Rahma’s mother didn’t want her daughter to undergo female genital mutilation (FGM), a procedure that involves cutting or removing a girl’s labia and clitoris.
But when Rahma’s aunt discovered the nine-year old hadn’t yet been cut, she called an old man to the family home in Somalia. Her aunt told Rahma to lie on the table and open her legs.
“He was so old, I remember he couldn’t even see where he was cutting me,” Rahma says. “He was shaking and I was shaking. My mum was out at work. I was excited because everyone around me had got it done. But it hurt so badly.”
An investigation for The Ferret, funded by the People’s Postcode Lottery, has revealed that Rahma is just one of over 22,000 women and girls in the UK identified as having FGM during a healthcare appointment since April 2015. The real number is likely to be much higher, with researchers estimating there could be 137,000 affected women and girls in England and Wales.
Rahma is sitting in the offices of Integrate, a Bristol-based charity committed to ending FGM and empowering young people. Now 18, she has been part of Integrate since she first came to the UK from Somalia and started secondary school. At Rahma’s request, her name has been changed to protect her identity.
“I was quite old not to have had FGM. I was in the mosque in Somalia, and all the girls could hear me pee when I went to the toilet,” Rahma says.
“If you’ve had type three FGM, then you pee really quietly. I came out of the toilets and the girls were staring at me and everyone was talking about how I hadn’t had FGM done.
“My auntie couldn’t believe my mum hadn’t done it – she was like ‘you’re a big girl’. She told me she would arrange it.”
When Rahma’s mother returned home, she found her daughter lying in bed in pain. Rahma says her mum still feels guilty about what happened.
“She says to me that you were vulnerable and I wasn’t there for you. But it wasn’t her fault. It was my auntie. Mum was against it.”
In the weeks following the FGM, girls like Rahma are told to remain still, with their legs pressed together so the vaginal opening which is stitched together during FGM can close.
“I was moving about because it was painful,” she explains. “Because my mum didn’t want me to get it done, she said I was okay to move around and that it didn’t matter if it opened up a bit.
“But when my auntie would visit and see me moving, she’d shout at me. She’d say ‘why are you doing this, sit down, close your legs together!’ So I’d have to, until my mum came home.”
Throughout her adolescence, Rahma has experienced “painful and heavy periods where it is hard to go out.” Complications around menstruation are a common side effect of FGM.
“Every time my period is painful I cry to my mum and she tells me she’s sorry, that this never would have happened if I hadn’t got FGM done,” she says.
According to the United Nations (UN), across the world at least 200 million women and girls are living with the impact of FGM. It’s defined by the World Health Organisation as comprising “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.”
The UN estimates 68 million more are at risk of undergoing the procedure before 2030. The majority are found across African countries including Somalia, Egypt, and Burkina Faso, as well as in Sri Lanka and Indonesia.
There are three different types of FGM, ranging from type one which is the partial or total removal of the clitoris, to type three which removes the clitoris and labia, and narrows the vaginal opening.
Historically FGM has been justified for religious reasons, although in the UK it is illegal and recognised by the UN as gender-based violence. Some families believe that girls can’t be married unless they have undergone FGM and the practice is linked to underage marriage.
Feminist activist, Nimco Ali, told The Ferret that, no matter what, “the law says FGM is violence against women and girls, and child abuse.” She is a prominent British campaigner against the practice, who underwent it herself at age seven.
It is not easy to quantify exactly how many girls and women in the UK are like Rahma and living with the impact of female genital mutilation – and how many girls remain at risk. But data from the NHS and academic researchers give a good picture of the scale of the problem.
FGM rates in England
Since April 2015 NHS England has been collecting quarterly data from healthcare providers across the country, including GPs, acute hospital providers and mental health services. This NHS enhanced dataset shows the first time a woman or girl is recorded as having FGM, and all appointments by women and girls recorded as having FGM, including multiple appointments by one person.
Since April 2015 there have been 21,510 newly recorded attendees and 43,005 total attendances. The most recent data, from between April and June 2019, shows 2,905 total attendances by women and girls with FGM, of which 975 were newly recorded.
Many of the attendances involved women and girls in need of medical care related to FGM, but not all. More than three quarters – 78 per cent – of the data collected by NHS England was from women attending midwifery or obstetric appointments.
