I welcome Ms Sioban O'Brien Green and Ms Salome Mbugua from AkiDwA and Ms Meghan Doherty from the Irish Family Planning Association. Before the presentation commences, I draw attention to the fact that while members of the committee have absolute privilege, this same privilege does not apply to witnesses appearing before the committee. The delegates are, therefore, advised against making comments on, criticising or making charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. I ask Ms O'Brien Green to commence the presentation.
Female Genital Mutilation: Discussion with AkiDwA and Irish Family Planning Association.
Ms Sioban O’Brien Green
I thank the joint committee for the invitation to make a presentation. We are here on behalf of the national steering committee on Ireland's plan of action on female genital mutilation, FGM. The World Health Organisation's definition of female genital mutilation, which dates from 1997, is the partial or total removal of female external genitalia for non-medical reasons. The term "non-medical" is key in this context. The World Health Organisation classification which was revised in 2007 to reflect the reality of women's experiences of female genital mutilation globally and help health care professionals to document the type of female genital mutilation their patients have experienced, lists four types of female genital mutilation. Type 1 is a clitoridectomy. As part of type 2, the labia minora is also removed. Type 3 which is common in certain parts of Africa is where the entire external genitalia are cut off, often using pieces of glass, stone or razor blades. The remaining external tissue is sealed, usually using thorns, catgut or string. The area seals up and closes over, leaving a tiny opening to pass urine and menstrual fluids. Type 4 which is more common in southern Africa refers to a variety of practices, including procedures for dry sex practices. These are often shorter in duration than types 1 to 3 but have lasting tissue damage consequences and result in problems delivering babies because the tissue roughens and scars over.
Where does female genital mutilation take place? We have documented cases in more than 28 countries in Africa. It is important to note that prevalence rates vary widely between countries, ranging from perhaps 5% in Niger up to possibly 97% in Egypt. Some countries which have high prevalence rates, including type 3, are Eritrea, Ethiopia, Somalia and Sudan. An increasing number of women from these countries are coming to Ireland to seek asylum and make it their home. We also have anecdotal evidence that FGM is occurring in Europe. Criminal prosecutions have taken place in a number of European countries against people accused of aiding and abetting FGM on girls.
It is very difficult for us to understand the reason such a harmful practice can become routine and normal in people's lives. The practice is strongly associated with controlling women's sexuality, gender and equality, marriageability and preserving virginity until marriage for girls. It is also regarded as a right of passage into womanhood and has — wrongly — acquired associations with certain religious requirements, particularly in the Muslim faith. FGM is not mentioned in the Koran. It is deeply rooted in tradition in certain tribes in certain regions of Africa and has been practised for millennia. As such, it predates all current world religions.
In the summer of 2008 the AkiDwA carried out a study of prevalence rates of female genital mutilation in Ireland. We copied a study done by the London School of Hygiene and Tropical Medicine and FORWARD UK and mapped it onto the 2006 Irish census data to ascertain how many women living in Ireland were likely to have undergone female genital mutilation in their country of origin. The purpose of the study was to quantify the magnitude of the FGM problem in Ireland.
We know that some families may try to continue practising female genital mutilation when they move to a new country as a way of upholding their traditional values. From the study, we estimate that in April 2006 approximately 2,585 women who had completed the census had undergone female genital mutilation. We know this an under-estimation because not everyone completes the census and data on migration changes show that since 2006 more women from FGM practising countries have come to Ireland. Female genital mutilation is a reality in Ireland. We need better data collection models, particularly in hospital and medical settings. Frequently, when women who have undergone FGM present at maternity hospitals, their condition is not recorded on their chart or file.
The health care issues presenting in primary care settings in Ireland include repeated bouts of cystitis, painful periods, different contraceptive needs, problems with cervical smears, pyschosexual marriage problems, psychological problems and the possibility of infertility relating to pelvic inflammatory disease at the time of undergoing FGM. Specific maternity care issues also arise. For example, there is a high risk of post-partum haemorrhage and infection, as well as problematic and long labour. Child protection issues also arise, especially in cases where a mother who has undergone FGM has daughters. In such circumstances, girls may be vulnerable to undergoing FGM.
