Abstract
Background Female genital mutilation (FGM) includes all procedures that intentionally harm or alter female genitalia for non-medical reasons. In 2015, reporting duties were introduced, applicable to GPs working in England including a mandatory reporting duty and FGM Enhanced Dataset. Our patient and public involvement work identified the exploration of potential impacts of these duties as a research priority.
Aim To explore the perspectives of GPs working in England on potential challenges and resource needs when supporting women and families affected by FGM.
Design and setting Qualitative study with GPs working in English primary care.
Method Semi-structured interviews focused around a fictional scenario of managing FGM in primary care. The authors spoke to 17 GPs from five English cities, including those who saw women who have experienced FGM often, rarely, or never. Interviews were audio recorded and transcribed verbatim for thematic analysis. Lipsky’s theory of street-level bureaucracy was drawn on to support analysis.
Results Managing women with FGM was experienced as complex. Challenges included knowing how and when to speak about FGM, balancing care of women and their family’s potential care and safeguarding needs, and managing the mandated reporting and recording requirements. GPs described strategies to manage these tensions that helped them balance maintaining patient–doctor relationships with reporting requirements. This was facilitated by access to FGM holistic services.
Conclusion FGM reporting requirements complicate consultations. The potential consequences on trust between women affected by FGM and their GP are clear. The tensions that GPs experience in supporting women affected by FGM can be understood through the theoretical lens of street-level bureaucracy. This is likely to be relevant to other areas of proposed mandated reporting.
INTRODUCTION
Female genital mutilation (FGM) is defined by the World Health Organization as ‘ all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’.1 FGM has no known health benefits, and many documented harms.1 Potential harms include immediate risks; such as haemorrhage, infection, and death; enduring risks, including obstetric complications, menstrual and urinary problems; and psychological impacts including anxiety, depression, and post-traumatic stress disorder.2 An estimated 200 million women and girls in 30 countries are living with the consequences of FGM.3 Global migration from areas where FGM is traditionally practised means that FGM is a worldwide health concern.
Using household survey data on FGM prevalence in countries where FGM is traditionally practised, and the UK 2011 census and birth registration data, MacFarlane et al estimated that approximately 137 000 women and girls born in countries where FGM is traditionally practised were permanently resident in England and Wales in 2011. Though there was significantly higher prevalence in urban areas, it was estimated that there would be no local authority areas without any women affected by FGM.4 Therefore, it seems likely that many English GPs will have clinical encounters with women and families potentially affected by FGM. Understanding how to support affected families and meet their care needs is vital, and the recent increase in service provision recognising the needs of women and communities affected by FGM is timely and welcome.5
FGM is an ancient cultural practice that has been the focus of recent education, safeguarding, and policy.
In July 2014, the UK government hosted the first Girl Summit, in partnership with the United Nations Children’s Fund (UNICEF), at which they pledged to mobilise domestic and international efforts to eliminate FGM within a generation.6 The prime minister announced a raft of measures including legislative changes, a GBP 1.4 million FGM Prevention Programme with NHS England, and training for professionals.6
Following this, policy introduced in 2015 included a mandatory reporting duty; requiring all registered professionals in England and Wales to report cases of FGM in those aged <18 years directly to the police when FGM was identified on examination, or through first-hand disclosure. The consequences for not doing so include professional sanctions.7 An FGM Enhanced Dataset (applicable in England) was also introduced, requiring submission of quarterly data returns, including personally identifiable data (such as name, date of birth, and NHS number) to NHS Digital from all NHS acute trusts and GP practices. The stated aim of the FGM Enhanced Dataset is to support the DHSC FGM Prevention Programme by providing prevalence data of FGM in the NHS in England. Consent for data sharing is not required, however fair processing requires clinicians to explain the dataset to their patients.8,9
| The authors are unaware of any previous work considering GPs’ perspectives on supporting women with female genital mutilation (FGM) in primary care, including the impacts of recent English policy which includes a mandatory reporting policy and FGM Enhanced Dataset. GPs described tensions between their caring role and the policy requirements placed on them. The provision of specialist support, and holistic education could support GPs when caring for those from communities affected by FGM. |
Concerns about the potential impacts of these two policies have been raised by both professionals and community members.10–16 In the most recent data report for the FGM Enhanced Dataset, only 59 GP practices submitted attendance data in the year 2019–2020.17 There were approximately 6813 GP practices in England in February 2020.18
A patient and public involvement project to understand research priorities highlighted questions about how this legislation might affect trust in healthcare interactions.19 There is very little research about the primary care role in supporting women with FGM.20 The authors are aware of no published research considering English GPs’ perspectives in the context of recent policy.
