An exploration of attitudes towards female genital mutilation (FGM) in men and women accessing FGM clinical services in London: a pilot study.

This pilot study researched the attitudes towards and the knowledge of female genital mutilation (FGM) in adult women with FGM and their partners. The participant population consisted of English-speaking women and men over 18 years old attending specialist FGM clinics in two London hospitals. The participants completed a questionnaire on the attitudes and the knowledge of FGM, which were adapted with permission from the United Nations Children's Fund and the United States Agency for International Development household surveys. 54 participants (51 women, 3 men) took part in the surveys. 89% of participants thought that FGM should be stopped (95%CI: 0.81-0.97) and 72% said they knew FGM is illegal in the United Kingdom (UK). 15% reported that FGM caused no danger, or were unaware of any danger to women's health. This study demonstrates the opposition to FGM by participants, but some lack of knowledge regarding the legal and health implications. The exploration of attitudes in diaspora community groups is often cited as key to safeguarding girls from FGM. This is one of the first UK studies of individuals from FGM-practising communities, and we recommend use of the study questionnaires for a multicentre, cross-community study. Impact statement What is already known about this subject? Women and children are affected by female genital mutilation (FGM) globally and in the United Kingdom (UK). The majority of knowledge on practices and the attitudes towards FGM comes from UNICEF and USAID research in Africa and there is scant data on FGM practices in diaspora communities in the UK. What do the results of this study add? This study provides an appropriate questionnaire and protocol for use in community-based national research to improve healthcare for women by collecting up-to-date data on the attitudes towards FGM among the members of FGM-practising communities in the UK. What are the implications of these findings for clinical practice and further research? The implications of the results of this study are that health professionals need to understand that patients do not always know the law on FGM, even after a consultation. Health and social care professionals are placed in a unique position to work with community members to educate men and women to end FGM.

Setting up a clinic to assess children and young people for female genital mutilation.

It is now mandatory for health, social care professionals and teachers to report to the police all under-18s where female genital mutilation (FGM) has been disclosed by the child or where physical signs of FGM are seen. Such referrals are likely to result in a request for medical examination. New multiagency statutory guidance sets out instructions for physical examination but provides no details how services should be set-up. This review gives practical guidance learnt from the first year of the UK's only dedicated children's FGM service.

Cultural issues in child maltreatment.

AIMS: Waves of immigration from the latter half of the 20th century have changed the cultural and ethnic mix of major regions of the world. Dynamic multicultural societies now are a reality across the Western world. The relationship and influence of these diverse cultures to the understanding and identification of child abuse and neglect is challenging and complex. Health professionals working with children from culturally and linguistically diverse groups often find themselves with the challenge of exploring and resolving the tension between definitions of harm in child protection practice and various cultural and child-rearing practices. In this paper, we set out ways of thinking about the influence of culture when approaching and dealing with the suspicion of child maltreatment. METHODS: We will explore how culture shapes the experiences of childhood, child-rearing practices, and identify common barriers in working with children and families from culturally diverse backgrounds when presenting with child maltreatment. We will use case examples from Europe and Australia to illustrate the real life challenges of working in the area of child maltreatment across cultures. We will review the scientific literature exploring the nexus between culture and child maltreatment, identifying the gaps in the literature and highlight areas for future research. RESULTS: We suggest a model for dealing with cultural issues in child maltreatment that is culturally competent and respectful. CONCLUSIONS: The model for cultural competency in child health and child protective services incorporates four domains for advocacy and action - individual, professional, organisational and systemic.

Pattern of hospital referrals of children at risk of maltreatment.

BACKGROUND: Increasingly emergency departments (ED) and other acute services in the hospital provide first access care, especially out of hours and for poorer families. Studies of detection of child maltreatment in the hospital have focused on children presenting with injury, although maltreatment may be suspected when parents present to the hospital with problems related to violent behaviour, drug abuse or mental health problems. METHODS: A consecutive case series is described of patients referred for suspected child maltreatment from one inner-city general hospital after training was given to clinical staff and 2 years after the creation of a new post comprising a full-time, experienced child protection advisor (CPA) on-site to support clinicians with concerns about child maltreatment. RESULTS: There were 44 referrals to the CPA over 2 months in 2005, of whom just under half were initiated by clinicians caring for a parent. 15 referrals came from the ED (five followed a parent presenting to the ED), 14 from maternity obstetric services, and 15 from the neonatal or paediatric wards. Most families (38; 86%) were referred by nurses. One-quarter of referrals were already known to children's social care. CONCLUSIONS: Clinicians need to be aware that half the vulnerable children in hospital are identified through one or other parent. It is hypothesised that the availability of an experienced child protection advisor on-site, combined with child protection training, makes it possible for clinicians caring for adults with problems related to violence, drug abuse or acute mental illness, to take action to address the potential vulnerability of their children.

Epidemiological surveillance study of female genital mutilation in the UK.