In Ireland general practitioners, midwives and social workers who come into contact with the AkiDwA health project are working without training, information and guidelines. Today we launched a handbook for health care professionals in conjunction with the Royal College of Surgeons of Ireland, copies of which have been made available to members. This is the first handbook of its kind in Ireland. It outlines the issues I have raised and provides practical information and care guidelines for women who have undergone FGM.
One problem which is not documented is that when women are cared for poorly, one tends to have poor, costly health outcomes. For example, unnecessary caesarian sections may be performed which can leave patients vulnerable and even result in death, as noted by the confidential inquiry into maternal child health carried out in the United Kingdom in 2007. Most midwives follow the recommendations of the report which examines the period from 2003 to 2005. It found that four women in the United Kingdom had died as a consequence of a failure to diagnose FGM early in pregnancy and provide appropriate care. Such cases could arise here.
The action plan developed in 2008 by a multi-agency steering committee proposed the introduction of a Bill prohibiting female genital mutilation. The legislation needs to reflect realities for women and encompass principles such as extraterritoriality. This means ensuring its provisions cover cases in which girls who are normally resident here are taken out of the country to undergo female genital mutilation. In the United Kingdom the penalty for this crime is 14 years in prison. The action plan also notes the importance of education and training, especially for midwives, social workers and general practitioners. Most health care professionals work without policy and guidelines and are crying out for their introduction. Information such as the handbook we launched today is also very important, as is the need to have appropriate care referral paths.
As I stated, doctors and midwives often do not know what to write in their patient care notes when confronted with female genital mutilation. As a result, we do not know the number of women who have undergone FGM presenting at specific hospitals and clinics. The key issues arising in Ireland in the context of health in the national action plan are the need for professional supports, care pathways and information, all of which must be placed within a solid policy and legislative framework.
The plan of action was researched and developed with guidance from Euronet-FGM, an international European monitoring agency. Its goals are to prevent female genital mutilation, provide quality care and contribute to the global campaign to end FGM. The statements cited in the presentation were made by health care professionals and women with whom we have worked in the course of the AkiDwA health project on FGM. The first is from a woman who experiences painful periods, as a result of which she has poor attendance rates at college. She also has difficulty talking to her teachers and doctor about the issue. Other issues concern health and supports for staff. A midwife in the Health Service Executive west region said she can ask questions on female genital mutilation but does not know what she should do when clients say they have undergone the procedure.
A social worker in the HSE south region who is dealing with two cases of FGM has contacted us and does not know how to frame the care she needs to provide to female children in terms of child protection within current child protection legislation, and is looking for clear policies and guidelines. The last quote is from a women who underwent FGM and is now living in Ireland. I thank the committee.
The delegation can make further contributions after questions have been posed.
I thank the delegation for the presentation. As harrowing as it is, it is something we need to know about. We delude ourselves when we think it is an issue which does not concern us when clearly it does. I am not certain the practice occurs in Ireland but there are women living here who have undergone the procedure.
It is an issue for us as members of the European Union. Women and young girls can be taken out of the country, have the procedure performed abroad and come back. They do not go on their own; they are taken out. How do we reach that community? This is not the first time we have dealt with issues of minorities not coming forward to discuss issues within their own group. We still have difficulties.
How do we protect people who come forward? How do we assure mothers and fathers of young girls that if they come forward, they will be supported and protected? As the delegation may know, we do not provide adequate protection for women who are trafficked for the purpose of sex. We do not provide it for the Travelling community, an issue we have been dealing with for a much longer period.
How do we get information to communities that people should come forward and will receive a degree of protection? We need to know those communities very well before we can have answers. I am interested in hearing any suggestions or answers from the delegation.
