The London borough of Southwark has the highest proportion of women in England and Wales who have undergone Female Genital Mutilation (FGM), new figures reveal.
Almost one in 20 (4.7%) women living in Southwark are estimated to have experienced the brutal practice, 10 times the England and Wales average of 0.5%.
One in 10 girls (10.4%) born in Southwark are also born to mothers who have had FGM, also the highest percentage in England and Wales, reflecting a problem that doctors and maternity wards are still struggling to understand, let alone treat.
The south London borough, which is home to some of London's best-known landmarks, topped the list in a study carried out by Equality Now and City University and funded by the Home Office, which offers estimates of FGM prevalence for each local authority area.
The report revealed women in every area are affected, but the top 10 boroughs are all in London: Brent has the second highest incidence of FGM at 3.9% of women, while Newham and Lambeth both have an estimated prevalence of 3.2%.
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The report builds on interim findings published in 2014 which showed that an estimated 137,000 women and girls in England and Wales are estimated to be living with the effects of FGM. Many are thought to have had FGM abroad before moving to the UK.
Outside London, Manchester, Slough, Bristol, Leicester and Birmingham also have high prevalence rates, ranging from 1.2 to 1.6%.
The research used census and maternity data as well as other information to create its estimates, using information on migrants who have come from countries that traditionally practice FGM.
The procedure varies but can include removing the clitoris of a young girl, removing the inner-and-outer lips of the vagina, and sewing together the vulva - traditionally without anaesthetic - causing severe pain and lifelong physical and mental effects.
“From what we’ve seen, it comes down to migration," says Anber Raz from Equality Now.
"Southwark obviously has a higher population of migrants who have come from practising countries, but then again, you need to look at more details about which countries they have come from."
Many countries practising FGM are in Africa, and Southwark has the highest-density of African-born residents of anywhere in the UK at 13%, but the pattern of FGM is not simply geographic.
In countries such as Egypt, Guinea, Somalia and Djibouti, FGM happens to almost all women: 90% aged between 15 and 49 are affected, whereas in countries like Cameroon and Uganda the figure is less than 2%. Sometimes FGM is practised in a certain location, sometimes in religious groups, sometimes racial ones, and sometimes it's just part of specific family traditions.
It was in Southwark, perhaps fittingly, that the UK's first trial for FGM took place in February. But Dhanuson Dharmasena, the 32-year-old doctor accused of illegally stitching a young mother back up after she gave birth, target="_hplink">was swiftly declared innocent and prosecutors were accused of staging a "show trial".
Dharmasena was cleared within 30 minutes after it emerged his only crime was unknowingly using an illegal 'figure of eight' stitch to try to help the woman, who was bleeding profusely, when he had never treated a woman with FGM or received any training.
Some felt that the trial's collapse reflected the desperation of authorities to secure what would have been the first conviction for FGM, despite it being illegal for nearly 30 years. The government has been taking tougher measures: often, girls are taken out of the UK for the procedure to take place, and from last week authorities have been able to seize the passports of girls of their relatives if they think they will travel abroad to have the children "cut".
London is the best-served area for FGM support, but "even then that’s not enough,” says Raz of Equality Now.
The Africa Advocacy Foundation works with communities affected by FGM in Southwark, as well as Lambeth and Lewisham. Agnes Baziwe from the foundation says: "The challenges we have experienced in Southwark in the course of our work include a lack of coordinations between the different agencies working to support women and girls at risk and those who have experienced FGM.
"There is a need for greater commitment to address current gaps in FGM service provision in Southwark, by working closely with key individuals and grassroots organisations competent in engaging with FGM practising communities."
The fact that one in 10 babies born in Southwark is born to an FGM survivor presents huge challenges. At Guy's and St Thomas' Hospital, the major hospital in Southwark, the African Well Woman Clinic offers services for those who have experienced FGM, including pregnant women.
Some women don't even realise they have experienced FGM until they have sex or become pregnant, which can bring serious physical and emotional dangers - research suggests death rates of mothers and babies in childbirth are higher than average. "To deal with all of that once you’ve just found out you’re pregnant too, it’s a big shock to the system," comments Louise Robertson, the communications manager of 28 Too Many, which campaigns against FGM.
Raz from Equality Now says: "Just depending on how severe the form of FGM performed is, childbirth can be excruciating – I mean, it is in normal circumstances, but it’s much, much worse if you have undergone FGM. You’d be unlikely to have a natural birth."
The psychological effects of FGM are under-researched too, such as PTSD and flashbacks, and women who have FGM can be more prone to depression. And when daughters are born to mothers who have had FGM, they can also be at risk, though not necessarily.
All of the African Well Woman Clinic staff are female - crucial, the clinic feels, to providing a "a culturally sensitive and non-judgmental environment."
But too much cultural sensitivity has also worked against those who call for an end to FGM.
