Female genital mutilation (FGM) has risen steeply up the policy-making agenda since July 2014, when the then Prime Minister, David Cameron, hosted the Westminster Government’s first-ever Girl Summit to kick-start a national programme to end FGM and child, early and forced marriage.

However, progress towards this aim has been negligible. In September this year the House of Commons Home Affairs Committee again raised concerns about the failure by the criminal justice system to identify and prosecute perpetrators, despite glaring evidence that girls resident in the UK are still being ‘cut’, here and abroad.1

Alongside legislative and criminal justice initiatives, there have also been strenuous efforts to educate at-risk communities that the practice is both illegal and harmful to girls, and to raise awareness among health and social care professionals that they must be alert to FGM and report it if a client discloses they have been subjected to FGM, or they believe a girl may be at risk of FGM.

Much of this heightened profile is due to the efforts of campaigners like psychotherapist Leyla Hussein, who herself was subjected to FGM as a girl, and who has been advising the Department of Health in England on its education and awareness programme.

Leyla is founder of the Dahlia Project in north London, which offers a safe, therapeutic space and counselling for women who have undergone FGM, and also provides training to healthcare and other professionals. ‘I wonder how many therapists have been missing the fact that this woman in front of them may have been subject to FGM. Today many more counsellors and psychotherapists will be working with refugee and asylum seeking girls and women from countries where FGM is practised. It is worrying that so many in the profession don’t know even the basic information about the types of FGM,’ she says.

She had to teach her therapist about it, when she first disclosed. ‘It changed our relationship – it was so alien to her. It became this big thing between us in the therapy room. Women should feel supported; they shouldn’t have to explain what it is. They should be able to tell their own story; they are not there to teach.’ She believes that every counsellor and psychotherapist should ensure they have had at least a basic training in FGM, the communities most at risk, the physical and psychological effects, and what support and specialist services are available locally. She says counsellors must be prepared to ‘ask the question’.

‘That can lead to so many other things – health and medical care, psychological support, and to preventing it happening to others, because they will go and talk to other women who have daughters,’ she says. ‘It isn’t something they will readily speak about, either because for them it is no big deal, or because of shame. They want you to bring it up. I know that from my experience, and other women tell us that. If you ask, you are not being judgmental, you are just clarifying, and 99 per cent will be honest with you, and then, when you explain the psychological impact, they say it makes so much sense.’

Leyla spent six months working with a school counsellor and the school’s attendance officer. ‘When we looked through the attendance register, we could see who the girls were from their pattern of school attendance. These girls are likely to miss school every month because of their menstrual cycle and the pain of having a period. We were able to identify four girls and approach them in a sensitive and supportive way. Two of them were failing in their schoolwork and, with extra support, they were able to do much better.’

Ros Jerram, FGM Manager at the Manor Gardens Health Advocacy Service in north London, agrees. The project trains community facilitators to educate their own communities about the effects of FGM and why the practice should stop. They hold workshops in women’s homes, where the women feel safer and more able to disclose. They also train doctors, social workers, mental health workers and the police. ‘One of the main problems in terms of preventing FGM is that it’s not mandatory for teachers in schools or school staff to have training on FGM. But it’s the teachers and support staff in schools, including the school counsellors, who are mostly likely to know about girls who have had FGM or to get disclosures. They need the training to support girls and prevent it from happening. If the counsellor doesn’t know about FGM and doesn’t think to bring it up, a girl may never bring it up herself,’ Ros says.

Some local authorities have developed risk assessment tools to help professionals in contact with parents and children to ask the right questions and overcome their anxieties that challenging FGM is racist or culturally insensitive: ‘There is a lot of anxiety about cultural sensitivity but, at the end of the day, it’s child abuse; it just hasn’t been treated as such, and you have to report it as you would any form of child abuse,’ Ros says.

Good counselling practice

Counsellor Melanie Mendel was until very recently part of a small team running the Acton African Well Woman Clinic, in west London, where there is a large Somali population. The project was set up by two midwives 10 years ago and was the first to provide a community-based, midwife-led deinfibulation service, to which women could self-refer.

‘Anyone working with FGM needs to have background knowledge of the practice and the terms used by the different practising communities, and understanding and sensitivity to a cultural practice that is deeply rooted in their belief system,’ she says.

‘We had very limited funding so I could only see women for up to four sessions, which wasn’t enough if they really needed to explore issues. I used my role to offer a safe environment where they could tell their story if they wanted to, and supportive counselling in relation to the deinfibulation procedure. If they needed more psychological input, I would refer them to the specialist psychosexual department at Queen Mary’s Hospital or University College London Hospital. Usually they didn’t – therapy is quite new to many of them, although this is changing with the second generation; within their cultures and communities they tend to rely on extended family for support.’

