Good afternoon and welcome to the Women and Equalities Committee. Today we are holding an evidence session on female genital mutilation, also known as FGM. We have three panels today. In the first we will hear from Aissa Edon, a midwife and founder of FGM Hope Clinic, and Valerie Lolomari, the founder of Women of Grace. Welcome and thank you for coming. The first set of questions is about the prevalence of FGM, and I am going to hand over to Catherine.

Thank you both so much for coming to speak to us about this issue. What is your current sense of the prevalence of FGM in the UK? Are things getting better or worse?

Thank you for the opportunity. In the UK at the moment there are about 137,000 women and girls who are affected by FGM, which is from a study carried out, I think, between 2014 and 2015 on a national scale. Since then, nothing much has been done. Having said that, the acute hospitals carry out a study every quarter, which they need to report back to NHS Digital. I have the stats for last year: between April and June last year, they had a total of 2,175 individuals who attended clinics where FGM was identified. They had another 3,960 attendees recorded across the NHS trusts and practices. Then, out of this lot, they had 985 newly recorded women and girls. Newly recorded means that this was the first time they were being seen at the clinics and recorded on the database. So collectively, since April 2015, we have had about 36,600 women and girls who have attended NHS services where FGM has been identified. Do you want to pick up from there, Aissa?

Valerie told you the numbers. I am actually not a very numbers person, so maybe that is why I am here today. For me, one person with FGM is one too many. I represent more the side of survivors and the side of maternity care because I am a midwife. The impact in maternity, in childbearing and all the consequences after is what we really need to talk about. It is not about numbers; it is about quality of care, and it is about how impacted women are during one of the most challenging and most important parts of their lives due to FGM.

Thank you. As well as the numbers, we need to know about resources, how widespread it is, if there are patterns that we can identify, and if it is going up or down. I completely agree that we need to hear both sides, which is why we have a fantastic spread of panellists today with different expertise, so feel free to just talk to your areas of strength.

I could not agree more, Chair. Are there cases of FGM actually happening in the UK now, or do you think not?

It is absolutely happening every day. Again, it is about evidence. Unfortunately, we do not have evidence—real evidence—but we know because we have our networking. We also know how FGM is spread and working, and how it is embedded in the communities and in the cultural background of communities. It is happening every day in the UK. Either we are bringing FGM practitioners to the UK to have it done in the UK, or the little girls are brought out of the UK. They are UK citizens or UK-born, and they are taken to their country of origin where it is practised, and that is where they have the FGM done. But we absolutely have FGM practice in the UK.

Most of the cases that are recorded are of survivors who have been cut before they came to the UK. It might still be going on in the UK, but we really do not have proper evidence for that. One of the reasons that make us feel as if it is still happening here is the east of England case that happened, I think it was 2019, where the little girl was rushed to hospital because she was bleeding, and it was confirmed that she had been cut. Apart from that, we do not have any proper physical evidence to show that it is actually happening here. Even if it is happening, it is underground and they are hiding it, and we do not have the proper physical evidence.

Thank you. What communities in the UK are most likely to have survivors of FGM?

I like to think that we think it is Africa because you have 30 out of 55 countries on the African continent practising FGM, so that makes it very high—we turn around and we think it is just Africa—but FGM can be practised absolutely anywhere. Asia, the north-east—it can happen anywhere.

Obviously, we have a high prevalence of Somali communities in the UK, and they are the ones who, most of the time, have type 3 FGM. I believe everybody knows how many types of FGM there are. The Somali community is one of the most prevalent communities with female genital mutilation but, like Valerie said, we have other communities—for example, the Nigerian community and some Ghanaians. It depends. The prevalence will be a little less because there are less people coming; they will go to other countries. The higher prevalence is with the Somali community, but you also have to understand that things are evolving. We have mixed-race marriage unions and because it is a cultural practice, even the child who is going to be born from this mixed union might be subject to FGM because of the cultural background of the father or the mother. It is not only black skin, and it is not only African people who are affected by female genital mutilation, so we have to be really careful and mindful about not just making it an African issue. It is a global issue, it is a worldwide issue, and it is not only black skin, or dark skin or brown skin. Everybody is involved in that.

Thank you so much. I apologise that I have to leave early, sadly, but thank you for coming.

We have heard about it being so prevalent around the world, and obviously it is not just black girls who experience this. From your experience, what would you say is the main driver? I hesitate to use that word because there is no excuse or reason—it is violence against women and girls—but would you say there is a common thought behind doing it? The survivor we spoke to said that girls who had not been cut were considered to be prostitutes. Is that common in your experience?

It is a misconception of purity and to make you eligible to be married. I was mutilated when I was 16 and my grandmother thought she was doing it out of love and preparing me for marriage, but the sad thing was that I got married to a man who is from an area that does not even know what FGM is.

There are a lot of false beliefs behind FGM. The list is endless but let me give you some examples. Obviously, purity is one of the primary ideas behind FGM. Being able to marry your children is another. There is a huge false belief that FGM is religious. It is not linked to any religion. We find FGM practised in mummies—I do not think we had any religion at that time. We did not have Christianity, Islam or Judaism and none of the holy books were stating FGM as a requirement. That is one thing we really need to nip in the bud straightaway. The belief is more about it being a cultural thing that happens, and it is done out of love a lot of times. Valerie shared her story; my story is similar, but I was not as old. I was six years old, and I was supposed to be adopted by a French family. A few months before I left for my adoption at six years old, they decided to practise FGM on me to send me with a gift of culture. My little sister at the time was only one year old. So it was not about being pure, about being married, or about being promiscuous. I am originally from Mali. When I did my midwifery dissertation, I went to Mali to understand where FGM is coming from and why it is still going on. When I went to Mali, I really understood that, first, they do not have an understanding and it is not something we talk about. It is just part of the culture and that is what we do. Also, they say, “Oh, you’re not going to be promiscuous if you have FGM.” But they did a study, and there are more prostitutes with FGM practised on them than non-FGM prostitutes so, again, it does not cut off the problem. We talk about hygiene as well. One of the complications of FGM is fistulas. Women are going to be wetting themselves, peeing themselves, pooing themselves, and that is going to mean not being clean. There is a lot of false belief, and we have the rights and we should challenge every time we hear this. It is not done for a religious purpose and it is not done to be more clean: it is only for the control of women’s sexuality. One of my mentors is here, and I always loved it when she was in conferences talking about this. One of the other things is about men, the power of men, and the fact that if the sex of the men touches the clitoris, the men will be infertile or can die. So Comfort, we can let them die, yes? It is really important to challenge all these things. I am a midwife, and they say that if the head of the child touches the clitoris, the child will be disabled and will have mental health problems. Again, that is something we can clearly challenge.

How do members of affected communities tend to react to campaigns against FGM? I know that my friend Nimco Ali, for example, has had death threats.

Some members support the change and they come on board to protect the women and girls. Some other communities are very resistant. They do not want you to talk about it at all because they believe it is a deep-rooted culture. The others also adopt the medicalisation piece of it, where they think if you do it properly in the hospital it is acceptable. It does not make it right: it is still illegal and it still hurts. We heard about the story in Egypt where some children were killed even though they had it done through the hospitals.

Can you repeat the question to make sure I have understood?

How do people in communities react to people who are arguing against FGM? We heard from a survivor and it sounded as though it was a very dangerous thing to do.

I am very French and maybe not politically correct, but I am going to really say what I want to say. It is why most of the survivors in the UK are a little sensitive about the campaign against FGM. It is about how we approach the situation. It is about how, without understanding the culture behind, we decide that FGM has to be looked at like we look at domestic violence and child abuse. It is child abuse, and I am not denying that. I agree with that, but the culture is embedded and the practice is not the same. There are a lot of things that we need to understand before attacking that. I believe that when the UK started to go with the law as a priority, it was really like an attack and not like, “We want to understand; we want to help and support the prevention and the education.” I have been part of the hospital reporting, because we need to know numbers. We also really forgot about the health consequences, and that is the problem. Most of the communities do not understand the link between the health complications they have and the practice. If they are not educated and they do not understand that, how can they understand that it is against the law? How can they understand it is harmful? How can they understand that I am trying to do something for love for my child because my culture has told me that it is something that I do for love, and the UK Government are coming at me to do something I feel is part of protecting my child? That is the way we are. I was honoured to have a Mary Seacole leadership award in 2016, and I can assure you the community is really, really eager to have some help and support. I had men coming to my focus group crying because they did not know how to sort the situation out and help their wives who were living with the consequences that they feel they cannot do anything about. So it is not that they do not want help or feel it is not important. It is useful to have the Government application, but it is just the way it is done that is a problem.

