Archives Blog Review

Female genital mutilation in London and the UNICEF report; a local perspective on worldwide statistics

Arch Dis Child 2014;99:A73.

Female genital mutilation in London and the UNICEF report; a local perspective on worldwide statistics

Hodes D, Armitage A, Dykes A


Background In July 2013 the UNICEF report stated that 125 million women worldwide are affected by female genital mutilation (FGM). Despite an estimated 20,000 children at risk in the UK there is a complete absence of data on presentation in childhood and ignorance among many healthcare workers. Although, since 2003, it is illegal to take a child out of the country for FGM, there have been no prosecutions.

Aims To increase understanding of FGM by collecting and analysing details of all paediatric presentations of suspected FGM to a London clinic from 2006 onwards.

Methods Retrospective data collection on all suspected FGM cases referred to the tertiary safeguarding clinic in an inner London teaching hospital from 2006, including details of referral, history and examination findings.

Results Of 32 referrals 13 (41%) were since the start of 2013. 26 were Somali, 5 Ethiopian and 1 Malay. Common routes of referral included: healthcare workers (7), school concerns (7), siblings of cases (4) and family disputes (5). 22 (69%) were confirmed to have had FGM.

Of the 22 with FGM 15 were examined, of whom none had undergone WHO type 3 FGM (infundibulation). 10 girls (60%) had a normal or near normal examination (WHO type 4) with 5 (40%) having WHO types 1 and 2. Four children were taken from the UK after 2003 (i.e. illegally); unclear perpetrators and a lack of evidence have prevented prosecutions.

Conclusions Physical signs of FGM may be subtle and a normal examination does not exclude it. Our findings support the limited evidence from UNICEF that there is a trend toward less severe forms of FGM. WHO Type 4 without anatomical change was the commonest category in this small cohort and hence use of a revised classification (UNICEF) reflecting current practices could improve understanding of FGM and its implications for the child. Pursuing prosecution for neglect, as opposed to FGM, might be more successful in protecting children. The observed increase in referrals in 2013 supports the success of recent awareness campaigns and increases the chances of a criminal prosecution in this country.

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Archives Original research

Spatial modelling and mapping of female genital mutilation in Kenya.

BMC Public Health. 2014 Mar 25;14(1):276. doi: 10.1186/1471-2458-14-276.FREE

Spatial modelling and mapping of female genital mutilation in Kenya.

Achia TN.


BACKGROUND: Female genital mutilation/cutting (FGM/C) is still prevalent in several communities in Kenya and other areas in Africa, as well as being practiced by some migrants from African countries living in other parts of the world. This study aimed at detecting clustering of FGM/C in Kenya, and identifying those areas within the country where women still intend to continue the practice. A broader goal of the study was to identify geographical areas where the practice continues unabated and where broad intervention strategies need to be introduced.

METHODS: The prevalence of FGM/C was investigated using the 2008 Kenya Demographic and Health Survey (KDHS) data. The 2008 KDHS used a multistage stratified random sampling plan to select women of reproductive age (15-49 years) and asked questions concerning their FGM/C status and their support for the continuation of FGM/C. A spatial scan statistical analysis was carried out using SaTScan™ to test for statistically significant clustering of the practice of FGM/C in the country. The risk of FGM/C was also modelled and mapped using a hierarchical spatial model under the Integrated Nested Laplace approximation approach using the INLA library in R.

RESULTS: The prevalence of FGM/C stood at 28.2% and an estimated 10.3% of the women interviewed indicated that they supported the continuation of FGM. On the basis of the Deviance Information Criterion (DIC), hierarchical spatial models with spatially structured random effects were found to best fit the data for both response variables considered. Age, region, rural-urban classification, education, marital status, religion, socioeconomic status and media exposure were found to be significantly associated with FGM/C. The current FGM/C status of a woman was also a significant predictor of support for the continuation of FGM/C. Spatial scan statistics confirm FGM clusters in the North-Eastern and South-Western regions of Kenya (p < 0.001).

