decision making dilemmas. 415 00:50:07,380 --> 00:50:13,080 It's all well and good for us to say this. Here's the medical evidence that you shouldn't do this. 416 00:50:13,080 --> 00:50:19,500 Actually, they're part of the community, and so they have all the social pressures as well. 417 00:50:19,500 --> 00:50:34,590 And in a rural community, that's quite significant. So in summary, them medicalisation it's happening is increasing and it's highly contested. 418 00:50:34,590 --> 00:50:42,390 Some people in the Ministry of Education support medicalisation because they say we're not going to get abandonment, total abandonment, 419 00:50:42,390 --> 00:50:50,670 at least if girls just go and just go on to have the sooner done in a in an age, 420 00:50:50,670 --> 00:50:54,930 they will be better schools, a school schoolroom if we interrupted less. 421 00:50:54,930 --> 00:51:05,300 So education is important. Let's medicalised cutting that it won't interrupt people's education so much. 422 00:51:05,300 --> 00:51:16,790 Medicalisation, obviously, a great show and a lot of internationals, it's opposed publicly by most of the Ministries Ministry of Religious Affairs. 423 00:51:16,790 --> 00:51:22,610 It supports it and they want to see training of health professionals. 424 00:51:22,610 --> 00:51:27,260 It's supported by some within Ministry of Education and Health. 425 00:51:27,260 --> 00:51:39,410 And this point here, as you've seen from the cross, is actively sought by most community members. 426 00:51:39,410 --> 00:51:51,830 And so really thinking about harm reduction to A. Medicalisation won't necessarily lead to that abandonment, everything. 427 00:51:51,830 --> 00:51:55,850 So really, that's what I want to leave you. 428 00:51:55,850 --> 00:52:07,520 Health professionals facing decision making dilemmas that have brought about through their own social norm to the communities. 429 00:52:07,520 --> 00:52:16,850 And so it's not that easy to make decisions just based on health complications, as we we might imagine it to be. 430 00:52:16,850 --> 00:52:32,850 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. 431 00:52:32,850 --> 00:52:33,840 And so far, 432 00:52:33,840 --> 00:52:48,000 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. 433 00:52:48,000 --> 00:52:50,980 And that's really where we are at the moment. 434 00:52:50,980 --> 00:52:59,730 Causation, nurses, training midwives, and that is part of the big public debate that's going on in Somaliland. 435 00:52:59,730 --> 00:53:13,928 I wonder which side of that you might sit. Thank you.