I am horrified at the thought of what we have been told by the delegation. I was looking at the chart and I think the practice is terrible. I know this practice is done in African countries, but is it being carried out in this country, the UK or other European countries? Are the laws in Ireland adequate to cover this matter?
It is difficult to stop talking about it because it is so horrible. I am not a woman but I know the mutilation that is happening is terrible. Do our laws and those in other European countries provide enough protection for women who come to this country? Is the practice carried out outside of Africa? Is it carried out in other European countries?
I would like to be associated with the welcome extended to the delegation. It is important, as I said earlier to the youth group, that the committee would hear from groups. Even though this is a difficult subject, it is good to see the matter and hear about it.
Recently another well-publicised case was highlighted at a briefing in the Oireachtas which was arranged by some of our colleagues. As a man, I found it very difficult to listen to the details. I am a father of boys but I have a small granddaughter. One tries to bring the things one knows and hears into one's politics. I have taken an interest in Africa over the past 14 years or so and have been there on a number of occasions, including recently.
I live in Tallaght and there is a project in the Institute of Technology Tallaght which provides funding for an educational project in Mukuru, a slum in Nairobi. When I have travelled to Africa I have always found the difficulties there are completely different compared with those in my constituency and community. I have lived in Dublin all my life and we may think we have problems, but it is only when one goes to Africa one can see things differently.
This subject strikes a chord with all of us. A number of groups in my town have organised cultural activities and whenever I or my colleagues visit them, this issue comes up. It is an issue that perhaps none of us would have talked about until recently but it is right that we do so.
I applaud the efforts of the delegation in highlighting the issue and hope what it has said and done today will be picked up because there is a need for it to be highlighted, especially as we are a changing cultural society. It is an issue which has struck us all and come as a great shock to me and many other colleagues. I am glad we have had this session. I applaud the work of the delegation and wish its members well.
I welcome the delegation and thank its members for the presentation. I cannot understand how any human being could carry out such an horrific procedure on another human being. Another delegation appeared before the committee to discuss mental health, especially positive mental health. All I can think of now is the psychological effect this must have on the women affected and what their mental health must be as a result. If there are services in the countries concerned, it is a question of enabling the women affected to get help and counselling following what is a dreadful procedure.
Does the delegation have any data on the mortality rates related to this procedure? My limited knowledge of it is that it is carried out in backstreet areas by people who are not qualified using instruments which are not sterilised. I can only imagine that mortality rates are not good. I agree there needs to be a database of those who have undergone this procedure and who present to our hospitals. There also needs to be an appropriate level of service for such people because not alone have they undergone an horrific procedure, they have come to our country in search of refuge. We need to be in a position to offer them help and assistance.
I share Deputy Aylward's concern regarding practices in European countries. We had a situation a number of years ago where, I understand, a circumcision was carried out on a young boy. It is the same type of horrific treatment of another individual. If that has happened on one occasion, who can know that it has not happened on another occasion.
I also share Deputy Lynch's concerns. When people from a foreign country come to Ireland and, for the most part, go to towns and cities, people are very concerned with minding their own business. Integration into a community can take a long time owing to language and religious differences. It is not the kind of information to be shared with someone on a first meeting. There may be people whom we all know who have come to our country to live and to whom this has happened. We have no knowledge of it, they do not feel that they are in a position to share their experiences with people and it is a hidden burden they continue to carry.
We all share the same concerns. These people need help, counselling and psychological assistance and may not receive it. I commend the work of the delegation, thank its members for the presentation and wish them well as they continue this valuable work.
I join members in thanking the delegation for the presentation. As a committee we are interested in seeing what we can do to lend practical support to it in the delegation's campaign. Our committee would be interested to know what we could do to lend practical support to the campaign. It occurs to me that in the next six weeks of so we will have one of our regular meetings with the Minister for Health and Children and the Health Service Executive, so we can engage directly with them to have proper education programmes across the health services so that health professionals can engage effectively with people who have been subjected to this inhumane and barbaric treatment. It may also be open to us to make submissions to the Department of Justice, Equality and Law Reform on what type of legislation it might bring forward, as well as the Department of Foreign Affairs concerning what the United Nations might do. We will have an opportunity to discuss that afterwards but the committee would be in a position to assist AkiDwa in that way.