Street-level bureaucracy is a sociological theory advanced by Michael Lipsky that seeks to explain how public servants think and act when they are delivering public policy in the course of their work on the service front line. Lipsky found that professionals typically face constraints (such as excessive workloads, or limited time and resources), which limit their ability to respond to (all) of their individual clients’ needs. Professionals therefore tend to develop routines of practice, which inevitably influence outcomes. Lipsky described professionals working in this way as ‘street-level bureaucrats’. Exercising professional discretion is central to the work of street-level bureaucrats, who face, what Lipsky describes, an ‘essential paradox’:
‘On the one hand, the work is often highly scripted to achieve policy objectives that have their origins in the political process. On the other hand, the work requires improvisation and responsiveness to the individual case.’21
It has been suggested that Lipsky’s observations apply to the work of GPs who are faced with enacting policy while trying to maintain a trusting therapeutic relationship with their patients.22–24 In this study, Lipsky’s theory is drawn on to explore GPs’ perspectives on supporting patients who may be affected by FGM.
METHOD
Study design
This was a qualitative study using semi-structured telephone interviews with GPs based around a fictional scenario (Box 1) of a woman (‘Samara’) presenting to primary care and seeking support for her FGM. The scenario was piloted with two GPs and designed to resonate with scenarios likely to be encountered in FGM-related education.
Samara is a 22-year-old woman. Born in Somalia, she came to the UK 8 years ago with her parents, sister, and brother. She finished her education in England and speaks good English.
She comes to see you because she is going to get married shortly and would like to be referred to be opened up before her marriage having been ‘closed’ as a child in Somalia.
Six months later, she comes back to tell you she is now pregnant with her first child and would like to be referred for antenatal care. |
Box 1. Fictional scenario of a woman presenting to primary care seeking support for female genital mutilation
Sampling and recruitment
GP practices in eight English cities in the Southeast, Southwest, Midlands, and Northwest regions were contacted once by email with information about the study. Using the published list of FGM specialist clinics from NHS England at the time of study recruitment, both cities that had a local specialist clinic and those that did not were chosen. Aiming to speak to GPs with different levels of exposure to FGM, and by using published local maps of demographics and ethnicity, those areas likely to have practice populations with differing prevalence of FGM were selected. In addition, where possible, the Named GP for safeguarding in these cities was approached by email to ask whether they would consider sharing the study information through their local networks. Recruitment was enhanced through snowballing.
A total of 17 GPs (n = 16 female, n = 1 male) from five English cities, with a range of experience, and with varying access to a local specialist clinic, participated in the study.
Data collection and analysis
Semi-structured telephone interviews were conducted by the first author (a GP and a National Institute for Health Research in-practice fellow) between March and November 2018.
The fictional scenario was used to help create a neutral space for GPs to consider possible responses to issues they might face when seeing women affected by FGM, and strategies or resources that might help.25,26 GPs were then invited to reflect on communicating, and managing the requirements of the FGM reporting requirements.