CONCLUSION: This suggests that the fight against FGM/C in Kenya is not yet over. There are still deep cultural and religious beliefs to be addressed in a bid to eradicate the practice. Interventions by government and other stakeholders must address these challenges and target the identified clusters.

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Archives Blog News

Ending female genital mutilation in the UK

Lancet. 2013 Nov 16;382(9905):1610. doi: 10.1016/S0140-6736(13)62353-3.

Ending female genital mutilation in the UK.

[No authors listed]


“Four women held me down. I felt every single cut. I was screaming so much I just blacked out.” So wrote Leyla Hussein in The Guardian last week about her experience of female genital mutilation (FGM).

About 140 million girls and women worldwide are currently living with the consequences of FGM, which includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. FGM can cause severe bleeding and problems urinating, cysts, infections, infertility and complications in childbirth. It has no health benefits for girls or women, and is a severe violation of their rights…

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Archives Blog Original research

The Association of Female Circumcision with HIV Status and Sexual Behavior in Mali: A Multilevel Analysis.

J Acquir Immune Defic Syndr. 2013 Dec 27. [Epub ahead of print]

The Association of Female Circumcision with HIV Status and Sexual Behavior in Mali: A Multilevel Analysis.

Smolak A.


OBJECTIVE: In the regions of Africa where female circumcision (FC) is practiced it is often regarded as a protective against HIV infection because it is believed to help women resist “illicit” sexual acts. This study examines the association between FC, HIV status, and sexual risk behavior in Mali, while taking into account multilevel factors. The following hypothesis was tested: FC is associated with HIV positive status, but not with decreased sexual behavior.

DESIGN:: The sample consists of 13,015 Malian women of reproductive age (15-49 years old). The sample is a nationally representative survey of randomly selected respondents using a stratified multistage sampling strategy. Measures included biospecimens for HIV antibody testing and survey results reporting on: number of partners, sexual debut, premarital sex, and sociodemographics.

METHODS:: Multilevel modeling (MLM) was used to assess the significance of difference in HIV status and sexual behavior with FC. MLM was also used to adjust for age, education, ethnicity, wealth, religion, region, household, and community membership. Multiple imputation with 10 imputations corrected for 10% missing data.

RESULTS:: Participants with FC were at 2.100 (p<0.001; 95% CI: 1.844, 2.389) higher odds of being HIV positive. Women with FC did not significantly differ from women without FC in number of sexual partners (p=0.634), age of sexual debut (p=0.888), or odds of having premarital sex (p=0.575).

CONCLUSION:: FC is associated with HIV positive status, but not with a decrease in sexual risk behavior. These findings have important implication for FC and HIV prevention.

Archives Blog Original research

Behavioural and biological determinants of human sex ratio at birth.

J Biosoc Sci. 2010 Sep;42(5):587-99. doi: 10.1017/S002193201000012X. Epub 2010 Jun 3.

Behavioural and biological determinants of human sex ratio at birth.

James WH.

The Galton Laboratory, Department of Genetics, Evolution and Environment, University College London, UK.


The human sex ratio SR (proportion male) at birth has been reported to vary with many variables. The explanation of this variation is not established, but I have hypothesized that it is partially caused by the hormonal concentrations of both parents around the time of conception. The present note suggests how this hypothesis might accommodate recent sex ratio findings relating to ‘psychosexual restriction’, female genital cutting, sexes of prior sibs, finger length ratios, the autism spectrum disorder, parental occupation and maternal eating disorders. Tests of such suggestions are offered, and it is hypothesized that: (a) in women, Manning’s R (the ratio of the lengths of the 2nd and 4th digits) is positively correlated with offspring sex ratio (proportion male); (b) women who have undergone female genital cutting (FGC) have high androgen levels; (c) offspring sex ratio correlates positively with ‘masculinity’ of parental occupation, the correlation being mediated by testosterone levels. It is noted that the lines of evidence for three hypotheses (James’, Manning’s and Baron-Cohen’s) are mutually supportive.