She sees the psychological and emotional effects of FGM as a spectrum, ranging from severe post-traumatic stress disorder at one end to her own experience in the community clinic. ‘A thorough assessment is key to understanding both the woman’s individual experience at the time and how she conceptualises the experience now, as well as her psychological state. Some will have more severe trauma, so they may need long-term therapy.

‘But, for most of those attending the clinic, that is not their immediate need. They usually come for deinfibulation prior to their first sexual relationship and/or marriage, and most are very accepting of it. Their problems are about their relationship with their partner, infertility or childbirth. These are issues in the present. It’s important that we don’t lose sight of that, as, in my view, that is where we can really make a difference. You need to stay in the present, with what is happening now and how it is affecting them now. All I offered was good, basic counselling – listening without judgment, being empathic, and working with what they brought.’

For Farah Nadeem, a counselling psychology student in training, a key issue is the effect on the therapist of working with women living with the trauma of FGM. She is just completing her doctoral thesis on the therapist experience of working with FGM. She interviewed seven experienced practitioners: two clinical psychologists and two humanistic and three psychodynamic psychotherapists.

First, she says, she learned that it’s vital to take an individualised approach to each client. ‘The clients come from different communities, different tribes, different areas of Africa. Don’t put them all in one box. Not all have had FGM when they were very young. Some of the interviewees had worked with women who had it when they were older – for one, it was done when she had baby out of wedlock.’

Second, she believes it’s vital for the therapist to have experience of working with trauma. ‘I worked with domestic abuse and rape, and then I was allocated an FGM client – it’s very different. You have to be confident in working with trauma – you can’t be afraid; the client will pick up on it.’ And third, she says, practitioners need to be very alert to the possibility of vicarious traumatisation. ‘It’s hard for the client but it’s also hard for the therapist. Self-care is very important. Make sure you have good clinical supervision and personal therapy; take time out, because what they tell you does stay with you.’

BACP survey

In February 2016, BACP was asked by the Department of Health and NHS England to conduct a survey of its members’ knowledge, training and experience of working with FGM.

Just over 2,000 members (5% of the membership) responded; most were from England (1,706), with far fewer responses from Scotland (93), Wales (79) and Northern Ireland (56). Just over half worked in private practice; just under half in the voluntary sector; 20 per cent worked in a healthcare setting, 15 per cent in primary or secondary education; 12 per cent in a workplace setting, and nine per cent in higher/further education.

Worryingly, few in any of the settings knew who their designated FGM or safeguarding lead was. Most of those who did know were working in primary/secondary education (36.9%), but, even here, almost two-thirds of counsellors either did not know, or did not have, a designated FGM or safeguarding lead in their school or college. BACP says this suggests that schools need to do more to ensure all staff members, including counsellors, are given training in safeguarding procedures when they start work there.

Just a third (33.6%) of those working in healthcare, 23 per cent in voluntary sector organsations, and 22 per cent in workplace settings knew of their safeguarding lead in their organisation – and there were a lot of ‘don’t knows’ across all the sectors. BACP is concerned here, too, that so many counsellors working in health settings aren’t adequately briefed on what to do if they come across a child at risk of FGM. As the BACP report points out: ‘It is possible that practitioners working in these settings may have disclosures from adult clients about a child who has undergone, or who is at risk of, FGM, and in these cases there is an expectation by the Government that they should still share this information with their local safeguarding lead and follow their organisation’s safeguarding procedures. Therefore, it is still vital that practitioners working in these settings are aware of their organisations’ safeguarding policies and procedures with regards to FGM.’

There was also a general low level of awareness and understanding and a lack of confidence among the respondents about working with FGM. Nearly half (47%) admitted they were not at all confident that they understood the four main types of FGM, or that they could recognise signs that a client may have been subjected to FGM (38%) or knew what presenting issues such a client might bring to counselling (34%). Worryingly, too, more than a third (36.6%) of those working with this age group lacked confidence in their understanding of their safeguarding duties if a girl under the age of 18 disclosed to them that she had been subjected to FGM.

Some 192 respondents had worked with FGM survivors, and they provided a wealth of information about the clinical issues involved. Top of the list of helpful factors when working therapeutically with FGM survivors, they listed cultural respect, knowledge and understanding, non-judgmental acceptance, listening, providing a safe space to talk, reflect and explore feelings, empathy, and some knowledge and understanding of FGM: ‘Have really good listening skills without leaving them in silence. Be very, very real with them,’ one respondent said.

The overwhelmingly most unhelpful factors highlighted by respondents were a lack of, or an assumption, of understanding about the issue and a judgmental attitude, followed by therapist reaction, a focus on child protection and mandatory reporting, and time-limited work: ‘Attempting to “help” when none is needed,’ said one.

However, less than a quarter of the respondents had received any training about FGM. BACP says practitioners should at the least be aware of the common issues, and be mindful of the huge diversity across this client group.

See the full BACP report Counselling professionals’ awareness and understanding of female genital mutilation (pdf 1.5MB)

Catherine Jackson is editor of Therapy Today.