It is particularly the elderly women in the family, simply because they have gone through it. When I had the courage to talk to my grandmother about the suffering I had to go through for being mutilated, she turned around and looked at me and said she is very sorry and that as far back as she could remember every woman in the house had to go through that. So she did not know any better. They do not know the dangers and the consequences of what they do; they just follow the culture and tradition. It is mainly the female elderly women—the grandmothers, the aunties in the House—that initiate this for my community.

I like that she said “for my community” because we have to be really careful. FGM practice is different across the board. Not every community practises the same way. That is why we have four types of FGM. Not every community is the same. In some communities it is really taboo; in some communities it is like a party—a rite of passage. It is different; it is not the same. So you have to be really careful when you are generalising the practice. In some places, men are nowhere to be seen; they do not know what is happening. Some are really eager to be implicated. In some communities, as Valerie said, it is more the older generation. But, again, it really depends. In my community in Mali, when I did my midwifery degree I sat down with my biological father and I told him what the application of FGM had done to me. He did not know about it, but it was because he did not want to know about it. He was there when it happened and he saw me after, but he did not want to be implicated, so he left at the time. So we have to be really careful. I had surgery later in my life to have reconstruction of the clitoris. When I did that, my biological brother came. I knew his mum was the one who brought me to do my FGM. I wanted to make sure—because he was married in France—that if he had a little girl, that would not happen to her. He did not want to talk about it. But they have the power: men have the power behind this. When I was doing my study with the Mary Seacole Trust, I understood that men are aware, they have the power, but they think it is a female problem. The females say, “Oh, we do that for the men.” So it is very confusing. Nobody will take ownership, but it is a global problem. Everybody is involved with that, and we need to really not only involve females because they have already been through it, know about it and know the consequences. We also need to involve men, because they cannot say, “I’m not aware.” They are aware, and we need to make sure they are part of the campaign and part of the changes as well.

Before I move on to the impact of FGM, I want to talk a bit about the culture and the cases that are happening in hospitals. In terms of language, what would different communities call FGM? Obviously, it would not necessarily be genital mutilation for them. What would they call it? What would they describe it as?

As a midwife, it is very rare that I say female genital mutilation when I am talking to the women because they do not understand. They will understand cutting. Some are going to understand sunna or pharaonic cutting. I am always adapting my language to the person I have facing me. Sometimes I do not even use language; I use pictures for them to understand, because that is really important. Also, you have to know that, because FGM is now done in such a broad range of ages, in some countries—like Mali, the country I am from—they are doing it at 40 days of life. Who remembers at 40 days of life what has happened to them? Nobody. So that is the thing. I have so many survivors who came to me who did not know they had had FGM prior to coming to an FGM specialist clinic because they see that in the media. That is where they learn that they have FGM, because they did not remember. Their body remembered that something had happened, but they do not remember that they had FGM. It is really important to show pictures because they can see their genitalia, and they know that their genitalia do not look like the picture you just showed them. That is how I do it.

When you are pregnant and you go into your first midwife’s appointment, you get a checklist and it says, “Have you had FGM?” Would you say that that is a suitable question to ask, or are we not going to catch everybody who has?

Not necessarily. It is a suitable question if you are trained to ask the question, but most midwives are not trained to ask the question. They have put this question in their checklist, but they have not necessarily been trained, because there is no suitable training in the hospital. They do not have the professional curiosity to train themselves on that one. There are a lot of medical terms that even educated women are not going to understand, regardless of whether it is FGM or not FGM. Furthermore, with FGM, we maybe need to change the terminology, but the terminology does not matter if we have to ask the question. That is really important. Sometimes we want to think about everything. It does not matter if you keep FGM, but if you know how to explain or how to show the image, it does not matter if you say FGM. For me, it does not matter. What matters is to ask the question to everyone, regardless of their ethnic origin or skin tone. It is important to ask every woman throughout maternity care when they are booking an appointment if they have undergone female genital mutilation, cutting, or sunna. As I say, as midwives, we should adapt our language to the person we have in front of us.

Thank you. Valerie, I was a bit shocked when you said that there are examples of FGM being carried out in hospital situations. Does that mean that they are being carried out in other countries by medical professionals?

Yes, absolutely.

I want to come back to some things Aissa said about pushing back with the culture. Valerie, you said your grandmother just did not know any better; surely, medical professionals know better, or should know better.

They do not. Some do it for the profits. They get paid.

They do it for profit?

Yes, they get paid for doing it, and some think that doing it in the hospital makes it okay. It does not make it okay; it is still illegal. Children still die from that.

Could I add to that? That is shocking, but healthcare professionals in most countries, the UK included, do not understand the impact of female genital mutilation. They do not. Again, when I did my dissertation in Mali, regardless of what number is said, the prevalence is not 82%, it is not 89%, it is 98%, okay? That is the reality in Mali. I have been to ministries, schools and hospitals. I was in a dispensary where there was a doctor who was treating the consequences of female genital mutilation day in, day out. I interviewed 50 midwives in his dispensary—in the place he was working. They did not have a clue about the consequences, the impact, the health impact of FGM and FGC. They did not. And that was long ago, but not too long ago, in 2009. Imagine: in the country where the practice is, they do not understand the implications; how can they in the UK, where it is supposedly not practised? Again, that is why I am saying education is the cornerstone of this campaign. Education is the most important thing. Health is the second most important thing. That is where we are going to prevent it, change the attitude and the understanding, and we are going to link the problem to the action.

What are the short and long-term impacts of FGM? We heard a lot from a survivor about the long-term impact it had on a group of women, who were young girls at the time, including that a number of them had subsequently died. Valerie, could you outline the short and long-term impacts of FGM, please?

FGM is a life sentence. It has been over 40 years since I was mutilated, but I still suffer. It leaves a long-lasting impact on you mentally. I still do not feel as if I am a real woman. I still struggle with infections. I still have pains. FGM is a terrible thing: it just does not go away. It takes away your confidence. It takes away your liberty. Every single day, I feel as if I did something wrong to deserve that. It has left me with physical pain, psychological pain and emotional trauma, and it is going to be with me for the rest of my life.

The short-term, immediate consequence of FGM is death. We have to be clear about that. Every day, I do not know how many because, again, I am not a numbers person, but one death is too many because of FGM. The other consequences are that you have infection and acute pain. You also have proper, complete haemorrhage, and that is where the deaths are coming from. The long-term consequences are psychological, but also physical and sexual. We need to be really clear. Childbearing can be one of the dangerous times because of the practice of FGM. I am not talking about only type 3, because with type 3 people say, “Oh, it is the most horrific one because women are closed up and they are not going to be able to have their child.” But even a type 1 can make a life-threatening situation for childbearing and childbirth. All survivors have different stories. They have different health implications. We cannot tell one story and assume that another survivor will suffer the same consequences as it is not true. We are all different. Even as a human, if you broke your leg, you are going to heal differently. You are going to work differently because you are a different person. FGM is the same thing. I had type 1 female genital mutilation at six years old. I am 43 years old—I was discussing this with Gillian before—and a few years ago I was still wetting myself. I was incontinent because of FGM. I am a midwife. I was working as a community midwife. Sometimes when I had to go to the houses and I was blocked in traffic, I would smell of pee and be wet because I could not hold on to my urine. Having sex: when you started to be a young girl, you wanted to have a partner, which was impossible because pain and fear of sex were something completely covering me forever. I have now fought against all these consequences. I had reconstruction of the clitoris 20 years ago. I feel complete. I feel a female. I feel that I have back the power that they took from me, but I still suffer from a psychological fear of sex. I am still sometimes suffering with nightmares—not as much, obviously, but it is still there and will always be there. Even though I have a beautiful clitoris back, I will still feel like someone who had female genital mutilation.

Thank you for sharing and for being so open. That is incredibly powerful. Valerie, we see beautiful, strong, wonderful women in front of us—very, very real women, so thank you.

To echo the Chair’s words, you are amazing. What you have been through and what you have done to become activists to support and fight against this horrific act is incredible. On that topic, I would like you both to talk about your respective organisations. Aissa, you founded the Hope Clinic, and Valerie founded Women of Grace UK. Could you tell us a little about how your respective organisations work to combat FGM and to support survivors?

At Women of Grace, we offer our survivors care and support to help their health and wellbeing, to get them back into good shape so they can go back to their communities, impact them positively, and raise a voice to put an end to female genital mutilation. We collaborate with local authorities to fight against female genital mutilation. We train professionals. We go into schools, we train the teachers, we age-appropriately train the students, and we train NHS staff. We have a peer support group. We have also created a safe space these women can come to regularly. One of the unique things we do at Women of Grace is the survivors run a health and wellbeing class, where they make the tea and coffee and the other bit of the community comes in, not just to buy the tea and coffee but to have a chance to talk to the survivors, to give the survivors a voice, and then raise awareness, because it is very important for us to raise awareness. When I started my advocacy, one of the things I was told is, “This is not the kind of thing we want to discuss here. It only happens in Africa.” That is just pure ignorance. We have seen that where we are based with predominantly white people in the area, they have now come to understand what female genital mutilation is just by communicating with the survivors during the health and wellbeing classes.