Ms Sioban O’Brien Green
I will start by answering some of the questions and my colleagues can contribute too. As regards working with communities and establishing protection for people, we had a presentation this morning from a specialist midwife working in Liverpool. She has worked in this area for 15 years and in her clinic they have community link workers. They are from different nationalities and groups working in the community. They talk to pregnant mothers coming into the hospital, asking them how long they plan to stay in the UK and if they are planning to circumcise their girls. They ask what supports they need and whether they should talk to their husbands. There are good practice models in Europe, Canada and Australia for setting up appropriate links with communities.
In AkiDwa we have been working with local communities, including 55 Somali women on this particular project. Very often it is about opening a dialogue and it may be the first time people have talked about it. There are methods of good practice that we can implement that are extremely cost-effective and which have good outcomes for people. It is important to involve the mums and dads, which is vital in terms of child protection. Talking to mothers in hospital when they are giving birth is not sufficient. One needs to get mothers and fathers before the birth to ask them about possible social work referrals. We do not want to have a situation that we see in parts of Ireland where social workers are called in about a month after the women has a baby and it is the first time they are talking about harmful traditional practices and female genital mutilation with the mother and father. To start off with, such conversations can be difficult sometimes for health care professionals but there are easy routes and practical steps we can take.
It is important to build a capacity in communities to say "No" to FGM. Legislation is one part of the process but it is also necessary for communities to say this is a practice they want to reject, that it is not something they want for their daughters, that it is something they have left behind and that they want to stop. It takes time, communication, capacity building and support for the mothers who are not always listened to in their communities. That is something we have been doing in AkiDwa for a while.
Ms Salome Mbugua
In 2005, we wanted to start engaging with the community because one can never change people; they must become willing to change themselves. In 2005, AkiDwa started the process of engaging with the African community in Athlone. We had several group discussions and, naturally, the understanding of FGM was very good. More than half the 50 women who participated in that focus group discussion had undergone FGM. It was difficult because after talking to them and raising their awareness, there was nowhere we were able to send them. One may tell them to go to counselling, but most of the counsellors in Ireland do not know about FGM. That is why our project was important last year. It was funded by the Minister of State with responsibility for integration to equip health services, including counsellors, so they can understand the issues surrounding FGM.
Many of them were willing to leave that harmful culture alone but the problem was coming from back home. They were being pressurised by their families and relatives reminding them that they must take their daughters back home for mutilation. Therefore they requested the Irish Government to work with the national governments in their home countries. I do not know whether that can happen, however. We have ambassadors from different African countries here whom we could begin to involve. Perhaps the Irish Government could contact some of these overseas countries to see how we can work on that matter.
I must emphasise that we are reaching out to the communities concerned but it is meaningless without the necessary legislation. Having a law protects people who know what is forbidden. If they break the law they will suffer the consequences and it will protect the children involved.
Are we to understand that this practice is illegal in most African countries?
Ms Salome Mbugua
In our presentation this morning I mentioned that I have just returned from Kenya and Uganda. In Kenya five girls had been mutilated. It is illegal to do it in Kenya but it is still going on. A nine year old girl died in December — she bled to death after it was done to her. The laws and registrations exist in many African countries but they are not being enforced, so these practices are still continuing.
Here in Ireland the issue of FGM is complicated and sensitive. It is also hidden, so it might be happening but we do not know. Our organisation is not aware of it but it might be happening. We are asking the Irish Government if it can help with the registration process so we can protect children. Perhaps a child will have to die to have the registration process introduced. It would be good to have a law or a registration process in place so people will know about it. People fear the consequences of breaking the law. If legislation is put in place together with registration, people would know it was there and we would be protecting children.