Leyla Hussein, an FGM survivor and campaigner, was reduced to tears in 2013 when members of the public happily signed a fake petition she set up saying that FGM was part of her culture, so should be protected.
When she was seven, growing up in Somalia, four women held Hussein down and cut her clitoris. "I felt every single cut," she told The Huffington Post UK last year. "I was screaming so much I blacked out.” It pains her to speak of the horrific memory, and discussing it, even in her 30s, is "re-traumatising" for her.
Hussein told HuffPost that there is a widely-held misconception that FGM is solely an islamic practice. “We live an era where anything bad is seen to be something to do with Islam. I cannot blame people for associating FGM with Islam when you turn on a TV and you see crazy men shouting ‘Allah Akbar’ and beheading people. And yet all of these things are very un-Islamic.”
She thinks one of the reasons for the myth may be that those who speak out about FGM tend to be Muslim women from Somalia, but in fact, in countries like Nigeria, the biggest group that carries out FGM is the Christian community. Figures released by Unicef in 2013 show 55% of Christians are affected by FGM in Niger, compared to just 2% of Muslims.
Thanks to austerity measures, campaigners say more funding is desperately needed for projects like Hussein's Daughters Of Eve, which supports women and girls affected by FGM. “She has more people coming to her than she can possibly help," says Raz from Equality Now.
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Historically, UK doctors and social services have been hesitant to intervene when they see suspected FGM, for fear they would be called racist. “I think that has been a problem in the UK," says Robertson from 28 Too Many.
"It’s beginning to be addressed now because there is much more discussion and information about FGM in the public domain," she adds. "The campaign has been sending out very clear messages in the uK that FGM is illegal, that it is child abuse. As long as you approach it from that way, hopefully people have more confidence to tackle the issue.”
But Robertson warns: "The flip side of that is that this is such a deeply-rooted practice, and sometimes the people in the UK who continue to practice might not be accessing mainstream media. It’s all well and good having lots and lots of articles about FGM in the Guardian, but if that family where FGM happens aren’t Guardian readers, how are they going to get those messages?" That's why community outreach is essential, she argues.
Another challenge had been that UK front line workers have simply been unaware of FGM, let alone how to deal with it, such as in the case of Dr Dharmasena.
This is changing - information was recently sent out to every GP about FGM, and the Department of Health is working to train all professionals, perhaps even at university level. "Hopefully some of these misconceptions that tackling it would be racist behaviour or culturally inappropriate will be dispelled,” says Robertson.
And from around this Autumn, councils, social services, police and medical staff will have a duty to act when they suspect FGM has taken place or is planned to, under the Serious Crime Act. "Often there has been a reluctance because FGM has not been viewed as a child protection issue. So it’s not integrated within local child protection procedures, and it should be because it is a child protection issue," says Raz.
Southwark was one of the areas singled out in the Home Affairs Committee's 'case for a national action plan' on FGM last year, and many affected women do live in large cities where migrant populations are clustered.
But the fact that no area in England and Wales was unaffected in the Equality Now report should be a wake-up call for the entire country, Raz explains: “Even in the most remote of areas where probably these populations are quite small, there is still a likelihood that there are some women and girls who may have had it done.
"In which case, it’s really important that local authorities ensure that there are adequate services in place to support them, because those women and girls will be even more isolated from places like London where services are better, but also there are bigger population and more understanding, so they will have that support.”
The Home Affairs Committee noted that the Government's 'dispersal' policy for immigrants - moving their away from big cities to ease pressure on London and other urban centres - "will have created large migrant communities in small towns, some of whom are from FGM-practising countries."
Raz from Equality Now adds that every local authority needs a "holistic" approach to FGM, which brings in trained medical and social staff, community outreach workers and which "includes survivors and listens to what they need." This is perhaps more urgent in rural areas rather than urban boroughs like Southwark, "so people aren't having to travel hundreds of miles to get to London."
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Robertson, from 28 Too Many, says evidence like the Equality Now report is crucial to convince those who carry out FGM to change their attitudes. "It’s almost a situation where you’re trying to talk to people who don’t want to listen. Because they are brought up believing this is right, and it’s been happening for generations in their families, they don’t want to question it, and also it can be very difficult if it’s something you’e gone though yourself, you’ve always suppressed that and not really come to terms with the fact that something has happened to you that other people regard as horrific.”
She thinks that gradually, a shift is occurring: “Quite a lot of people now see at its heart its about gender inequality, and not recognising the rights of girls and women. It’s about control, it came to be prevalent and persistent in very patriarchal societies.”
In UK, London, and Southwark, the fight continues.
Equality Now is working with Trust for London, women's fund Rosa and The Royal College of Midwives to create guidance for Local Authorities on how they can prevent FGM, and help women who are living with it in their area.
It stresses that working with community groups is key, as well as "the need for sensitive interventions, involving FGM survivors and community experts, which raise awareness of the harms of FGM without stigmatising whole communities."