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Archives Blog Original research

Female genital mutilation and its prevention: a challenge for paediatricians.

Eur J Pediatr. 2009 Jan;168(1):27-33. Epub 2008 Apr 25.

Female genital mutilation and its prevention: a challenge for paediatricians.

Jaeger F, Caflisch M, Hohlfeld P.

Service de Pédiatrie, Hôpital de Pourtalès, Rue de la Maladière 45, 2000, Neuchâtel, Switzerland.


Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents’ responsibility in taking a health risk for their daughters. It is important to know the family’s opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4-9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

This article can be accessed in this LINK

Archives Blog Original research

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

Lancet. 2006 Jun 3;367(9525):1835-41.

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M.

National Centre for Epidemiology and Population Health, Australian National University, ACT 0200, Australia.

Comment in Lancet. 2006 Jun 3;367(9525):1799-800.

Lancet. 2006 Aug 12;368(9535):579.

BACKGROUND: Reliable evidence about the effect of female genital mutilation (FGM) on obstetric outcome is scarce. This study examines the effect of different types of FGM on obstetric outcome.

METHODS: 28 393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGM, and were classified according to the WHO system: FGM I, removal of the prepuce or clitoris, or both; FGM II, removal of clitoris and labia minora; and FGM III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital.

FINDINGS: Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM I, II, and III, respectively: caesarean section 1.03 (95% CI 0.88-1.21), 1.29 (1.09-1.52), 1.31 (1.01-1.70); postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12); extended maternal hospital stay 1.15 (0.97-1.35), 1.51 (1.29-1.76), 1.98 (1.54-2.54); infant resuscitation 1.11 (0.95-1.28), 1.28 (1.10-1.49), 1.66 (1.31-2.10), stillbirth or early neonatal death 1.15 (0.94-1.41), 1.32 (1.08-1.62), 1.55 (1.12-2.16), and low birthweight 0.94 (0.82-1.07), 1.03 (0.89-1.18), 0.91 (0.74-1.11). Parity did not significantly affect these relative risks. FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries.

INTERPRETATION: Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGM.

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Archives Blog Original research

Disentangling the complex association between female genital cutting and HIV among Kenyan women.

J Biosoc Sci. 2009 Nov;41(6):815-30. Epub 2009 Jul 16.

Disentangling the complex association between female genital cutting and HIV among Kenyan women.

Maslovskaya O, Brown JJ, Padmadas SS.

Division of Social Statistics, School of Social Sciences, University of Southampton, UK.


Female genital cutting (FGC) is a widespread cultural practice in Africa and the Middle East, with a number of potential adverse health consequences for women. It was hypothesized by Kun (1997) that FGC increases the risk of HIV transmission through a number of different mechanisms. Using the 2003 data from the Kenyan Demographic and Health Survey (KDHS), this study investigates the potential association between FGC and HIV. The 2003 KDHS provides a unique opportunity to link the HIV test results with a large number of demographic, social, economic and behavioural characteristics of women, including women’s FGC status. It is hypothesized that FGC increases the risk of HIV infection if HIV/AIDS is present in the community. A multilevel binary logistic regression technique is used to model the HIV status of women, controlling for selected individual characteristics of women and interaction effects. The results demonstrate evidence of a statistically significant association between FGC and HIV, after controlling for the hierarchical structure of the data, potential confounding factors and interaction effects. The results show that women who had had FGC and a younger or the same-age first-union partner have higher odds of being HIV positive than women with a younger or same-age first-union partner but without FGC; whereas women who had had FGC and an older first-union partner have lower odds of being HIV positive than women with an older first-union partner but without FGC. The findings suggest the behavioural pathway of association between FGC and HIV as well as an underlying complex interplay of bio-behavioural and social variables being important in disentangling the association between FGC and HIV.

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