Is AkiDwa suggesting the establishment of a register for those at risk? If the mother has already undergone the ritual and is about to have a baby, is the child at risk from the culture or family pressure? Is that what is being suggested?
Ms Sioban O’Brien Green
We are not talking about legislation alone. When women from high prevalence countries come here, as with other countries, to give birth in a hospital, there is usually no pelvic examination until they are in labour. It means that people are often not skilled enough to ask about FGM and may not know about the country's prevalence. Therefore it may not be discovered until the woman is giving birth and at that point it may be too late. One may have to go for a C-section because the birth canal is not wide enough.
We suggest that it should be asked about when the booking visit happens. The hospital's social work team and translators should be involved before the birth so there is some capacity to say that FGM is unacceptable in Ireland. We cannot say it is fully illegal, although it is probably illegal under the Non-fatal Offences Against the Person Act. One can at least start working with the family before the birth in that case. However, if it comes to a crisis point, according to some of the social workers I have spoken to, the family may have gone home and expressed a desire for their daughter to undergo FGM. We could have been working with the mother and father before the birth, but at that point it involves the removal of children for child protection purposes. A register is not necessarily needed, but proper patient probing and history taking is required. At that point, if intervention needs to be done, one has five or six months to work with the patient. One can bring such patients back in for more regular maternity booking visits. In addition, one has more time with the social worker, some translation or counselling skills are involved, and the father may come in too. However, that is not happening at the moment.
Are other European countries that may have had this problem longer than we have ahead of us in their legislation and the way they handle the situation?
Ms Sioban O’Brien Green
We are fortunate enough that the UK legislation covers Northern Ireland so one could be facing a £20,000 fine and 14 years in prison for aiding and abetting the practice. If one comes south of the Border, however, it is the soft option. We are not sure whether the legislation will be strong enough. Ms Doherty is familiar with all the European legislation and may wish to comment on it.
Ms Meghan Doherty
I just wanted to make a point about how complicated FGM is. Dealing with it by legislation on its own does not work. That was the whole idea behind developing the plan of action. A European Commission-funded project noticed that it was not being dealt with effectively in 15 European countries. The Irish Family Planning Association was invited to get a steering committee together to identify the needs that were particular to Ireland and the issues that needed to be dealt with as well as figuring out a way to develop a joined-up policy. Therefore, the Department of Education and Science, the Department of Justice, Equality and Law Reform, the Department of Health and Children and the asylum service are working together with community supports to raise public awareness, as well as in communities that would practice FGM.
We are focused on the legislation, which is important. A review published by the Women's Health Council early last year suggested that the current legislation is inadequate because if one did not realise that FGM was against the law, that could be used as a defence. However, it is also important to note that the passage of legislation would greatly help people working in hospitals, social workers and so on. They are looking for a foundation on which to build their policies. The plan of action we have developed in conjunction with the HSE, Irish Aid and the UN High Commissioner for Refugees, as well as a number of community organisations, including the Somalia organisation, needs to be examined from a holistic perspective. We are talking to the Minister of State with responsibility for overseas development aid about the role Irish Aid could play in this because many Irish people work in developing countries where this an issue. Midwives work in these countries and they return to Ireland with a great deal of knowledge, which needs to be tapped into and shared with the women affected and other health workers in Ireland.
The other 15 countries that were part of this project have a different legislative basis from which to work. Certain countries have passed laws while others use existing legislation to prosecute. For example, France has had quite a few prosecutions but the intention of the legislation is not to persecute, stigmatise or marginalise communities. Its purpose must be to support families to abandon the practice because, ultimately, we are looking for the complete eradication of this practice.
Perhaps the committee should contact the Minister of State with responsibility for overseas development aid, Deputy Peter Power, regarding this business.
Is the practice mostly tribal or is there a religious element? Which religions prescribe that this practice must be carried out to become a member of a particular faith? Ms Doherty referred to our hospitals. When a woman comes in to have a baby, she must fill a form and answer questions relating to blood type, medication and so on. It would not be difficult to include a question about this practice and one hopes the women would answer honestly. This would provide a starting point.
