Responsive, person-centred, referral systems and clearly defined clinical pathways to well-coordinated services are crucial to meet the health and well-being needs of survivors of female genital mutilation (FGM) across the life course (WHO, 2016). This paper focuses contextually on Northern Ireland (NI) as a devolved UK region.

Northern Ireland has strategic frameworks, multiagency guidance, and pathways for FGM safeguarding, ending violence against women and girls (EVAWG), and ending domestic and sexual violence. However, there is currently no comprehensive integrated clinical pathway for referral to specific established services to support FGM survivors with the physical and psychological consequences of FGM, particularly outside maternity services. FGM is an area requiring regional policy and commissioning attention and development. 

Key challenges in Northern Ireland

Lack of clear FGM clinical pathways

There is no standardised tiered clinical pathway guiding healthcare professionals, from initial presentation (wherever an FGM survivor with care needs may present), through to assessment, referral to services, treatment, and follow up care. Existing pathways focus primarily on safeguarding, risk, prevention and pregnancy. FGM identification frequently occurs during pregnancy. Non-pregnant women and older women can remain unidentified and unsupported. There is limited guidance for the referral and care of non-pregnant FGM survivors. As a result, FGM referral systems and services are inconsistent and poorly integrated into routine, sensitive, responsive specialised health and social care services. 

Limited training and awareness

Many health and social care professionals have limited education on FGM. Regulatory bodies (Nursing and Midwifery Council (NMC), General Medical Council (GMC) and Social Work regulators) expect registrants to understand the legal, ethical, safeguarding, and health implications of FGM and to deliver person-centred, trauma-informed, sensitive, non-discriminatory care.  

While FGM training is mandatory for some professional groups in NI (midwives, gynaecologists, obstetricians, social workers) it is not mandatory for NI nurses, beyond mandatory general safeguarding training, despite their frontline roles and professional responsibilities, when patients present at their practice settings requiring FGM-related clinical care. In addition, underdeveloped clinical pathways limit the effectiveness of role-specific training. 

Fragmented Services

Although examples of good practice and support exist, services, such as primary care, maternity care, general adult service, mental health support, community engagement and safeguarding, often operate in silos. They would benefit from proper integration and coordination through clinical pathways and the multiagency guidance.

Maternity services have some dedicated clinics and protocols, but there are no established support services and clinics for non-pregnant FGM survivors. Healthcare staff frequently lack clarity on referral routes to specialist FGM assessment and services for treatment and care for physical problems, psychological support, and ongoing care.

Unlike England and Wales, NI does not collect and publish comprehensive FGM data, that we are aware of, limiting informed service planning and commissioning. 

Cultural and language barriers

Women may be deterred from accessing and engaging in the FGM healthcare support they need for a number of reasons, including:

• Limited culturally competent services.
• Language barriers.
• Fear of discrimination.
• Concerns about involving or implicating families or communities.
• Lack of awareness of available services and how to access them.

Consequently, the needs of women from minoritised communities may remain hidden and unmet. 

 
Current healthcare provision

FGM-related services in NI are limited.

Some provision exists within maternity care, including a cultural liaison midwife in one Trust. Women may be also referred via their GP to gynaecology or sexual health services.

However, NI has no dedicated specialist FGM Clinics, unlike England (24 clinics), Wales (1 clinic), and Ireland (1 clinic) where FGM survivors can access specialist multidisciplinary care.

There is no published data to inform NI data on whether women have self-referred or been referred to clinics outside of NI. It would incur significant burden for them to do so.

There is also limited access to dedicated psychosexual counselling and trauma-informed therapy for FGM survivors.

What needs to happen now

Priorities for action are to:

• Develop a comprehensive, accurate FGM data set to establish baseline need and inform commissioning, high quality service design and training/education needs.
• Establish a Public Health Agency /Department of Health- led stakeholder group, including commissioners, policy makers, clinicians, charities, community groups/service users, to develop an evidence-based comprehensive survivor-centred model of care.
• Consider feasibility of NI only services, or all-Ireland services, and/or referrals to highly specialised clinics in England where interventions are non-viable in NI.
• Design and implement regional specialist FGM referral pathways for children, pregnant women and non-pregnant women across primary, secondary and tertiary care, linking gynaecology, urology, obstetrics, mental health and sexual health services.
• Develop accessible and culturally sensitive information resources and pathways for women about FGM, services available, and how to access them – aligned to the clinical pathways.
• Introduce clear referral criteria, and routine, culturally sensitive, enquiry during care episodes by healthcare professionals, during consultations in general practice surgeries, sexual health clinics, emergency care departments, mental health services, community teams and NINES teams (a nurse led service for adults and children who are new to Northern Ireland), to enable early identification, interventions and support.
• Routine culturally sensitive enquiry in primary, sexual health and mental health services needs to be introduced. Expand awareness of healthcare professionals beyond maternity settings to include general practice, emergency care and community teams. Consider roles such as that of a cultural liaison nurse.
• Invest in community outreach and education programmes.
• Improve integration and coordination across agencies and services through well-developed, communicated, and linked up multi-agency and service pathways.

Conclusion

Increased diversity in the NI population, alongside a growing focus on reducing health inequities, highlights the urgent need to improve services for survivors of FGM. Updating the NI Multi-Agency Practice Guidelines and embedding clear evidenced based data driven clinical pathways, and accessible information and pathways for FGM survivors, would support informed early identification and referral, self-referral, and equitable access to care.

There is also a clear opportunity now to develop a comprehensive FGM training/education framework to prepare and support all healthcare staff to deliver high quality sensitive, culturally competent services for their roles, informed by the NHS England (2018) FGM Training Standards, professional regulator and professional colleges standards and recommendations, tailored to the NI context. 

Further Resources 

• World FGM prevalence map – National FGM Centre
• FGM and Health Consequences Infographic 2022

Advice

• Talk to your GP: you can talk them about the feelings you are having, and they may refer you to specialist services if they feel it will help you.
• Health care professionals may have access to support resources through their professional bodies and employing organisations.
• Students will have access to support resources on their university website.