FGM in focus

Exploring Imperial’s community-centred approach to empowering conversations around female genital mutilation

An illustration of women of a wide array of ethnicities and cultures

Living a life free from harm is a basic human right which is denied to millions of women and girls across the world who are at risk of many different forms of violence.

Globally, an estimated 200 million girls and women have experienced female genital mutilation (FGM). It is a procedure that causes injury to the genital organs for non-medical purposes by cutting or removing the external sexual organs and is most commonly performed on girls under the age of fifteen. It is very painful and can seriously affect long-term health, both physically and mentally, causing particular harm during pregnancy and labour.

While the practice is most common in Africa and South East Asia, it happens worldwide, including in the UK where an estimated 137,000 women and girls have undergone FGM and many more are at risk.

Juliet Albert and Suhad Adam are two women who have dedicated their lives to ending the practice and to supporting women who live with the consequences of FGM. They work at Imperial College London’s Sunflower Clinics which offer specialised services to victims of FGM.

We meet with them to find out what led them to their cause, and how the Imperial clinic aims to tackle the issue by taking a community-centred approach.

The FGM specialist

Juliet Albert

Juliet Albert

“I got a phone call in the middle of the night saying she’s giving birth now. I raced to her house, and after the baby was born, I noticed straight away that the mother had FGM.”

Acton, 1998. Juliet Albert, who had been qualified as a midwife for nearly two years, was called to the home of one of her patients, a Somalian woman.

“I didn’t really know what female genital mutilation was. I had no idea actually. I’d never come across it before, I hadn’t been told about it during my midwifery training,” she said.

It was a turning point in Juliet’s career. Determined to educate herself, she came across FORWARD, an African-women led organisation that works to end violence against women and girls. As part of this, they provide both community and professional training about FGM. Juliet attended a session.

After a short career break to start her own family, she started campaigning for an FGM service in a hospital but also in the community. She opened the Acton African Well Woman Clinic in 2007, alongside a clinic at Queen Charlotte’s and Chelsea Hospital. The Well Woman Clinic was the first community-based clinic for non-pregnant women with FGM in the UK. It was led by midwives and located within the community, to be as easy to access as possible.

“I’d seen other clinics and decided we needed to set up this model. There’s a counsellor, because we know that women don’t often take up psychological support – there’s a lot of shame and taboo surrounding FGM,” Juliet said.

The majority of the women they saw when starting the clinic were Somalian, so the service was also supported by health advocates who were Somali speaking women. “They’re not just a translator,” Juliet said, “they have come from a similar background and understand coming to the UK, experiencing war, being a refugee and asylum-seeking.”

"The health advocate role is very pivotal because they’re the bridge between me, or healthcare in general, and the community.”
Juliet Albert

In 2017, when the African Community clinic was forced to close due to lack of funding, Juliet and the team moved the clinic into Queen Charlotte’s and Chelsea Hospital in Acton. They had become well -established within the community at that point.

“I was very worried when we moved this clinic into the hospital setting that nobody would come, but actually we’re just as busy, if not busier,” Juliet said.

It is now one of the three Sunflower clinics, run by Imperial College Healthcare NHS Trust, dedicated to helping women with FGM. Women from anywhere in the UK can self-refer to the service and will be seen within two weeks of contacting them. Before their appointment, women can speak to staff at the clinic by text, email, WhatsApp or phone. Every year the clinics provide support for 600 pregnant women and 90 non-pregnant women.

Since they’ve been open, they’ve helped more than 800 women who weren’t pregnant and thousands of pregnant women. The numbers of women accessing the service who aren’t pregnant are rising, which Juliet believes is down to both awareness of the clinic and the consequences of FGM rising but also increased accessibility to the services due to the rise in social media and online presence.

Despite moving to a hospital setting, Juliet has ensured that the clinic maintains its strong community link: “We have a health advocate who does community engagement work so that people know about the service. A lot of it is work which is really, really important. The health advocate role is very pivotal because they’re the bridge between me, or healthcare in general, and the community.”

What is female genital mutilation (FGM)?

FGM is also known as female cutting or female circumcision. It is a procedure that causes injury to the female genital organs for non-medical purposes by cutting or removing some or all of the external genitalia. FGM is performed in many communities as part of tradition or culture – though there are no religious texts which say that it should be carried out.

(The map above shows the prevalence of female genital mutilation in women and girls aged 15-49 across the world. The highest prevalence is in Somalia (with 98% of women and girls between 15-49 years old having experienced FGM), Sierra Leone (90%), Malaysia (88%), Egypt (88%), Mali (88%) and Sudan (87%). For more information visit the National FGM Centre.)

The health advocate

Suhad Adam

Suhad Adam

Suhad Adam is one of the health advocates at the Sunflower clinic. She moved to the UK with her husband seven years ago from Sudan, where she volunteered in the community supporting women with FGM.

She remembers talking to her husband, a surgeon, at their home in the UK: “He’s so worried when he sees women with FGM. With type 3, many patients can’t do a smear test. It’s difficult for them to even open their legs because there is a trauma about what happened,” she said. “And then we speak together at home, these women – they need help. I was thinking why – I already did this in my country – why have I not continued to do that in London?”

She decided that she wanted to do something in London to help women in her community, so took a one-year course to become a health advocate at the Sunflower Clinics, where she now works alongside Juliet.

For Suhad, helping her community is the real driving factor behind her work. “I think it’s my experience, before there was a bridge between me and the ladies when we spoke about FGM, I felt like they were stressed.” But this is changing, she explains. “Now I feel that the women are relaxed. And I feel happy, I did something good for them.”