Is genital mutilation practised on the black market or the back streets in Ireland or other European countries? Is this practice confined to Africa? Are people willing to carry out this practice in Ireland? Deputy Conlon referred to the boy in Waterford who died following a circumcision. That happened a few miles down the road from me and there was a big hullabaloo about it at the time. A person on a back street carried out that practice and he was found out eventually.
Ms Sioban O’Brien Green
I refer to an earlier question about mortality rates, which we did not answer. The WHO carried out a major study in 2006 involving 28,000 women in six different African centres. The organisation collated an action plan to address poorer maternal health outcomes. One death in every 100 births was associated with women who had undergone FGM and, very often, both the mother and child died. One of the midwives who worked with us in AkiDwa on the health plan last year had worked in Sudan and she witnessed one maternal and one child death per week in her clinic, which were directly related to FGM. Approximately 6,000 women undergo the practice and six die every day.
What age are they?
Ms Sioban O’Brien Green
The age varies, depending on the tribe and the region. It is usually carried out between the ages of five and ten.
Ms Salome Mbugua
It depends on the tribe and the region. I come from Kenya and every tribe does not practice FGM, as is the case in Nigeria and many other African countries. However, in Somalia, the practice is carried out in almost the whole country. Religion is a strong factor. Although it is not in the Koran, it is part of the religion.
With regard to age, when we worked with women in 2005, a group of women from Benin in Nigeria said that if one is not mutilated and one gets married to a man who comes from a tribe that mutilates, one must be circumcised before one gives birth. The age depends on different tribes.
Ms Sioban O’Brien Green
With regard to the practice being carried out here, nothing has been brought to the attention of the DPP or the Garda. The women's health council review and the action plan pointed out that. Groups of families seem to have brought circumcisers into other European countries to do groups of girls at a certain age. It most commonly occurs during school holidays, which are a high risk time for girls going home at the age they get circumcised. A programme was implemented in Belgium last summer. The Home Office, the London Metropolitan Police and Heathrow Airport run a campaign working with airline and immigration officials called Project Azure looking at girls brought to African countries where circumcision is practised and intervening with parents and children at the airport if they feel a girl is at risk. The school holidays tend to be a high risk time and, as a result in the UK, teachers also undergo training in order that if girls talk about going away for their holidays a girl and coming back a woman or if their mother says there will be a special party and celebration when they return to their country of origin, the teachers are aware the girls could be at risk.
Is there anecdotal evidence from our accident and emergency departments that the practice has taken place here?
Ms Salome Mbugua
No, it is a sensitive and hidden practice. Male circumcision is very open but female circumcision is very hidden. We are not aware of it.
Ms Meghan Doherty
There are several reasons for the practice, all of which are based on women's position within society both in Ireland and in developing countries. It is a system of complete gender inequality where women are more susceptible to sexual, domestic and physical violence and they have less access to education, economics, resources and so on. These are all huge contributing factors in why this practice continues.
Ms Sioban O’Brien Green
I thank the committee for having us. We are keen to see legislation progress in some shape or form. It is sadly lacking. Midwives, doctors and social workers say they do not know how to work with these families without legislation. The action plan was a labour of love for those involved in it and we would like some ownership, leadership and direction. We have asked for, perhaps, TASC to come on board because an interdepartmental group is needed to move the plan forward. The plan covers the period 2008 to 2011. Ireland is in a wonderful position where instead of being reactive, for instance, in the tragic case of the little boy who died in Waterford, we can be proactive and preventative rather than coming in after a tragedy. We have the opportunity to be seen in Ireland as leading the way and progressing the issue positively.
I thank the members of the delegation for putting this matter firmly on our agenda. The committee will support them in any way possible. We will go into private session to see what practical steps we can take in support of the group's campaign. We look forward to maintaining contact on this matter.
The joint committee went into private session at 4.50 p.m. and adjourned at 4.55 p.m. sine die.