The majority were in London, where 8,203 women and girls with FGM attended healthcare appointments since April 2015. Over the same period in the north of England there were 4,204, while in the Midlands and the East of England there were 3,908.
Female genital mutilation recorded by NHS England
|Region||Newly recorded April-June 2019||Newly recorded April 2015-June 2019|
|East of England and Midlands||270||3,908|
|North of England||250||4,204|
|South of England||80||1,703|
Source: NHS England
Statistics can only be collected when a woman or girl attends a health appointment and is identified as having undergone FGM. This may only happen if she is having a gynecological procedure, or in need of support for sexual and reproductive health.
Some women simply won’t come into contact with healthcare services at all – or have not come into contact with them yet. This is especially true for women with insecure immigration status, who may not feel safe attending a doctor’s surgery, let alone disclosing their FGM status.
FGM rates in Wales, Scotland and Northern Ireland
NHS Wales also collects data in order to identify the numbers of women and girls attending healthcare services who have undergone FGM or are in need of medical support as a result of FGM.
In 2018 NHS Wales recorded 271 newly recorded cases of women and girls presenting with FGM – the majority of whom lived in the Cardiff area. This was an increase from 174 the previous year. The total of newly recorded cases from 2016-18 reached 465, with 326 of those cases recorded in Cardiff and Vale University Health Board.
This reflects NHS England’s findings that there are more incidences of FGM in busy urban areas than rural regions.
A similar trend was found in Scotland, where the Liberal Democrats used freedom of information requests to reveal 231 cases of women with FGM being treated in Glasgow and Edinburgh. NHS Greater Glasgow and Clyde identified at least 138 women with FGM between 2017-18, and NHS Lothian, which serves Edinburgh, identified FGM on 93 occasions.
In Northern Ireland, data collected by the BBC saw that FGM incidences were again concentrated in the capital: 17 cases were identified in Belfast between 2016-18. Five further cases were recorded in Northern Ireland’s Western and Northern health trusts.
Adding these totals to the newly recorded cases in NHS England, public healthcare providers across the UK have identified 22,228 women and girls currently living with the consequences of female genital mutilation. The real figure is likely to be much higher.
Female genital mutilation in the UK
|England April 15-June 19||21,510|
|Northern Ireland 2016-18||22|
The Department of Health and Social Care declined to comment on our findings, referring us to NHS England. “The FGM Enhanced Dataset is a very powerful dataset in that it is the most comprehensive dataset that we have in understanding the numbers of girls and women with FGM,” said an NHS England spokesperson.
“This has direct implications for the commissioning of services.” The data has already led to a government intervention to ensure better support for women living with the impact of FGM.
In September 2019 eight walk-in FGM clinics opened in England in communities where women are most likely to have been affected. NHS England suggested that this was “a model of care” for those with lived experience of FGM.
“We do hope that these clinics will be able to create attitudinal change within the community,” added the spokesperson. “While prevention will hopefully be a product of the service being active in the community, the main focus is to support survivors of FGM with their health and wellbeing needs.”
Breaking the cycle
Some data collected on the prevalence of FGM in the UK is based on the experiences of migrant women who were born elsewhere and then came to the UK as a child or adult – girls like Rahma.
This includes the data gathered and analysed in 2012 by researchers from City University and women’s rights organisation Equality Now. They authored a report that sought to estimate the “numbers of women with female genital mutilation living in England and Wales, the numbers of women with FGM giving birth, and the numbers of girls born to women with FGM.”
They estimated that 137,000 women live with FGM in England and Wales, having collected demographic data about women who had migrated to the UK from countries where it is widely practised, and the girls born to them. The report also derived its estimates by gathering data about the prevalence of FGM “from reports of household interview surveys in the countries in which it is practised.”
Professor Alison Macfarlane, who co-wrote the City University report, stressed it was important to acknowledge these estimates were from migrant women. But she added: “All the available data suggest numbers are now very low among women born in England and Wales.”
This is backed by NHS England data, which shows that far fewer women and girls born in the UK undergo FGM than those born abroad. Between April and June 2019 individual attendances by those born in the UK with FGM was 65, compared to 610 born in the East Africa region where FGM is more prevalent.
The relatively low rate of FGM in girls born in the UK suggests that families from FGM-practising countries are breaking the cycle and getting closer to the UN sustainable development goal to end the practice by 2030.