The story of FGM Hope Clinic started because I am a midwife and because I have seen day in and day out the care in maternity for female genital mutilation survivors, and, for me, it was unacceptable. I have been lucky enough to meet people like Janet Fyle, Comfort Momoh, Juliet Albert and Efua Dorkenoo—who passed away. What I was seeing them doing is what I wanted to be doing, but because I also have this survivor side of my story, it was really important for me to be implicated. At the time, I was in the hospital and did everything by the book to get these services going in my local hospital. When I opened the clinic, I was doing deinfibulation, because that was the really important part in our maternity care, so deinfibulation as well as a birth plan. There are so many professionals who are not aware what FGM is, so many midwives and gynaecologists who do not know what FGM is, and when they treat a survivor, sometimes it is the shock in their face, or the way they treat the woman that makes them more victim than anything else. So I wanted to make sure that there is a birth plan for each and every one of the women who are there. Then there was a coffee morning, because education and prevention is the most important thing as well. For this coffee morning, I was baking my own cake on the Saturday—doing that in my own time because the NHS was not providing me time to do that, but it does not matter because the importance is the survivors. Unfortunately, due to political and financial restriction, the clinic closed, so nobody would be helping these women. So I decided with my broken English to go to policy. I am not a politician at all, but I decided to fight for the FGM Hope Clinic to become a charity, which it did in 2016. Obviously, I could not do the clinical part any more because I did not have a clinical setting but, for me, it is really important to signpost the women who are coming to me to professional FGM clinical services that are the best of the best and that can support them. Sometimes they have to go to Birmingham or London. I have people from all over the UK. It is not only a London problem; it is a UK-wide problem. I am known by my network as the one who had the reconstruction of the clitoris—the one who has got one step forward. I must be honest: I have had more women coming to me in the past years who do not come for the clinical things, because they can find it anywhere, but they really come for the fact that I went through this surgery 20 years ago. I was one of the 600 first in the world. So they come to me, and they want the support. Unfortunately, I have not been able to support them in the UK because I am French, and I have also trained in Belgium. I have to help them to go abroad to have the surgery. It is very organic. We support them because we do not want them to be on their own in a country where it is not their language. It is a time when they are very vulnerable as well. So my family and my friends host them, they go with them to the appointments and, if I can, I take some days off. I take some time off to go if I can. We have no financial support at all because I do not know how to sell as good as Valerie. We do not have financial support, but it does not matter because it is one girl at a time. I am very proud to say that more than 20 girls have had the surgery throughout the years, and that changed their lives forever. Hopefully, Juliet and I are going to talk later, but I will carry on until the UK decides that it is also their business to work with the survivors, because there really is a demand. We need to stop being deaf and we need to listen to this demand. I wish FGM Hope Clinic did not exist, because that would mean all the women and girls who want to have the reconstructive surgery could have it in the UK, and I would not need to do it anymore.

One of the things that has come over loud and clear—you said it explicitly before we came to my question—is education and healthcare being absolutely key. It is about supporting survivors from a healthcare perspective, but there is also the education piece, raising awareness and changing perceptions. What is the most effective way to persuade family members and communities not to undertake FGM? I know you have mentioned awareness, but do men and women have different roles to play in preventing it?

I cannot talk for all FGM communities, but you have to identify the cultural dynamic. You have to identify who are the decision makers in the family. Is it the grandmother? Is it the father? Who is the decision maker in the family? For me, it is not about trying to persuade them; it is just showing facts. Who can deny that when a girl has FGM, one of the consequences is fistula? Who can deny that, from six years old to my 38 years old, I was incontinent? Who can deny that? Nobody can deny that. It is about showing facts, but it is going to be a long journey—a long process. It is not going to be that we do just one talk and say it one time and yes, that is fine, we are going to have a solution on FGM. It is going to be consistency, persistency and non-judgmental. We are not here to judge the practice. We know it is bad, thank you—we have already said that several times—but what can we do now for the practice to stop? It is to understand the culture, understand the people who are practising the culture, and find the way, without judging them and without them feeling judged, to educate them, and for them to find their own voice and say, “Okay, yes, I am against FGM.”

For us, it is about engaging the religious leaders as well—the people who make the decisions. Every culture is different, but knowing that you are working with them, you will be able to have access to the women. In some cultures, the women respect their religious leaders—the people who make decisions over them. For example, for one of the communities we are working with now, we had to go through the imams. We spoke to them, raised their awareness and they understood. Then, they came with us into the activities. The women seeing their decision makers in the room with us, knowing that we are all together, raised a lot of awareness and understanding, and that gave us even more access to the communities.

What you have said is really interesting: it is not about religion; it is about stakeholders, whether that is a religious leader who people look to for guidance or whether it is a grandma.

We also need to focus on education. The women already know. They already know they are in pain. They already know they have consequences and they suffer. The education is for the broader family and for the broader community, because sometimes women have pressure, and with this pressure, even though they do not want their little girl to go through FGM, they are going to have to because of the pressure of the community. They might be strong at the beginning for years and years and at one point they give up because we are not supporting them by convincing and educating the people who are pressuring them.

I am mindful of the time, but I could honestly sit and listen to you for ages. Just quickly, in about 30 seconds each if that is okay, if you could ask central Government to do anything, what would it be? I know that is pretty hard in 30 seconds, but how could we support you?

Tougher monitoring, especially at the UK borders. I have had the opportunity of working with the police and the Border Force, and we had to go to the airport to talk to clients going to and from the prevalent areas. That was very effective. Also, maybe funding the grassroots organisations. These are people who are working on the ground in the community. They need funds to raise better services for the survivors.

I agree with Valerie, and I would add that you have to involve education, by which I mean education in schools, from primary school to doctor’s school—all the schools. The funding is really important. The clinical settings of FGM specialist clinics need some funding and support to do the good work and carry on the good work they are doing. We have to open the door to other things, because women are asking for more than just education, prevention and care of the consequences. They want the next steps as well: reconstruction of the clitoris and thinking about that, because women are desperate for it.

Thank you very much. I know we have been tight for time. If there is anything that you wish you could have expanded on, or you want to expand on, please write in and we can have that as written evidence. Thank you so much. Witnesses: Janet Fyle MBE, Professor Hassan Shehata and Juliet Albert.

Thank you very much to our second panel for joining us. We have Janet Fyle MBE, professional policy adviser at the Royal College of Midwives; Juliet Albert, specialist FGM midwife at Imperial College; and Professor Hassan Shehata, senior and global health vice president at the Royal College of Obstetricians and Gynaecologists. Welcome to you all. Thank you so much for joining us.

In your experience, what are the most significant and frequent health complications for women and girls who have experienced FGM that you have come across?

Thank you very much for the opportunity to give evidence. As was mentioned earlier, I would classify them into four categories. There are physical complications, obstetric complications, sexual complications and psychological complications. There are short-term and long-term complications. If we start with the physical complications, obviously the physical mutilation could mean that these young girls eventually, later in life, may need to have reconstructive surgery. At the time of the procedure, there is the risk of bleeding, infection, and long-term problems like urinary tract infections and other complications, which may also lead to fertility problems later in life, and so on. Obstetric complications are a major concern because there is recent data to show that at the moment there are 230 million women and girls who have undergone FGM, 30 million are expected to undergo FGM over the next four years, and 44,000 women die because of FGM every year. That means one woman dying every 12 minutes. So there will probably be at least six women who have died by the time we finish this session. I could not really describe the psychological complications better than what was said today: the low self-esteem, the depression, the anxiety, and all the problems that come with it. Then there are the sexual problems, from lack of desire to the fear of having sex. That comes with all types. I recently visited Malaysia and was really shocked to see open advertisement in Malaysia for babies at the age of six months undergoing FGM. The idea is that they do pricking of the clitoris with a small needle. It is more like a cultural tradition. However, some studies have shown that because the clitoris is so small, despite the needle being small, it causes nerve damage. Later in life, of course, there would be disfigurement and all the complications that come with it. I agree with the previous speakers today that whatever the type, they all lead to serious short-term and long-term complications. It is barbaric. Medicalisation, which you mentioned earlier, is a major problem, particularly for me. I come originally from Sudan and Egypt. These two countries unfortunately are not just bound by the River Nile but by this horrible procedure that they do. Sudan in particular does type 3. Medicalisation, which means procedures done by healthcare workers, in these two countries is as high as 80%. The most recent report says 64% are done by healthcare workers. In Egypt in particular, it is done by doctors. One of the things that I have developed with the Royal College of Obstetricians and Gynaecologists is to reduce medicalisation, because if you look at the most recent report on SDGs, it is very clear it is trying to identify how to reduce medicalisation. Medicalisation sometimes gives that confidence or false reassurance to patients that they are doing it in a clinic and that means it is safe. It actually leads to more people having it done because it is done in a clinic. That is a major concern. Unfortunately, doctors are doing it, midwives are doing it and traditional birth attendants are doing it. It is not related to religion because we see a very high prevalence of FGM in Sierra Leone, so it is not always related to the Islamic religion. So there are serious complications and millions of women, and we need to address that very quickly. I know this is about the UK, but I am quite disappointed—if I am going to be honest—by the reduction in global funding, because that will lead to less effective research. We need to stop this problem at its source, and we need to really work hard with other organisations to try to stop it at source. That is what we need to do.