OBJECTIVES: Describe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome. DESIGN: The well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns. SETTING: All consultant paediatricians and relevant SARC leads across the UK and Ireland. PATIENTS: Under 16 years old with FGM. INTERVENTIONS: Data on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM. MAIN OUTCOME MEASURES: Returns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland. RESULTS: The mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution. CONCLUSIONS: There were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies.

Female genital mutilation (FGM) in UK children: a review of a dedicated paediatric service for FGM.

OBJECTIVE: To describe the presentation and management of children with suspected or confirmed female genital mutilation (FGM) referred to a specialist paediatric clinic. METHODS: Data collected included referral source, age, ethnicity, circumstances of FGM and clinical findings in accordance with the WHO FGM classification. RESULTS: Between September 2014 and January 2019, 148 children attended the clinic of whom 55 (37.2%) had confirmed FGM. Police or social care referred 112 (76%) children. The proportion of looked-after children (LAC) was significantly higher in the group with confirmed FGM (17/55, 31%) compared with children where FGM was not confirmed (5/93, 5%). In almost all children where FGM was confirmed, FGM was initially disclosed by the child or family (53/55, 96%) and of these 48/55 (87%) underwent FGM prior to UK entry. The remaining seven cases were British children, potentially meeting legal criteria under the FGM Act, and one resulted in a successful prosecution. CONCLUSIONS: The number of children with FGM was significantly lower than expected based on UK prevalence estimates. Most children had undergone FGM prior to UK entry, and the majority of cases were initially disclosed by the child or family themselves. These results reflect the lack of large-scale proof of the practice of FGM in the UK and are consistent with growing evidence of the abandonment of FGM among communities after migration.

Clinical characteristics of children presenting with a suspicion or allegation of historic sexual abuse.

INTRODUCTION: Police-recorded sexual offences against children and young people (CYP) increased 85% in the UK between 2010/2011 and 2014/2015. Many children delay disclosure, but little data are available regarding characteristics of CYP presenting with historic child sexual abuse (CSA). AIM: To identify the clinical and CSA-related characteristics of CYP presenting with a suspicion or allegation of historic CSA. METHOD: Data were collected on all CYP<17 years presenting with suspected or alleged historic CSA (ie, >3 days since last sexual assault in prepubertal children, >7 days pubertal girls) between October 2009 and November 2014. DATA COLLECTED: source and indication for referral, alleged perpetrator, physical findings. Findings supportive of CSA were peer reviewed for consensus agreement. ANALYSIS: χ2 test, Fisher's exact test and logistic regression. RESULTS: Among 249 CYP, presentation with physical/behavioural symptoms was associated with age <13 years (p<0.01), and alleged penetration with ages 13-17 years (p<0.01). Where known, time since alleged CSA ranged from 1 week to 13 months. Anogenital findings supportive of CSA were present in 7% of examined children (16/233), significantly associated with alleged penetration (p<0.01) and more likely with increasing age (OR 1.46, 95% CI 1.23 to 1.72). Additionally, where tested, sexually transmitted infections (STI) were detected in 2.6% CYP (3/116). Alleged perpetrators were intrafamilial in 66% (126/190). No associations were identified between perpetrator type and gender (p=1.0), age (p=0.7) or indication for referral (p=0.35). CONCLUSIONS: Despite significant time delay since the alleged CSA, this study highlights the persistence of anogenital findings supportive of CSA in 7% and STIs in 2.6% of CYP.

The value of paediatric assessment in historic child sexual abuse.

INTRODUCTION: A perception exists that there are few benefits of a paediatric assessment in historic child sexual abuse (CSA), as the likelihood of finding forensic evidence is low. AIM: To determine the value of a comprehensive paediatric assessment in a dedicated clinic for children and young people who present following suspicion or allegation of historic CSA. METHOD: All children with suspected or alleged historic CSA, defined as >7 days after the last episode of sexual assault in pubertal girls, or >3 days for prepubertal girls and all boys, were assessed in a specialised paediatric clinic. Clinic data were collected prospectively between October 2009 and November 2014 and through retrospective case note review. RESULTS: Among the 249 children who presented with possible historic CSA, ages ranged from 0 to 17 years (median 7, SD 4.3). Of these children, 141 (57%) had a medical concern(s) related to the referral reason, 78 (31%) had an unrelated medical concern(s) and 55 (22%) had emotional or behavioural concerns requiring onward referral, while 18 (7%) children had physical signs supportive of CSA. Findings referable to social care were identified in 26 cases (10%), the police in 6 cases and 15 (6%) parents required professional help for anxiety symptoms. CONCLUSIONS: This study highlights the value of a comprehensive paediatric assessment in a dedicated clinic for cases of suspected or alleged historic CSA, by identifying a broad variety of unmet health needs in this group. The findings have important implications for the child, their families and the multiagency team.

Female genital mutilation: what every paediatrician should know.

