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Complex Situations (SLO7)
This was previously featured in an exam
A 9 year old girl is brought to ED by her grandparents with vaginal bleeding. She has recently returned from a summer holiday visit to her parents home town in Somalia. The girl appears very quiet and withdrawn. She is reluctant to be examined but indicates she is experiencing pain down below. What is the most likely diagnosis?
Answer:
Female genital mutilation (FGM) involves any procedure that includes the removal of any part of the female genital organs for cultural or any other non-therapeutic reasons. Girls are sometimes taken abroad for FGM, but they may not be aware this is the reason for their travel. Girls are more at risk of FGM being carried out during the summer holidays, as this allows more time for them to "heal" before they return to school. In 2015, section 74 of the Serious Crime Act was added to section 5B of the FGM Act 2003 mandating that all health and social care professionals in addition to teachers within England and Wales are required by law to report any ‘known’ cases of FGM in any under 18 year old which they discover to the police. It is essential that all healthcare professionals are aware of what FGM is and their clinical and legal responsibilities regarding the matter.Female Genital Mutilation
Complex Situations (SLO7) / Obstetrics & Gynaecology
Last Updated: 13th February 2023
Female genital mutilation (FGM), which is also known as female genital cutting, involves any procedure that includes the removal of any part of the female genital organs for cultural or any other non-therapeutic reasons.
Background
It is estimated that approximately 2 million females worldwide undergo a type of FGM each year, with the majority of them being unaware that they are even at risk. There is an estimated 137,000 females in England and Wales who have undergone a type of FGM, including 10,000 girls under the age of 15 years.
There are many reasons why this custom is still seen as acceptable by those that agree with its practice. They believe it has a positive meaning by enhancing marriageability, improving hygiene and ensuring virginity. They also believe that clitoris removal reduces a women’s promiscuity, which reduces the risk of pre- or extramarital sex and family dishonour.
FGM has become more prevalent within the UK due to an increase in immigration of women from countries where FGM is practiced. FGM is illegal in the United Kingdom for females under the age of 18, and must be reported to the police if detected. It is an extremely harmful procedure and has been recognised as a form of child abuse and gender violence against women.
Types of FGM
Please note identifying the type of FGM can be difficult, and is not required of ED staff.
| Type | Description |
|---|---|
| 1 | Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris) |
| 2 | Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora |
| 3 | Infibulation: narrowing of the vaginal opening through the creation of a covering seal (formed by cutting and repositioning the labia), with or without removal of the clitoris |
| 4 | Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area |
Effects of FGM
There are no health benefits to FGM. It can cause serious harm, including:
- severe and/or constant pain
- infections, such as tetanus, HIV and hepatitis B and C
- pain or difficulty having sex
- infertility
- bleeding, cysts and abscesses
- difficulties urinating or incontinence
- organ damage
- problems during pregnancy and childbirth, which can be life-threatening for the mother and baby
- mental health problems, such as depression, flashbacks and self-harm
- death from blood loss or infections
UK Law
In 1985 the Prohibition of Female Circumcision Act was passed within UK law stating it is an offence for any person:
- 1) To excise, infibulate or otherwise mutilate the whole or any part of the labia majora or clitoris of another person, or
- 2) To aid or abet, counsel or procure the performance of another person of any of those acts on that other person’s body.
In 2003 the law was updated to the Female Genital Mutilation Act making it illegal to send children abroad for the purpose of FGM. If found guilty of an offence under this act a person may be imprisoned for up to 14 years.
In 2015, section 74 of the Serious Crime Act was added to section 5B of the FGM Act 2003 mandating that all health and social care professionals in addition to teachers within England and Wales are required by law to report any ‘known’ cases of FGM in any under 18 year old which they discover to the police. This duty came into effect on the 31st October 2015.
Any healthcare professional (HCP) who fails to report a case will risk losing their registration, and potentially their career. Therefore, it is essential that all HCPs are aware of what FGM is and their clinical and legal responsibilities regarding the matter.
Key Recommendations
- There is no requirement for a HCP to ask every female if she has undergone FGM, only those they believe to be from a high-risk area or background.
- If FGM is discovered or disclosed during a patient’s journey then it is mandatory that this is recorded by the HCP who makes the discovery in the patient’s health records.
- Females over the age of 18 who have undergone FGM do not need to be referred to social services or the police. They should be supported and offered relevant follow up, should they want it. Other females within their immediate or extended family (especially those under the age of 18) should be identified and consideration should be given to their risk of FGM and need for protection.
- Any child (less than 18 years of age) who presents with symptoms of FGM, who discloses the fact, or you as their HCP suspect they are at risk of FGM, then it is your responsibility to report this to the police, and implement relevant safeguarding procedures as with any child abuse case. This information must be shared with social care, the GP and health visitor as part of safeguarding actions.
- Frontline staff should be empowered to recognise and manage those patients who have undergone or are at risk of FGM by developing their knowledge and awareness of the subject. A simple to follow Female Genital Mutilation (FGM) flowchart has been developed for all ED staff to use when presented with a female patient (adult or child).
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