Are there any other significant health problems that you may have come across?

Hassan has articulated it very well.

There are a lot of women with type 3 FGM who are coming for deinfibulation—the opening procedure—and we have done over 1,000 women in the last 15 years. They are having it done often under local anaesthetic, but there are some clinics in the UK where they do not have access to deinfibulation under local anaesthetic, and women are having to go on long gynae-theatre waiting lists to have deinfibulation under general anaesthetic. We see a lot of that, and as Hassan was saying, we see a lot of women with type 1 and type 2, who are still suffering a lot with pain, other problems with urinary incontinence, and the psychological impacts.

Talking about the psychological impact, one of the things that sticks with me is that for some survivors of FGM, the psychological impact is equivalent at times to soldiers who have seen action on the battlefield. If you could contextualise that, we will see where these women are coming from and how much help we need to give to them.

On that point, is there specific support, or medical and health services, that you feel should be provided for women and girls with FGM?

I was going to start off by saying that I would answer all your questions, but you need to bear in mind that I came here with one objective, which is to get across to you that survivors of FGM are being neglected. We need a proper service, not pilots that will end. When we talk about counsellors, we need someone who is an expert in counselling women who have had FGM. I will take you back a little. In 2015, some individuals here, the Royal College of Obstetricians and Gynaecologists, and GPs, came together. I led a multi-intercollegiate group, and we made eight recommendations, and the Government responded well. Britain is leading actually; however we look at it, however much we complain, we are leading in this area. One of the recommendations was that FGM is considered as child abuse, which the UN adopted from us. However, we have gone down so much that we have let women down. This is the Women and Equalities Committee. As much as I am going to answer all your questions, I want you to think about a basic service for these women. That would be a safe space where they can talk to clinicians about the condition they find themselves in, and expert support from a psychologist who understands how to counsel women for FGM. We must not forget that as much as we focus on non-pregnant women, and maternity has done extremely well in terms of identifying women antenatally and during birth, and we can offer deinfibulation, we need to think about women on the other side of the scale—menopausal women. Could you think, for one second, about what I am going to say to you? There is a woman sitting in her living room, she has had children, they have been to university, they have gone to work, they have their careers, and she is alone. Her husband has found a younger woman, and she is all alone at home. She has a urinary tract infection, she has repeated infections, she is depressed, she has pain, she does not know what to do. She is all alone and we do not do anything to help her. When the NHS reviewed one of the pilot clinics, it came back to say the NHS had a net benefit of £200,000 by providing this basic service to women. I will answer your question, but I am going to keep reminding you to keep in mind that you need to be doing something around inequalities, because this is the Women and Equalities Committee.

There are 28 specialist clinics across the UK, and there is no clinic in Northern Ireland. We had a woman travel to our London clinic from Northern Ireland. She was told she had to wait three years on a gynae waiting list to be seen because there was nobody to deinfibulate her there. There is one clinic in Wales and one clinic in Scotland. Clinics and services are very variable. Sometimes women have to travel very long distances. We know that non-pregnant women sometimes have to go to a clinic that is situated in a maternity setting, where obviously it is very difficult if they get noticed. They might not be married, and people might see them and assume that they are pregnant, when actually they are not pregnant; they are trying to access a specialist clinic. We have to be aware that things like self-referral, no geographical boundaries and fast-track walk-in services are really important for FGM survivors, because there are so many barriers for them in accessing specialist care. A lot of women do not even know that their problems are because of FGM, so the GP and primary care staff really need educating so that they are able to say, “Yes, this is what I think you’ve got, and therefore you need to go to a specialist service.”

Some answers that you come up with hopefully will be covered in some other sections as well. We have questions on health services, reconstructive surgery and the effect of FGM on pregnancy and childbirth.

You have already answered some of my questions, thank you, and thank you for sharing your experiences with us today. We are talking a lot about women’s health hubs. What do you think the role is of women’s health hubs in helping FGM survivors, or what role can they play?

I can start. There is an opportunity for us with women’s health hubs, because the idea is that we are going to have these specialist hubs that look after women. If we have appropriately trained, accredited personnel, it would be good accessibility for survivors of FGM. The concern I have with women’s health hubs is that it seems they are going to be the solution for a lot of things, and at the moment there does not seem to be any secure central funding. For example, I come from South West London ICB, and it has been asked to reduce its budget by 30%, so I am not really sure how we are going to fit in all these things. In principle, it sounds like a great idea, because you will have a meeting of primary care and secondary care in the community nearer to the clients, and that makes sense. But we need to ensure that the people there are going to be well trained, with psychological training, that they will be asking the right questions and will know how to deal with that. One of the biggest problems we face in the country at the moment is language barriers. Coming back to the question earlier about what FGM means in different languages, in Sudan and Egypt they call it tahara. Tahara means purification, so the name itself is awful. What we need to go back to is how we allow for language barriers. There are no standards in the UK for language barriers. The MBRRACE report shows most of the women who die have problems with language barriers: if you do not speak English, you are 25 more times likely to die. At the moment, we do not have any standards. If you look at the recent information sent for people to bid for interpretation services, it is very basic. At NVQ level 3, you can do the service. There is a lot of work we need to do. Yes, it will have a role, but we need to do it properly. We cannot just say, “Women’s health hubs,” but no funding to follow.

In principle, a women’s health hub is the place to be, because if we could contextualise FGM within women’s health and wellbeing, then perhaps we might make progress. However, at the moment FGM is commissioned by the integrated care boards, and the ICBs also commission pelvic health services. So you have survivors of FGM and women who have had birth trauma vying for the same resources. Maybe moving forward what we need to think about is leadership and accountability. If the ICBs are funded to provide the services, the structures within the NHS currently must be used to get them to account for what they are doing, so they are not putting the money to cover a deficit, but towards providing services for women.

Women’s health hubs are so important, particularly for areas of low prevalence of FGM where there is not going to be a standalone specialist FGM clinic, and those women then will be able to access the women’s health hubs. I want to add that psychosexual counselling and trauma counselling are really important. It is not good enough just having a counsellor: they have to have FGM training. You hear stories of women going to see a counsellor, and the counsellor ends up crying because they know nothing about FGM. We need to make sure these are expert counsellors who have had FGM training and that there are health advocates the women can identify with, who can translate as well. You are absolutely right, Hassan, that language is really important too.

You mentioned specialist FGM support services; would that be a preferred method of support over a women’s health hub, or do you think there is some other solution there that might be worth while? That is open to the whole panel.

We have to be realistic. In areas of low prevalence, perhaps it is not realistic to suggest. Like I said, what we cannot have is non-pregnant women having to go to a maternity setting always. I do not know if you have other ideas about that, Hassan.

I agree with you. In high-prevalence areas like London, for example, we need to have specialist centres, but in low-prevalence areas, it would be reasonable to have something in the women’s health hubs, but with expertise. The most important thing is that at the moment we have a lot of training packages that RCM and RCOG have done through the NHS; they are not mandatory and they are now 10 years old. We need to really see how we can educate. The psychosexual training is really crucial because how you counsel these women is completely different. I agree with Juliet that the hubs will have a role in low-prevalence areas.

Also, in low-prevalence areas, if the women turn up at a women’s health hub, there must be a pathway for the individuals working within those women’s health hubs to say, “Ah, right, we don’t have those services here, but this is what I must do. I’ll refer you to this person.” As I said earlier, if you have a multidisciplinary team within those hubs, they have an idea what to do when someone turns up in an area where there is not an established service.

I wanted to add one thing. We are talking about accessibility, but one of the major problems that these women sometimes face is actually the fear of seeking access—first, because of stigma, and secondly, because of perceived charging. We know FGM is excluded from charging, but people do not know that. That charging coming in was a very negative move in the NHS. I am hoping that the new Government will reverse that, because a lot of women have a fear of accessing care because they are worried that they will be charged. Imagine somebody who does not speak English and does not know the details. It is very difficult. I have it in my own hospital sometimes, where our charging people will come and try to charge patients because they do not understand the law very well. Those are well-educated people who speak English as their first language, let alone somebody who is an asylum seeker. Also, people need to be culturally sensitive: do we know how to deal with them? On the negative side, sometimes when people find they have FGM, they focus on that and forget about everything else they came in for.