NHS England, however, was cautious. “We cannot confirm that the number of girls born in the UK undergoing FGM is low as a result of changing attitudes, due to low reporting rates,” it said.
Macfarlane’s 2012 report was followed by an update in 2015 that further identified the risks faced by girls born in the UK. The update found that between 1996-2010, 144,000 girls were born in England and Wales to mothers from FGM-practising countries.
“It was estimated that 60,000 of these girls aged 0-14 were born to mothers with FGM,” the report said. Over half the mothers were from countries where FGM is almost universally practised.
The report urges caution in assuming that all girls born in these families will automatically undergo FGM themselves. “It is not possible to quantify the prevalence of FGM among girls born in England and Wales to women from FGM practising countries,” it says.
It explains that even in countries where FGM is common, its prevalence is lower among women with secondary and higher education. “It is important to recognise the diversity of this group of migrant women and to assess their needs at an individual level,” it adds.
Female genital mutilation in Europe
|Country||Estimated population with FGM|
Dr Saffron Karlsen, from Bristol University, agrees. She warned against “extrapolating data from countries in Africa and Asia and other places where FGM is practised, and applying it to communities living in the UK.”
Karlsen is co-author of report published in March 2019 called When Safeguarding Becomes Stigmatising. The report raises questions about whether safeguarding measures designed to protect girls from FGM have left communities feeling ignored and criminalised, while women’s own experiences are dismissed.
“People see the statistics from countries like Somalia and Somaliland,” Karlsen explains, “which would suggest that 98 per cent of women and girls had FGM. They think therefore 98 per cent of girls born to those women and into those families are at risk.
“But you can’t just say 98 per cent of Somali women have FGM, and this many Somali women have moved to this country, and this many Somali women have had children, and so it’s 98 per cent of those children that are at risk, regardless of where they live or how their lives might have changed.”
The report authors interviewed focus groups, and found a “sense of the abuse of a disempowered community pervaded discussions of FGM-safeguarding.”
The report also states that women believed medical staff collecting information for the NHS enhanced dataset prioritised extracting information required for government statistics. They felt the need to gather data ignored women’s “health needs”.
At worst, it failed to consider “their trauma in connection with their past experiences of FGM” or how their experiences of safeguarding might exacerbate that, the report says.
Karlsen heard from women in Bristol’s Somali community who were not supportive of FGM. “They felt very strongly that their children should be protected from FGM and were very keen to be involved in working with different authorities and groups towards ending FGM,” she says.
“They didn’t see FGM as an issue in their culture anymore. They said their culture had changed, and FGM was now in the past.”
Rahma’s own family has broken the cycle of FGM. As well as her activism and her mother’s opposition to the practice, she said her brothers and father were “very against” it. She believes that most people in the Somali community in Bristol also oppose it, but she adds: “There’s a lot of work to do.”
Listening to women
Both Rahma and Karlsen agree that women and girls must be listened to if FGM is to be ended. This means focusing on the experiences of victims and survivors.
They point out that the women and girls affected can provide a vital insight into what safeguarding should look like, the challenges they face, and how public health policy can respond to their needs.
Rahma knows all too well how important it is for women and girls to have spaces where they can raise their voices. Being involved with Integrate has helped her develop her confidence and speak out about her own experiences of FGM.
“I told my friends I was a survivor and they couldn’t believe it,” she says. “They told me they thought girls who had had it done were quiet and shy. But you need to speak about it. Integrate has helped me to come out and feel good about myself and talk about what happened.”
“When we first started in 2007 no one was talking about FGM,” Zimmermann says. “Today so much has changed, and it’s survivors who are leading the work. That’s wonderful to see.”
Now Rahma hopes to work in healthcare so she can help other women who have undergone female genital mutilation. But most of all she wants to see a future where the practice has ceased for good.
“I really, really hope that no one has to go through that kind of pain,” she says. “Hopefully we can all come together and fight this as a whole.”
She takes a deep breath.
“And end it.”
This investigation was carried out by Sian Norris for The Ferret, in association with openDemocracy 50:50. It was funded by the People’s Postcode Lottery. Players of the lottery have raised over £486 million for charities and good causes in Britain and beyond, many of which are working to create a fairer and more equal world for women and girls.