She spoke about a woman she helped when she first started working at the clinic. The woman was pregnant and at risk of having had FGM, Suhad had asked her to attend the clinic so that they could determine if she had had FGM and if there would be any health implications. When Suhad first approached her about attending the clinic, the woman was frustrated, asking why she needed to come into the clinic when she’d already had three children in a different country.

“A child died in Somalia a year ago when she was cut, a 10-year-old little girl."
Juliet Albert

Suhad gave her time to calm down before calling her back. She spoke to her in her own language and found this invaluable to building trust and so eventually the woman agreed to come in. She met with Juliet for a 15-minute appointment to check if she had had FGM and what type she’d had. The woman was amazed at how simple it was. “That was a difficult case,” Suhad said. “But now that I’ve been working here nearly three years, I know the patients’ mentality, I know other things, it’s better.”  

A vital part of Suhad’s role as health advocate is engaging with the community, creating dialogue and helping educate. Although she has faced some resistance, it is something she is passionate about: “I think it’s very important to know, if you’re living in this country, you need to know the UK life and the law and know your rights,” she says. “There is a woman abused, there is a child abused. Because the women, they don’t know their rights. How can you help your family if you don’t know your rights? How can you help your children?”

This is something that Juliet has noticed in her work as well: “Occasionally we see women who are very recent to the country, so they don’t know the law and they don’t know about the health consequences. Part of our assessment is we have a long discussion about the health consequences, psychological and physical, so that women are really made aware of why they don’t want to carry on doing it," she said.

“We know from WHO figures that less severe Types of FGM, i.e. type 1 instead of type 3, are becoming more common and carried out on younger girls, who presumably can't make as much of a fuss so keeping FGM underground. We need to educate women and girls about the health consequences of type 1 – which are often as severe as type 3 and help them abandon the practice.”

During the assessments, Juliet and the team talk about type 1 FGM in particular and the health problems that it causes. “Some people say ‘oh, it’s just a little cut’. We’re trying to explain that it’s a human rights violation but you can also bleed to death, you can have nerve pain for the rest of your life, you might not have pleasure when you’re having sex – and that is your human right.”

Despite the changing attitudes, there is still more work worldwide to be done to protect women and girls from the harmful practice of FGM. “A child died in Somalia a year ago when she was cut, a 10-year-old little girl," Juliet said.

In general, attitudes are changing, especially in the UK. “Our experience of safeguarding is that, on the whole, women and their partners and friends that come to the clinic are very against FGM – not interested in doing it. Women have suffered lots of health problems and are very against it,” said Juliet.

It’s not just women who are against FGM, Suhad explained: “Immediately when the husband knows his wife has type 3 FGM, they take her to the hospital or to the midwife, to help.”

The attitudes surrounding FGM are changing in the UK, and Suhad is interested in speaking to more men, to provide support and learn their attitudes.

FGM and the laws in the UK

“I think it’s important to know if you’re living in this country, if you have children, they want to live here as well. You need to know the UK life and the law. How can you help your family if you don’t know your rights firstly?” (Suhad Adam).

In the UK, it is against the law for anyone to carry out FGM, to assist anyone carrying out FGM on themselves, sew someone back up after birth (known as reinfibulation), to take girls or women to other countries to carry out FGM or to help someone else carry out FGM (including making travel arrangements).

It is also the parent/guardian’s responsibility to ensure the protection of their child, and they can be sentenced to imprisonment for up to seven years if their daughter undergoes FGM, regardless of whether or not they were aware of it.

FGM has been a specific offence in the UK since 1985, under the Prohibition of Female Circumcision Act, which was then replaced by the Female Genital Mutilation Act in 2003, which modernised the act, providing anonymity for women and girls affected, making it illegal to assist someone in carrying out FGM on herself and making it illegal to take girls abroad for FGM.

The new act also increased the maximum prison sentence from five to 14 years to reflect the serious harm caused. In 2015 the Serious Crime Act tightened these laws, granting lifelong anonymity and adding a new offence of failing to protect a girl from FGM, as well as additional safeguarding procedures for teachers, healthcare professionals and social workers.

Find out more information on the Sunflower Clinics, including how to access the service.

Why does FGM happen?

Different cultures and communities have different reasons for performing FGM.

Many communities assume that FGM is beneficial to the girl as part of her transition into womanhood. Reasons for continuing FGM range from social expectations, where FGM is a tradition within a community, and as such there is a stigma around refusing FGM, making many girls feel like they have no other choice to beliefs on what is considered acceptable sexual behaviour.

Often FGM is performed to suppress female sexuality, believed to reduce libido or sexual pleasure, and therefore believed to make it less likely for her to have pre-marital sex and ensure marital fidelity. Often it is also believed to enhance male sexual pleasure and increase a woman’s “marriageability”.

There are no health benefits to FGM and it is often performed against a person’s will.

Next steps

Suhad Adam and Juliet Albert

Through Juliet and Suhad’s dedication, women have been able to access care and support which wasn’t previously available. Working together in the clinic, Juliet as a midwife and Suhad as a health advocate, their work is vital to safeguarding women.

Juliet has seen how effective their clinic has been and has recently received funding from NIHR Imperial Biomedical Research Centre to complete a PhD application with Suhad so they can further research how they can continue to support more women across the country.

“We’re going to be looking at the model of care, whether it can help to reduce psychological distress and help prevent FGM in the future – behaviour change model – but also the pain relief,” Juliet said.

Working with the women who’ve used the service, and in the wider community, they have the following questions in mind to take their research further: “Why do women come back to the clinic? Why do they recommend it? What’s good about it? Will it then be replicable?”

A third of patients who access the service are recommended by word of mouth, through friends and family and through the community engagement work of the health advocates, a third are recommended by their GPs and a third are recommended from other places such as NGOs, lawyers and social workers.

Through their research, Juliet is hoping that their community-based and easy-to-access care model will be replicable across the country.