I have a quick question before I hand over. Professor Hassan, did you just say that the training package for FGM is 10 years old?

Yes.

Would you say that it is time for a refresh, a review and an update?

Yes.

Before we came here, we spoke to the communities and to colleagues who work at the NHS, and the e-learning package is up for review and an update. I have been told that is going to happen.

From the RCOG, we have something called the Green-top Guidelines. We are now actually looking for new developers to do those, and normally we work together with the RCM and the RCGP. If we get support as well, that would be good, because that is the way to do it properly.

The point is that it is still not mandatory for healthcare professionals, and it needs to be. We have been talking about this for how long? And it is still not mandatory. It seems ridiculous.

Is it not mandatory for midwives?

It is not mandatory. It has been included in some training packages now, but it is not mandatory, no.

It is not mandatory. I know people ask about midwives because maternity has done very well and has increased awareness of FGM in the last 10 years. The Royal College of Midwives pushes for every midwife to undertake the training. We talk about training, but there are other aspects of training: bias training, the nuances, professional curiosity and how to ask questions around FGM. It is not just your standard training. There is something that has to be skills-based with all the packages that are around there. It must be implemented where people are working, so that they see live examples of how to talk to women about FGM.

If you see us looking at our phones, it is normally so that we can say to each other, “Can you make sure you ask that?” We are trying to be effective, but we are not being rude. As MPs, we get to meet regularly with ICB chief execs, NHS chief execs, and the local Healthwatch. I am an MP in Derbyshire, which is predominantly a white Caucasian county, but Derby city is pretty ethnically diverse. From an awareness perspective, Caucasian white British people need to understand. What is the best question I can ask of the ICB, the CEO of the NHS Trust and Healthwatch, to establish what they are doing right now? If they are doing nothing, who I can point them in the direction of to find out best practice, and then hold them accountable, so that at my next meeting I can say, “What have you done about FGM?”?

I will answer that. We need clear leadership and the priorities of the ICBs, because they have been given the money for pelvic health, and FGM has been placed within that. It is about how much money they have put into the FGM services. It is not just a counsellor; it is an expert counsellor. In many places it is the midwives who undertake most of the work around FGM in terms of deinfibulation. You should ask that question about whether they have a multidisciplinary team, how it works within their ICB and how accountable it is.

If the answer is quite low, who can we point them to? That might be a question to follow up on, if you can share information with us. As a Member of Parliament, I would like to leverage this opportunity to start those engagements with my key local people.

Reconstructive surgery has been mentioned several times. How successful is it in terms of the physical and mental wellbeing of the women who have reconstructive surgery compared with those who do not?

Reconstruction surgery has been available since 1998 in France, and over 6,000 women there have had reconstruction surgery. It is available in so many different countries in Europe: Belgium, France, Switzerland, Spain, Italy and the Netherlands. There is quite a lot of evidence. We did a scoping review in 2024 and found that in 94% of cases there was some improvement. The complication rate was only 3%. This is not life-threatening surgery and this is not expensive surgery. It can be done as day-case surgery. Women are seeking reconstruction surgery for three main reasons. The first is long-term genital pain. Secondly, there is sexual dysfunction or lack of sexual pleasure. Thirdly, there is what we call body dysmorphia, so not feeling whole or complete. The evidence shows that for a lot of women it is extremely beneficial. It is not for every woman; not everyone needs or wants reconstruction surgery. However, we feel really strongly that it is something that should be available in the UK. We have the expertise in the UK. We have vulval reconstruction surgery for cancer patients, we do gender reassignment surgery, feminising surgery. We have the technique and the expertise, and what we are pushing for is for there to be a clinical trial so that we contribute to the evidence. The WHO specifically said in 2016, “We need more evidence,” yet the UK is not contributing to this, which is really shameful. I did a survey of service leads across the UK, and they all agreed unanimously that reconstruction surgery should be available. In terms of numbers, 90 women in one year had attended FGM specialist services requesting reconstruction surgery. We know that there are women who want it—not everyone, but there are a number of women in the UK who want access to this. Sometimes they are travelling abroad, like Aissa said, and we know that surgical tourism is expensive and costly for the NHS if they come back with problems. Yes, we feel it is completely unacceptable, and we have applied for some funding from the NIHR to conduct a clinical trial, which we will find out about in a few months. It is really important that we have services in this country. We need at least a centre of excellence in London and then another one in Manchester or Birmingham, so that women do not have to travel too far. We also really want trauma and psychosexual therapy embedded as part of the service, because we know that some women after trauma and psychosexual therapy may decide they no longer want reconstruction surgery. We want that to be integrated into the service.

As, Juliet knows, at the RCOG we have a slightly different view. That is really quite important. We welcome research into reconstructive surgery. We at RCOG have reported back to queries from the Government several times, saying that the evidence at the moment is still really not enough for us to have NHS centres for reconstructive surgery. I welcome the work that Juliet is doing, because she is really doing a lot of good work in research, and we support research. But at the moment the Royal College of Obstetricians and Gynaecologists does not support having NHS centres for reconstructive surgery until we are better informed. At the moment, the evidence is not there.

How do we get better informed unless we do research?

We support research rather than reconstructive surgery centres. That is the difference.

Would it be fair to say that there is a difference of opinion, or there are two different streams of thought? One is that there is evidence there to show that reconstructive surgery is hugely beneficial, and therefore it should be widely available in this country, and presumably it should be available as a service on the NHS; the other is that the Royal College of Obstetricians and Gynaecologists does not feel there is sufficient evidence.

There is no evidence at the moment. There are levels of evidence: there are levels A, B and C. The best quality of evidence is when you have a certain level of research that people do. At the RCOG, we have always put ourselves at a very high level of evidence-based practice. That is what we produce. At the moment, our evidence-based practice does not favour reconstructive surgery, and we are very clear about that. We need more research into it.

We are all saying the same things here. We have to do a trial to see whether it works, and that is going to be under way soon. I will let Juliet speak about that. We are saying the same thing, because in the UK health services you need to demonstrate through evidence that something is effective for the state to fund it and for it to happen.

You are all agreed that what we need in the first instance is a trial.

A trial, definitely.

Yes.

We have touched on this a little already, but what effect do you think FGM has on pregnancy and childbirth? How do you think the NHS supports a woman who has undergone FGM—particularly type 3 FGM—if she becomes pregnant?

As an obstetrician, I can answer that. There are two possible ways of looking at this. Looking at it from the UK point of view, if things are followed properly, we do the deinfibulation earlier on, and with that we try to avoid complications that may arise if somebody just arrives at the birthing stage. Because of the scar tissue, there can be complications immediately—mainly bleeding at the time of giving birth—as well as complications of nerve damage, and complications of infections, especially after delivery. There are lots of complications. Overseas, the problems are even worse because people do not get the deinfibulation, and they end up with obstructed labour, which leads to obstetric fistula and all the other complications—death of the baby, death of the mother, haemorrhage and infections. It is absolutely horrific when you look at what happens in Africa and in Asia where it is done. In the UK, as much as possible, if the woman is seen in the right centre with the right pathway, things are probably done in a reasonable way, but still there are many more complications that arise after delivery.

We have 25 specialist services and there are 215 trusts, so not all maternity services have an FGM specialist or an FGM champion, and they really need to. There needs to be an FGM specialist who can diagnose what type of FGM someone has. We obviously need better training so that at booking, when they are asked the question, the women understand the question and they have translators and counsellors. I was thinking about Derbyshire, and in Sheffield, for example, if a pregnant woman has type 3 FGM, they do not seem to be able to offer deinfibulation during pregnancy. They have to wait until labour. It is completely unacceptable. In some places there are different practices going on. It is very variable, and it is very patchy.

We have spoken about type 3, but I am conscious that Aissa mentioned earlier that it is not just type 3 FGM that is affected. Would you be able to touch on the other types of FGM as well?

My concern mainly with types 1 and 2 is, first, that they get ignored because people do not think they are serious enough. Secondly, I am worried about the gap we have with regard to how we identify young girls under the age of 18. Who assesses them? How do we assess them? Are paediatricians the right people? Do we have FGM experts, obstetricians, or midwives? How do you go about examining a child under 18, especially when they have complications as well? We have a big gap in our services at the moment, and understanding the implications.

