FGM: Top gynaecologist hits out at ‘political’ prosecution for female genital mutilation
Has the DPP picked the right target for a landmark legal case against a barbaric medical practice? Jeremy Laurance talks to Dr Katrina Erskine
Jeremy Laurance is a writer on health issues. He is former health editor of The Independent and the i and has covered the specialism for more than 20 years. He thinks the harm medicine does is under-appreciated, the harm it prevents over-rated, and that cycling works better than most drugs. He was named Specialist Journalist of the Year in the 2011 British Press Awards.
Monday 24 March 2014
A leading gynaecologist has launched a devastating attack on the decision to bring the first prosecution against a doctor for female genital mutilation (FGM) in Britain.
Dr Katrina Erskine, consultant gynaecologist and head of obstetrics at Homerton Hospital, Hackney, said she was angered by the case selected for the first prosecution because it gave a “misleading” impression of FGM, and risked deterring other doctors and midwives from giving appropriate care to affected women.
Dr Erskine accused the Director of Public Prosecutions (DPP), Alison Saunders, of putting politics before the welfare of women by announcing the historic prosecution days before she is due to appear in front of the Home Affairs Select Committee at its hearing on FGM on Tuesday.
The DPP had been under intense pressure to explain why there have been no prosecutions in Britain despite 140 referrals to police in the last four years. “I cannot help suspecting she needs something to say,” Dr Erskine told The Independent.
Ms Saunders announced last week that the Crown Prosecution Service (CPS) had decided there was sufficient evidence to press ahead with the case against Dr Dhanuson Dharmasena, 31, a registrar in obstetrics and gynaecology at the Whittington Hospital, London, for allegedly carrying out FGM on a patient. Hasan Mohamed, who is believed to be a relative of the patient, has been charged with aiding and abetting the doctor.
FGM is normally carried out on young girls, but the charges in this case relate to an adult woman who had just given birth. The woman had previously undergone FGM and it was alleged that in repairing her vagina following the birth, Dr Dharmasena carried out FGM himself, the CPS said in a statement.
Read more: The first prosecution is a watershed moment
Thousands treated for effects of female genital mutilation
Campaigners have already hailed the first case as a breakthrough in their battle to drive out the practice, which is estimated to affect 140 million women worldwide.
But Dr Erskine’s criticisms, coming from a senior gynaecologist with wide experience of FGM, will alarm the CPS – which urgently needs a successful prosecution.
Dr Erskine said other obstetricians were outraged over the decision to prosecute and warned it would distract attention from the real problem of FGM – the removal of the outer genitals – as opposed to the repair of the vaginal opening after a woman who had previously undergone FGM gave birth. “I am really cross about this. We have a very high prevalence of women with FGM at the Homerton and we are used to dealing with it. FGM is horrendous and barbaric and no one is trying to pretend it is not.
“We heard about the prosecution on Friday and everyone is up in arms. It will put off midwives and doctors involved in caring for women with FGM and it distracts from where our main focus should be which is on driving out the real practice of FGM which is barbaric. I cannot help suspecting this has something to do with the DPP being up before the Home Affairs Select Committee and she needs something to say.”
FGM is carried out in varying degrees, normally before puberty. The most extreme “Type III” involves cutting the clitoris and labia minora (inner lips of the vagina) and sewing together the labia majora (outer lips) to leave a small hole through which urine and menstrual blood can pass.
Dr Erskine said: “The size of the opening varies. I have seen women with just a pinhole. It is usually big enough to have sex but not big enough for a baby to come out.”
At Homerton Hospital, women who have undergone this FGM are offered the opportunity to have the opening extended in preparation for the birth before the baby arrives in a process called defibulation. However, in some cases this is not done until after labour has started. After birth, stitching can be necessary to stem the bleeding, Dr Erskine claims.
“There is a world of difference between slicing off a woman’s clitoris and labia minora and putting some stitches in if a woman is still bleeding [after giving birth]. What do you do? You have to stop any bleeding and that inevitably involves some suturing [stitching]. It would be completely misleading to call this FGM. The end result might look like FGM but it is not. This is conflating FGM with how to treat women post-labour.”
FGM is widely practised in parts of Africa and the Middle East but the scale of the problem in Britain is hard to assess. The Metropolitan Police has reported receiving 140 “references” to FGM in the four years from 2009-13, and the National Society for the Prevention of Cruelty to Children launched a helpline last year after claiming 70 women and girls a month were seeking treatment for FGM.
Dr Erskine said: “I have yet to see anyone born in the UK who has had FGM. I know it happens, but it is rare. All the women I have seen with FGM were born outside the UK and were cut before they arrived here.”
The mistaken beliefs around FGM included that it was more hygienic, that a woman was guaranteed to be a virgin when she married, that it preserved fertility and that it made women more attractive. “Mothers inflict it on their daughters because they believe they won’t get a husband without it ,” she said.
“This is where we should be putting our efforts – helping women to understand why it is wrong. Not on some poor doctor who may or may not have put some stitches in the wrong place.”
A CPS spokesperson said: “The decisions to charge Dr Dharmasena and Hasan Mohamed were made in accordance with the Code for Crown Prosecutors following careful consideration of all the available evidence”
There is still scant evidence FGM is carried out much in the UK
The medical profession has a long and inglorious history of closing ranks to protect its own. That may be the first, sceptical response to the intervention by a senior gynaecologist in the historic prosecution of a doctor for allegedly carrying out FGM.
But before dismissing it, consider: the alleged assault was not carried out secretly, in a back street, on a young girl, but openly on an adult on an NHS maternity ward in a major London hospital, following a birth.
It did not involve the removal of the outer genitals, as FGM is normally understood, but apparently the suturing of the vagina following delivery on a patient who had previously undergone FGM.
The announcement was made by the Director of Public Prosecutions, who is under pressure, days before her appearance before the Home Affairs Select Committee today.
Katrina Erskine, the gynaecologist who has decided to go public with her concerns, has almost 30 years’ experience of FGM and is passionate in her denunciation of what she describes as a “barbaric” act. She fears a bungled prosecution could do more harm than good.
The campaign against FGM has caught fire in the past year, a credit especially to the brave victims who have spoken out about their own abuse to protect others.
But there are dangers in the rush to judgement. There is still scant evidence that FGM is being carried out in this country on any significant scale, if at all.
Dr Erskine points to subtle distinctions between the suturing of a vaginal opening for medical reasons following a birth and repeating FGM. If these distinctions are not clear, young doctors and midwives at the start of their careers may be fearful of intervening to help.
It would be a cruel irony if the first prosecution in Britain made the care of such women worse, not better.
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