Female genital mutilation (FGM) is almost always performed on children and consequently paediatricians should have a central role in the detection and prevention of FGM. FGM has no health benefits and can cause lifelong damage to physical and psychological health. Extensive migration of FGM practising communities means that FGM is now a global problem. Paediatricians worldwide need to be familiar with the identification and classification of FGM and its impact upon health as well as current trends in practice. However information about FGM is hampered by the secrecy surrounding the procedure and a lack of rigorous evidence based research. This review summarises what is currently known about the health aspects of FGM and how paediatricians should manage children with FGM in their clinical practice.

Female genital mutilation in children presenting to a London safeguarding clinic: a case series.

OBJECTIVE: To describe the presentation and management of children referred with suspected female genital mutilation (FGM) to a UK safeguarding clinic. DESIGN AND SETTING: Case series of all children under 18 years of age referred with suspected FGM between June 2006 and May 2014. MAIN OUTCOME MEASURES: These include indication for referral, demographic data, circumstances of FGM, medical symptoms, type of FGM, investigations and short-term outcome. RESULTS: Of the 47 girls referred, 27 (57%) had confirmed FGM. According to the WHO classification of genital findings, FGM type 1 was found in 2 girls, type 2 in 8 girls and type 4 in 11 girls. No type 3 FGM was seen. The circumstances of FGM were known in 17 cases, of which 12 (71%) were performed by a health professional or in a medical setting (medicalisation). Ten cases were potentially illegal, yet despite police involvement there have been no prosecutions. CONCLUSIONS: This study is an important snapshot of FGM within the UK paediatric population. The most frequent genital finding was type 4 FGM with no tissue damage or minimal scarring. FGM was performed at a young age, with 15% reported under the age of 1 year. The study also demonstrated significant medicalisation of FGM, which matches recent trends in international data. Type 4 FGM performed in infancy is easily missed on examination and so vigilance in assessing children with suspected FGM is essential.

Multidisciplinary approach to the management of children with female genital mutilation (FGM) or suspected FGM: service description and case series.

OBJECTIVE: To describe the first dedicated clinic in the UK for children with suspected or confirmed female genital mutilation (FGM) including referral patterns, clinical findings and subsequent management. DESIGN AND SETTING: A prospective study of all children seen in a dedicated multidisciplinary FGM clinic for children over a 1-year period. POPULATION: Patients aged under 18 years referred for clinical assessment or for a second opinion on Digital Versatile Disc (DVD) images. METHODS AND MAIN OUTCOME MEASURES: Data were collected on reasons for referral, demography, genital examination findings including FGM type, and clinical recommendations. RESULTS: 38 children were referred of whom 18 (47%) had confirmed FGM; most frequently type 4 (61%). Social care and police referred 78% of cases. According to UK law FGM had been performed illegally in three cases. Anonymous information given to the police led to the referral of six children, none of whom had had FGM. CONCLUSIONS: Mandatory reporting and increased media attention may increase the numbers of referrals of children with suspected FGM. This patient group have complex needs and management in a dedicated multidisciplinary service is essential. Paediatricians and gynaecologists should have the skills to carry out the consultation and detect all types of FGM including type 4 which was the most common type seen in this series. This is the first dedicated FGM service for children in the UK and similar clinics in high-prevalence areas should be established.

Longevity and Patau syndrome: what determines survival?

The authors report of an 8-year-old girl with non-mosaic Patau syndrome. The median life expectancy of Patau syndrome is 7-10 days, and 90% die in the first year of life. Survival is often attributed to mosaicism and the severity of associated malformations. We delineate the developing phenotype and review the literature discussing potential contributory factors to longevity.

Variation in recording of child maltreatment in administrative records of hospital admissions for injury in England, 1997-2009.

BACKGROUND: Information on variation in the recording of child maltreatment in administrative healthcare data can help to improve recognition and ensure that services are able to respond appropriately. OBJECTIVE: To examine variation in the recording of child maltreatment and related diagnoses. DESIGN: Cross-sectional analyses of administrative healthcare records (Hospital Episode Statistics). SETTING AND PARTICIPANTS: Acute injury admissions to the National Health Service in England of children under 5 years of age (1997-2009). Outcome measure Annual incidence of admission for injury recorded by International Classifications of Diseases 10 codes for maltreatment syndrome (child abuse or neglect) or maltreatment-related features (assault, undetermined cause or adverse social circumstances). Proportion of all admissions for injury coded for maltreatment syndrome or maltreatment-related features. RESULTS: From 1997 to 2009, the annual incidence of injury admissions coded for maltreatment syndrome declined in infants and in 1-3-year-old children while admissions coded for maltreatment-related features increased in all age groups. The combined incidence of these categories remained stable. Overall, 2.6% of injury admissions in infants, and 0.4-0.6% in older age groups, had maltreatment syndrome recorded. This prevalence more than doubled when maltreatment-related codes were added (6.4% in infants, 1.5-2.1% in older age groups). CONCLUSION: Despite a shift from maltreatment syndrome to codes for maltreatment-related features, the overall burden has remained stable. In combination, the cluster of codes related to maltreatment identify children likely to meet thresholds for suspecting or considering maltreatment and taking further action, as recommended in recent National Institute of Health and Clinical Excellence guidance, and indicate a considerable burden to which hospitals should respond.