UCLH has a brilliant paediatric clinic, and there are some other clinics that now link up with satellite centres. So there are some paediatric experts, but again, it is a bit patchy. The other thing is that during pregnancy, we know that women with all types of FGM are more likely to bleed during labour, are more likely to tear, and have longer maternal stay. They have flashbacks sometimes during labour, or during suturing afterwards. We have not discussed the intersectional violence that is often alongside FGM. Over 30% of the women we see have suffered other intersectional violence. Sometimes it might be fleeing from war, rape, domestic violence, early forced marriage, or juju witchcraft. It is really common. The women we see in maternity services are quite complex cases.

Even vaginal examination is difficult sometimes because of the trauma and the flashbacks they have.

Sometimes we also need to understand the family dynamics of FGM and the community dynamics of FGM. When you were talking about types of FGM, there is a problem with type 4 FGM at the moment, which goes one way or the other. It depends on which judge you come in front of, I guess. I am sure the police will tell you. There is a lot of misogyny around FGM, and those of us with young friends and kids who do TikTok need to be aware that boys are going on TikTok and saying, “Oh, my girlfriend has to do a little bit of stuff under there so that she is neat and tidy.” My colleague was telling me that the girls themselves say, “Oh, well, we go to our GP, and I just fake it to my GP that I can’t bear to look at myself, I have mental health problems, and I’m going to kill myself.” The GP then refers to a psychologist who says, “Yes, go. You go to the NHS and you get some form of reconstruction done to your vulva.” We need to be really aware of the way that communities, and especially young men, are interpreting what women and girls should do. It is playing into the FGM scenario.

I wanted to add something on David’s questions earlier about whether it is the women or the men, and it links to this question. There was an article in The Guardian on 24 November last year that showed that FGM increased in Chad when Sudanese women and families went to Chad because of the war. It increased both among Sudanese women and girls—even post-marital—as well as Chad women and girls. It made me think about that because going back, there are probably not a lot of men because of the war there, but is it really conducted or led by the women? It made me think and I discussed it with other people, and the reality is that it is ingrained in society. I still think it is men trying to control women. They are not directly involved, but this is what is expected of the elders to do for their girls. It is really interesting. With all the war and all the problems that are happening, people are still thinking about this so-called purification—about doing that procedure in refugee camps, during war, and where people are hungry. They leave everything, and they are doing that. That really tells you how ingrained the problem is that we have to remove. Therefore, culture and society are issues, and unfortunately some people bring that culture and society with them even when they go to the western world.

Positive verbal messaging is really important. The other thing we have not talked about is how services are such an important point of contact with a woman. We should be thinking about supporting them with English classes and housing. If they are asylum seekers, we should support them. Funding for charities and grassroots organisations is really important, and we are working with them.

Just quickly, you have answered this already, but do you think the NHS is capable of helping women who have undergone FGM during pregnancy and childbirth? For example, does it provide the right training to midwives?

It is very patchy, I would say.

It is very patchy. The NHS could if it had good leadership in that area, a commitment, and a multidisciplinary approach to dealing with and supporting women and girls who have undergone FGM. It is capable of doing that. But FGM is siloed in many places, provision is patchy, and people are not taking it seriously. In areas where you have a good service, it is because the clinicians and the local communities are committed to doing well for the women. This brings me to my little list, because you are about to finish. Can I go through my little list? My ask today is for FGM services within women’s health hubs, or wherever they are, to be funded. They should be consistent, with clear specifications, protocols and guidance, and clear referral pathways across all entities where FGM services are provided. They should include psychological therapy by an expert counsellor, language support and a health advocate, and they should take a multidisciplinary approach and have good leadership. Training for healthcare professionals should not only be e-learning, but should be about how curious they are and how they ask the questions around FGM. The one thing we have not done since 2014 is a prevalence study. We do not know the prevalence of FGM in the United Kingdom. If you take England and London, for example, there is a particular borough that has the highest prevalence of FGM in the whole of the country, which is Southwark. We need an immediate prevalence study, and education and awareness, and education and awareness within communities. We have got to where are because we worked with the communities. They were the ones who raised awareness around tackling FGM. When we were speaking to them, they said, “Oh, don’t worry, the Government have forgotten about FGM. It’s finished. They’ve done their bit and they’re done.” We need to reignite the confidence that the communities had in us. The FCDO must improve its funding globally to reduce FGM. It is an imported problem and we have to stop it at source. Finally, we signed up to SDG 5, and 2030 is just around the corner. The Government need to begin to look at what they have done and how they are going to report and engage with the experts and people who have been working on this. Because of all the initiatives and good work we have done, people overseas and in other countries are adopting what we have done. We have been the leaders: we were the ones who took this on. We need to reconnect with the communities, fund the organisations that are working tirelessly, and never forget the survivors. I have left you with that picture of the older woman. It is not just the pregnant woman or non-pregnant woman; it is the woman in her menopausal years.

Before we move on, Janet, you just talked about confidence in the community. We are about to speak to the police about how child protection works in the police and their role in FGM. Is there a tension between securing confidence from the community and getting the women the treatment that they need, alongside the police work around prosecutions? Is there a tension? Is there one that should take priority over the other, or can they both work together?

I do not think so, because we continue to work very collaboratively with the police. We tell them truths when there is truth to be told, and we work hand in hand with them, but what has happened is that FGM has taken a back seat. I suppose if there is any tension, I would not like to blame them, because they are suffering from the same issues around funding. That needs to be looked at. We had what I would call our halcyon days, when the police, social services, health and education worked together. We should not forget that education piece.

It is a difficult job they face, to be honest. Our experience has been very good working with the police on this. It is a difficult job, and it is complex.

My question is not about how well you work together. If a woman comes forward and it is her auntie, her grandma, or her mother who has inflicted FGM on her, what confidence does that community have that you are just going to treat her, rather than end up prosecuting and her being part of that prosecution? Is there a tension between those two things? Is that a barrier for a lot of women coming forward?

Not now. Previously, perhaps, but not now. In the last couple of cases, the police were really on it and saying that they were going to prosecute, and they did. I do not know of any others. Of course, we could say that we can train the new recruits a little more in terms of just rushing in and saying, “Oh, because you’ve had FGM, you’re going to do it on your child.” There is something around training and understanding of how this plays out in the community and within health.

Thank you so much Juliet, Janet, and Professor Hassan. Professor Hassan, are we okay to do some questions around the international part of it in writing?

Yes.

Thank you very much, all three of you. Witnesses: Gillian Squires, Grainne Boyle and Angela Craggs.

I know you have been listening to the other two panels, so you know how this works. If there is anything that you want to follow up in greater detail, or that you want to go into greater detail but time is not going to allow it, please follow up in writing. Grainne, can you hear us?

I can hear you clearly.

Excellent. Thank you so much, and welcome to the Committee. Grainne is from the FGM helpline; she is the helpline practice manager at the NSPCC and is online. Welcome, Grainne, and thank you. We have Gillian Squires MBE, director of Honour Me Ltd and retired detective constable at West Midlands Police. We have Detective Chief Superintendent Angela Craggs, deputy national lead for harmful practice at the National Police Chiefs Council. Welcome to you all, and thank you very much for joining us. I am going to hand over to David first.

Yes, absolutely. Thank you for inviting us to be part of the conversation today. We are really delighted to be here; it is good to be here. In terms of the scale of FGM, it is really difficult to quantify due to the hidden nature of it. Like all forms of abuse, there is a lack of precise data showing its prevalence. It is estimated, however, that 170,000 women and girls are affected by FGM in England and Wales. But as with everything, it may not be a true reflection of the scale of the problem because there is so much silence around this issue. It is estimated that around 65,000 girls aged 13 and younger are currently at risk of FGM, but like many forms of abuse it is hidden. We know that it is a very complex and intersectional issue, and it is very difficult to get to the core of how we address this and how we engage with those communities. We know there is a sense of loyalty to community, there are cultural norms, there is a sense of shame and embarrassment, repercussions and fear of being shunned by friends, family and community, and all these contribute to the silence where FGM exists. So in terms of the work we have to do, we have to work collaboratively with agencies and hopefully then we have some possibility of arriving at the true nature of what we are dealing with.

Thank you for the opportunity to speak. We absolutely know the importance of understanding prevalence in this area. We know that we need to direct our resources appropriately, which is really difficult. In terms of numbers of cases reported to police, it is very low. They are not coming from victims, survivors or witnesses but from professionals in health, education and social services, so we know we do not get a full picture of exactly what is happening. We know it is hidden. We are looking for opportunities around prevention: how do we maximise proactive opportunities to deal with those who are inflicting harm on young women? The information coming through is almost zero, so it is very difficult for us to think about what response should be in place across policing. There have been four convictions in FGM-related cases nationally, and that is all. We often have to work with international forces and agencies as well, so the investigations themselves require a very specialised policing response. We need the initial response to be of a really high standard because that is the only way we can ensure the trust of the victim and witnesses, but we are not seeing the reports coming through that we should be. I do not know what you think, Gillian?