With consent, the interviews were audio recorded and transcribed verbatim for thematic analysis. A coding framework was developed by the first and third authors. Transcripts were checked and coding was iteratively developed27 to incorporate emergent as well as expected themes. The analysis was supported using NVivo QSR (version 11). Lipsky’s theory of street-level bureaucracy was drawn on to help shape and interpret the findings.21
DISCUSSION
Summary
FGM is experienced as complex to manage in primary care, with challenges including consideration of how and when to talk about FGM, and how to meet the potential needs of both the woman who presents and her family. Managing FGM reporting and recording brings additional tensions into the consultation. Access to specialist services and education about more than safeguarding were identified as important resources to support GPs caring for patients with FGM.
Strengths and limitations
As far as the authors are aware, this is the first study of the issues GPs consider when managing FGM in primary care. It contributes the perspectives of front-line clinicians on the policies of mandatory reporting and the FGM Enhanced Dataset. Using a qualitative approach and a fictional scenario, the authors sought to create an open space for GPs thoughts and reflections. GPs with a range of exposure to FGM were interviewed, including those with experience of seeing women with FGM never, rarely, and often. The present study included GPs who were safeguarding leads, and others who were not, in five cities, two of which had a local specialist clinic.
All 17 GPs were interested in participating in a conversation about managing FGM; all but one were women. The authors therefore cannot, and do not, suggest that these findings are numerically representative of the GP population, but did achieve considerable variation of experience and views in the sample.
GPs confront a range of issues which Lipsky’s social theory helps us understand as reflecting a wider issue in the tensions that GPs experience in relation to mandatory reporting.
Comparison with existing literature
The authors are not aware of any previous work considering GPs’ perspectives on supporting women with FGM in primary care, including the impacts of recent English policy. The existing FGM literature derives predominantly from obstetric and maternity settings. Some of the present findings resonate with these accounts, for example the challenges in talking about FGM including the use of interpreters,28–31 but the authors also heard about issues specific to primary care. In maternity care, asking about FGM will usually be immediately relevant to the woman’s current clinical care needs, and in the context of a clinical relationship that rarely outlasts the duration of pregnancy. In contrast, there is value in developing and maintaining ongoing relationships over the life-course in primary care, and a requirement to balance the needs of the woman who is presenting and her wider family, if registered at the same practice. GPs utilising trusting relationships with families within a strategy to facilitate care and safeguarding has been previously described.32
Though well established, street-level bureaucracy is an under used theoretical model in general practice.22 Previous work has used this theory to understand primary care responses to National Service Frameworks24 and policies to reduce unscheduled care.23 The presented analysis is supported by its resonance with Lipsky’s theory, notably the disquiet described at the removal of professional discretion.
The central findings presented here are the tensions expressed by GPs who perceived that policy required them to act as ‘law-keepers’ while also patient advocates, and GP concerns that these requirements could negatively impact on perceptions of trust, confidentiality and on patient–doctor relationships. Evidence from community settings suggests these fears may be well founded, with community research demonstrating that policies can deter members of FGM-affected communities from accessing services.14,16 Concerns have been raised that the response to FGM is ‘disproportionate’ in comparison with other child safeguarding,33 and of the lack of evaluation for mandatory reporting for FGM.34 Mandatory reporting is being considered in other areas of safeguarding in the UK.35,36
Beyond FGM, policies that require data sharing (or where there are fears that data sharing will occur) can deter patients, notably vulnerable patients, from accessing care and services.37–39 As with the GPs in the present study, doctors have voiced concerns about requirements to enact policies that they consider will compromise their professional ethos or relationships with their patients37,40–42 including through organisations like Docs Not Cops (http://www.docsnotcops.co.uk) and medact.43
Implications for research and practice
Making FGM specialist clinics available wherever there is need should be a resource priority. With input including GP and community expertise, educational resources including holistic aspects of care and safeguarding could be developed for primary care.
There is a pressing need to develop understanding about how the management of mandated reporting and data sharing impact on trust and communication in primary care. Adequately evaluating such policies is a research priority in the context of consultations on the expansion of mandatory reporting.