Thank you for inviting me to speak today. I have been involved in this area of work since 2009. I did not know anything at all about it back then but went on a very steep learning curve. I know, from all the work that we have been doing in the West Midlands, that this is a very hidden crime, as has already been said. It is something that is not talked about within communities themselves, let alone outside of agencies, and as it is against the law it is unlikely that people are going to talk to us. Referrals are very low compared to what we suspect. Most of the referrals we had in the West Midlands were around safeguarding—for example, a teacher phoning in to say that so-and-so is going on holiday to Sudan and has talked about a special celebration, and they are concerned that FGM is going to happen. Unfortunately, what teachers and health professionals are going to be looking for prior to FGM happening is all very circumstantial, which again adds to the problem of us not being alerted. That, along with cultural sensitivities and not wanting to be seen as being racist and jumping to conclusions, makes it really tricky for professionals. You have also heard that the education is really poor around this area in all agencies, so we are asking somebody to talk to a family about something that is very complex, and they do not have the tools or the skills to be able to do so. It is no wonder that we do not have those reports coming in. I know we have a lot of criticism within the police—I am saying we as if I am still a police officer; I think I always will be—but really this is not just a police issue around prosecution. This is an everybody issue. We all need to be brave enough to talk about it. We need to see it as child abuse and to ask pertinent questions without fear of being called racist. There is enough evidence that this happens in certain communities for us to say, “This is why I am asking these questions.” Professionals need to be more confident about it. That is why we do not have the amount of referrals come in that we could. In terms of FGM actually happening, the referrals that come through to the police are very few and far between. As I say, most of them are about children potentially at risk, so safeguarding is put in place to protect them, if needs be, once an assessment has been done. On those cases where we have had prosecutions, I cannot imagine we would have very many more about concerns where FGM has actually happened, if that makes sense. It is really difficult for us to give you an answer about prevalence because it really is the tip of the iceberg. It comes under the honour-based abuse umbrella and is very hidden.

In terms of prevalence, again, as the other panel member said, it is incredibly difficult to quantify, and like all agencies we face the same problems in terms of reporting to us. The helpline was established in 2013 as a national safeguarding helpline specifically to deal with contacts relative to FGM. In the duration of that period we have had 553 advice contacts, and only 17 of those have resulted in referral. We realise that is a disproportionately low statistic. Again, we encounter so many barriers. One of the issues we see very often is just a lack of information. People contact us based on suppositions and what they suspect may be happening, but it is incredibly difficult to reach evidential criteria where we can meet our threshold to refer, so that may account for some element of the under-reporting. The ages that we see can range from anything from three to 15 years, but we have had children younger than three who we know have been subject to FGM. Very often those children are taken from the UK on the premise of going to a special gathering, a ceremony, a family affair—something of that nature—and the FGM will happen in the country of their parents’ origin. We also understand that during covid statistics relative to FGM occurring in the UK rose because people were prohibited from travelling during that period, so there was a natural increase during that time. But on being able to arrive at a figure where we can say it is X, Y or Z, we just cannot do that. We just do not have that kind of collaborative data among agencies—police, social care, health visitors, maternity services—at the moment, and that is definitely an area where we all need to improve.

I would like to add to that. Going back to the conversations with prior witnesses, we had an investigation in the West Midlands police in 2012, and the Sunday Times did an undercover investigation into a doctor and a dentist practice in Birmingham. An undercover reporter went into the surgeries and initially asked the doctor if they could help practice FGM on their nieces. The doctor said, “No, I cannot, but I know somebody who can help you.” He gave the information of a dentist who was registered as a doctor and a dentist in his home country but only as a dentist here. He was approached, again by the same undercover reporter, and it was all filmed on a covert camera in a handbag. He said, “I cannot help you, I actively campaign against it.” They then go off camera for an hour, then come back on to camera, and he is offering to do it for £750. This was put in the Sunday Times without telling West Midlands police anything at all about it. What would have been a better storyline? Cutter prosecuted? But no, unfortunately I found out about it by going down to my newsagents on a Sunday morning and seeing Waris Dirie, a wonderful survivor activist, on the front page, and a double page spread about this investigation. They were obviously arrested but they denied it. There was a financial investigation—every investigation you can think of, in collaboration with the CPS. We looked down every avenue that we possibly could. The witness would not come on board—would not give us her name. We could not use the evidence on the camera because it was entrapment. The CPS unfortunately had no other option than to say, “No further action.” They were both struck off their dental and medical registers. The reason why it is important for me to tell you this is because this is not just about girls going abroad: this is about girls being cut in the UK. It is not just about women orchestrating this; it is about men, and it is also potentially about professionals. We need to be really clear that this is not just one line that we need to be looking down; we need to be keeping an open mind. We have intelligence to suggest that FGM is happening here in specific cities in the UK, although unfortunately we do not have names. One thing I always press when I am training professionals is about them having those conversations within those communities where they have trusted relationships, to try to find out what is going on. But again, with professionals’ lack of training they are unwilling most of the time to do that, to be able to give us the information to get in there and tackle those cutters. Going back 12 years, one of the midwifery clinics in London used to hand out anonymous questionnaires in which they asked questions like, “Is FGM happening in the UK? Where is it happening in the UK?” At that time it was pointing towards Birmingham. People were saying, anonymously, from communities, that it is happening in Birmingham. Yet here we are still, years later. We have more than we had in terms of prosecutions—although do not get me wrong: prosecutions are not the answer to this—but we need to be getting at those cutters because they are operating here in the UK.

Historically, as I think Janet talked about, following the collegiate guidance we all came together and were involved in a really strong stakeholder group at the Home Office, where we pushed for change. We had the Girl Summit and there was a lot of action with a lot of money put into it. The FGM unit created a change of legislation with the Serious Crime Act, and we had campaigns. Obviously, the Government cannot keep up that level of intensity on one subject, but it has diminished significantly to the point where it is now almost forgotten about. I was upset to find that the campaign I was involved with when I was on secondment to the FGM unit in 2018 and 2019, which involved survivors appearing on posters and campaigning for change, had been decommissioned by the Home Secretary, leaving us with no national campaign that professionals could use to advertise services. It is a very sensitive subject, and it has to be tackled sensitively. By Government leading it, we have stakeholders who can advise on that, and having that corporate approach will give people and professionals confidence to display materials and ask questions.

When was that decommissioned?

A couple of years ago; it was, I think, Priti Patel who decommissioned it.

Okay. thank you.

It is a combination, most definitely.

It is about funding locally, in terms of ensuring local delivery plans. It is about holding people to account at high-level meetings, like you were saying earlier, to say, “What are you doing? Come back to me to tell me.” Unfortunately, that is the only way people will do things, and we need to keep on top of it. In terms of Government, I know Jess Phillips very well and that she is going to do some great things in this area, so I have every faith in her. But at the very least we need a campaign and more funding in terms of grassroots in countries where this is practised, but also here in the UK. Unfortunately, the ones that are doing a lot of good are those small organisations that are survivor-led, so they are led because of passion. Because they do not have charity status and perhaps do not have the people to go to in terms of how to write a successful application, they are not getting the funding, and they are the people who need that.

Thank you very much. Gill, what training do police officers have to support victims of FGM? Is it standardised across all the forces?

No. The College of Policing does have some e-learning packages that are available, but they are generally around public protection. I do not know whether that has changed since I have retired. I can certainly speak for the West Midlands police in that we gave all officers mandatory training under Operation Sentinel, which was an operation leading awareness internally and externally around vulnerable victims and hidden crimes. Everybody in the force had mandatory training given by me, and within the West Midlands new recruits, CID officers, child abuse investigators and sexual offence officers all have training specifically around FGM, and obviously that is an ongoing process. I cannot speak for other forces other than that in my new business, Honour Me, I have been asked to go into other forces to give FGM training. What is apparent is that maybe they have had some training but it is not anything like they would have had with me in terms of the depth, clarity and emotion that comes with it.

Angela, you might want to touch on that as well, but I really wanted to know how the Foreign Office and the Home Office work with police to share intelligence on the risk of girls being taken out of the UK to undergo FGM. In particular, we have heard of cases where if people have dual citizenship, they will go out to Turkey on one passport and go to another country with a different passport. How is that working, and could it work better?

To come back to the question around training, it is important to acknowledge that. For example, I chair a silver group, which includes force leads from all over the country, and we talk very much about what is good practice and what training should look like. There are definitely examples of good practice throughout the country—little areas of good practice. As Gill says, some of the NGOs provide training to officers. We are currently working with the College of Policing around some advice notes, which are first responder advice notes, and then for secondary investigators, and a background note to level up understanding around the offence types. But the training itself is not mandated. That is a challenge for us because with such a lot of different priorities across policing, to get that kind of voice heard nationally is very difficult, so it is something that we are working on. In terms of the intelligence picture, there is the piece around what we know in this country. A couple of years ago we tried an approach with Crimestoppers, which was obviously anonymous, to try to increase the intelligence flow coming through. But in terms of the international piece as well, it is really important that live cases are brought to our attention to be picked up. It is definitely the case, or the suggestion—again, it is intelligence rather than really clear information—that people will travel from country to country before they potentially land in the final destination. We are obviously really lucky at the moment to be able to put in place FGM protection orders, and we have a really tried and tested system of getting and accessing those through our local authorities generally. There is a really good opportunity around that central piece of building really consistent good practice with the new national centre for VAWG and public protection that the Home Office are putting into place at the moment. We are hoping that is a really good opportunity to raise cases across all harmful practices, including FGM.

A last question from me. Gill, you mentioned convictions and prosecutions and that there have only been three convictions for FGM in England and Wales. What more do you think needs to be done to increase the number of prosecutions and convictions for FGM?

It is really important that we do not get hyper-fixated on prosecution. Prosecution is important as it sends a very strong message to communities that this is against the law and it will be upheld. However, prevention is what we need to be focusing on more. There are many reasons why we have not had prosecutions. We have touched on one already: the fact that the professionals are not trained and do not feel confident enough to ask the questions and therefore the referrals do not come through. Children do not want to give evidence against their parents. West Midlands Police were criticised about putting out a tweet about safeguarding being our first responsibility. It is, obviously, but the interpretation was that we would not prosecute. That is not the case, but in working together to safeguard children the best interest of the child is paramount. If you have a traumatised child, her best interest is not necessarily going and standing before a court and giving evidence against her parents or her grandmother, so it would not always follow that we would go down that route. I know there is a lot of controversy around that, but it has to be that whatever is in the child’s best interest comes first. There are lots of other issues around not having very many doctors who are specialised in being an expert witness in court around FGM. We did have two but I do not know the current situation, and I am pretty sure that they have retired. In terms of examination of children for FGM, we have very few who are able to identify it and are confident enough to give evidence in court. We have come across problems before with equipment. Whenever an examination for FGM is carried out it will be videoed so that we do not have to re-examine the child. Some instruments are old and produce a blurry picture, so when they are peer-reviewed by experts they cannot actually properly see what they are looking at, so we have had problems with that. Then, it can be two months or three months down the line before the experts can actually see the child to re-examine, which causes further trauma for the child, and in some cases with type 4 that evidence may have gone. Sorry, I have probably gone off on a tangent, which I am good at doing with this subject.

No, not at all. I wish we had a whole day for each panel. I am just trying to make sure that we get to the end of our questions and trying to manage everybody’s questions as well. That is really helpful, thank you. I am going to hand over to Samantha now, on child protection.

Grainne, it would be really good to understand more about the work the NSPCC is doing on preventing FGM and supporting survivors of abuse through the helpline. Could you talk about the types of calls you receive, whether they are from concerned professions, survivors or even people perhaps reporting others who are perpetrating FGM? Could you also touch on the work the Government have been involved in and whether that has included any funding?

When the helpline was established in 2013, there was initially some funding from the Government. However, that was short-lived so now the funding comes out of the main NSPCC Helpline fund. So it is all self-funded, because the NSPCC have identified the need for this national safeguarding helpline. In terms of the contacts we receive, they are predominantly from professionals, so mostly schools, teachers and DSLs who will contact us seeking advice. When they contact us, it is incredibly difficult to triage these calls because of the lack of information. They will come to us initially and say that they have concerns that a child may be being removed from school, or a child has returned from school after a long period abroad or a period of absence. Very often what we see is that they lack the confidence to even have very preliminary conversations with the family. We will say things like, “Have you spoken to the family to understand why the child has been absent from school?”, and they will say, “No, no, we do not feel confident enough to do that.” So we then have to have conversations around safeguarding being everyone’s concern, everyone’s priority and we have to put the needs of these children first. We understand these conversations are uncomfortable—we have them every single day—but if you want to protect children you have to have these conversations. We deal with a lot of those inquiries. We also have inquiries from medical professionals, although we would not see as many of those in numbers. Very often we will get calls from GP services seeking advice around mandatory reporting, and what their obligation is in relation to that. A lesser number of the contacts are actually from survivors of FGM, although recently we have seen an increase in that. We also work alongside Childline, who have had children actually reaching out and contacting them, although again the numbers are very low, and in the last three years it has been less than 15 children. There is a myriad of reasons for this. These practices are very normalised and hidden and there is the dichotomy of protector and abuser that people are very reluctant to engage in conversations with. So in terms of what we are seeing it is incredibly difficult to actually enact safeguarding in response to these calls because the limitations of the information just means that unfortunately referrals are not able to be made. That has a knock-on effect in terms of what we see in children’s services, police, the FCDO and the forced marriage unit, so it is a really difficult issue to solve.

Grainne, we have some questions around mandatory reporting and teachers and professionals. If we can follow those up with you in writing, that would be great. Sorry, but we are so squeezed for time.

That is fine—no problem at all.

They are effective and a really good way of involving the police and children’s social care actually working collaboratively and coming up with the most holistic response in the individual case, which means we get a proper understanding of the risk. We talked about the different power within the family and the community in some previous submissions. It is really important to get that right in order to put the most appropriate FGM protection order in place. I like them. There are sometimes cases where the police will take out the FGMPO because perhaps children’s social care do not necessarily think the risk is there in that case, so it allows that bit of autonomy across the professionals who are working on the case.

Yes. I work with the forced marriage unit, training police and social services on protection orders, and I have obtained orders myself operationally. Protection orders are great, although not always appropriate. They are really useful in terms of the fact that the threshold for obtaining one is quite low. It is not like other protection orders where you have to prove real harm rather than significant harm, so they are really easy to get. I will give you an example of an order that I got that actually repatriated children. The beauty of these orders is that if you are struggling with somebody who has already gone abroad and you want them back into the UK, they are great at being able to do that—particularly where you have countries that are difficult for our embassies to negotiate or have conversations with that would not put the victim at further risk. I had a case come in that told me about a woman who would be coming into the airport the following day. Her children were being left in Africa, where prevalence is high, and we were told the flight number she was coming in on. I obtained a protection order to be served on her the next day. When she arrived, she was arrested and it was served on her. She said she was coming back to the UK because she did not want to see her children harmed. But we know that honour is about the external family and community as well, that the pressure was there and that she had no say in it. In her phone call to her family abroad she said, “This order says that the children cannot be cut and they must be brought back to the UK within five days, because otherwise I am in breach of this protection order and I could go to prison for five years.” The power of that brought those children back. They were medically examined and had not had FGM, although we will never know whether they were going to or not. The important fact is that they are now protected by that order until at least the age of 18, and that can be assessed properly. So orders are not always appropriate, but they are really important in terms of our toolkit in protecting girls.

No, we would only comment on it from a safeguarding perspective.

In a quite animated way, yes. Protection orders, both forced marriage and FGM protection orders, based on the same legislation, have never been well known. I do not think professionals know as much about them and I certainly do not think heads of service or even legal services within social services are well aware, because of the amount of times I get pushback saying the threshold is not met. The threshold is not significant harm—I have obtained it on anonymous information before; you do not need that level of risk. It will not surprise you that there is an education aspect. Sorry, I am having a menopausal moment and have lost my train of thought.

This is a good Committee for that.

How embarrassing! They have never been sought for very much anyway. The numbers have always been low, and when I was seconded to the FGM unit my purpose for the secondment was to devise and deliver a series of roadshows around the UK to increase those numbers. I worked with the Ministry of Justice, we had some judges, and we held day-long multi-agency presentations around the UK. I will never know whether it is because of the roadshows or not, but the numbers did significantly rise during and after those roadshows, and now they have declined again. I do not think it is anything to do with the fact that the issue has gone away. It is to do with the fact that professionals are strapped because they have too much to do in too little time, there is a lack of awareness of what they are and what they can do, on every level, and they are seen as something that will take too much time.

I would only say that, as was said, it is one of the many possible tactics within the toolkit, so it is something to think about in respect of wider safeguarding. I know there is probably a point where whenever there is an FGM case there is an expectation around getting an order, but a lot of the time the cases that come forward are actually safeguarding risks, and professionals have different ways of managing those. We would absolutely like to see more orders, but I think we are getting quite good at nuancing our response to safeguarding as cases come forward.

Thank you to all three of you. That was a really informative session. As I said, I could have quite easily had a session for each of the panels, so thank you so much. We will follow up with the questions that we did not get to ask, and if you have anything else that you wish you had said—whether it was a menopausal moment or not—and you want us to know about, please do write in and work with Danni and the rest of the team. Thank you very much. That brings this session to a close.