Sunday, 6 July 2014

Mutilated genitalia, mutilated statistics?

 

I am sure that you will have detected that I am against Female Genital Mutilation. I think it is a foul practice carried out by stupid people. I also think it is stupid to condone stupid habits because of the notion that habits are sacrosanct because they are part of “culture”. Cultures vary: some lead to good lives, others to miserable ones. The National Socialists certainly had a culture: ideas, policies, plans, uniforms that some people still find exciting, a very vivid and memorable party symbol, marching songs and the profound belief that their habits would last a thousand years. Mercifully, though at the cost of millions of lives, their awful culture lasted only 12 years. For the record, I am also not a fan of Stalinism or Maoism or Pol Pot.  I am against FGM (as we must now refer to it) and want the perpetrators identified, named, and given a firm lecture whilst seated on a large sharp spike. However, despite my revulsion, it is also possible that there has been a massive hype about this, in the sense that FMG happens in other countries but rarely in the UK, hence my interest in whether anyone has any data for the UK. Andrew Sabisky makes a credible case for the sceptical position, giving the reasons why it may happen less when immigrants travel to new countries. Anonymous of 3 July 2014 19:23 sends a link to a publication by Julie Bindell, to see if that helps resolve the matter.

Not very much, I’m afraid. I have looked through the essay for prevalence estimates, and remain disappointed. The essay makes an admission: “The main assumption made in the calculations that follow is that the rates of FGM among groups in the UK are the same as are found back in the mother’s country of birth.”

This is an understandable assumption, in that behavioural continuity is the default position for cultures and for emigrants, but for the reasons advanced by Sabisky in his comments, it might be an over-estimate. Some habits can change if the social pressure which sustains them is weakened, or if those habits become difficult to follow for practical reasons in the new country.  So, most of the Bindell position is based on surmise. The references are unsatisfactory on the key matter of prevalence estimates. It is a policy paper, not an academic paper. It assumes there is a problem in the UK and that an institutional and legal response is required.

Unicef 2013 is probably the main study quoted by Bindell. The authors of that publication say:

More than 125 million girls and women alive today have been cut in the 29 countries in Africa and the Middle East where FGM/C is concentrated.

Of these, around one in five live in just one country: Egypt. Since certain minority groups and immigrant communities continue the practice in other countries as well, including in Europe and North America, the total number of girls and women worldwide who have undergone FGM/C is likely to be slightly higher. The actual figure remains unknown, however, since reliable data on the magnitude of the phenomenon in these population groups are largely unavailable.

So, they don’t know, and we don’t know. The authors, who have done a reasonable job in the circumstances, admit the estimates are probably too high, and too high for emigrants. Self report is of variable accuracy when compared with physical examination. The UNICEF report does its best. It asks mothers about their daughters (because the mothers ought to remember what was done to their children, even if their daughters themselves were too young to recall being cut). They find that there are big ethnic differences (honour cultures are the most rabid cutters) and that wealthy (and presumably brighter) Africans are less keen on the practice. Many African women would like the practice stopped. However, none of this is of direct relevance to what happens in the UK, though it certainly identifies the African and Middle Eastern groups who follow these habits.

Bindell gives the following figures on page 14:

1 Around 170,000 women and girls in the UK today have undergone FGM (own figures; see Appendix D).
2 Some 65,000 girls aged 13 and under are at risk of mutilation (own figures; see Appendix D).
3 More than 70 women and girls seek medical treatment every month for FGM
(NSPCC, 2013a).
4 Some 7,000 women affected by FGM give birth in London every year (Equality Now, 2010).
5 In the last two years alone, over 1,700 women and girls have been referred to specialist clinics that deal with FGM (Metropolitan Police, 2013).

Bindell adds:  However, it is believed that the true number of those who have undergone FGM is likely to be much higher, since only a small fraction of victims seek medical help (Metropolitan Police, 2013).

This is the familiar “tip of the iceberg” argument. However, when you look at the references these are not published papers. They are links to claims that have been made.  The calculation about girls at risk in Appendix D are the usual sort: count how many Africans are in the UK, Africans do this sort of stuff, therefore they are probably continuing to do this stuff. Probably so, but not certainly so. Below is the preliminary report from the NSPCC: 

As of September 2013, the helpline had received 96 contacts (voice and non-voice): 18 for advice, 35 for referral and 43 for an enquiry. Information was available for 27 contacts: 8 related to abuse that had taken place on the same or the previous day; 11 related to abuse in the previous month; 5 were about abuse that had taken place in the previous 6–12 months; and 3 related to historic abuse. Although the dataset is small, it does seem to indicate that the helpline is being used more for current or very recent incidences of FGM. Of those contacts for which information is available (44), 23 were made by professionals, 11 by members of the public and 10 by a parent, carer or relative of the child. It is interesting that, according to the available data, no survivors of FGM had themselves made contact using the helpline. All information received by the helpline is routinely referred to the local police, children’s services and the Metropolitan Police. By September 2013, some 35 referrals had been made to the police, and these had resulted in 47 investigations, none of which had led to a conviction.

Comment: Suggestive and worrying, but does little to establish prevalence. The reference is opaque about what a “referral” means. It is hard to get convictions even when you have been knifed in the street, but zero convictions don't help to establish any case.

The Metropolitan Police stuff does not establish that FGM took place in the UK or by UK parents taking their children abroad. The “reference” given by Bindell leads to a webpage which repeats the claim without giving any information. So, the claim that: “In the last two years alone, over 1,700 women and girls have been referred to specialist clinics that deal with FGM” is supported by ….. the repeating of the claim. What does “referred to specialist clinics” mean if we don’t know what the specialist clinics found? Did a Police surgeon do a medical examination? It is very hard to track down the real findings. I often find that references in policy documents lead to a dead end. I am still searching for a paper which gives hard figures on a sample who have been examined physically.

The Dorkenoo, Morison and Macfarlane (2007) paper is said to make a prevalence estimate. http://www.popline.org/node/201747 

This paper turns out to be a disappointment. They just count Africans in the UK and judge their daughters to be at risk of the razor. Lots of numbers and maps, but no capture/re-capture numbers. The authors also make it clear that they cannot entirely trust the Unicef numbers, so they are using an African prevalence rate about which they are doubtful and, in an act of faith, calculating how many Africans now living in the UK are “at risk” of behaving like Africans in Africa. They may be absolutely right that Africans will be Africans, but as regard messing around with genitalia, it is interesting to note that African women mostly wish that this practice should stop, and perhaps emigration gives them a chance to achieve freedom from this gross practice. Although the authors have worked carefully, they then pat themselves on the back and say “The results presented here are the most rigorous estimates to date. To obtain a clearer picture of actual prevalence among both migrant and second generation women, a survey of women giving birth in the UK would be needed, however.” Rigorous “to date” perhaps, but not rigorous in the usual sense of that word. They are right about the need for maternity ward estimates. If we had good data of that sort we would be on firmer ground,  but see below for a fuller procedure.

McCaffrey M, Jankowska S HO and Gordon H (1995) ‘Management of female genital mutilation: the Northwick Park Hospital experience’ British Journal of Obstetrics and Gynaecology, 102: 787–90.

Unfortunately it is hard to draw conclusions about prevalence from this study, let alone any data about prevalence of the practice in the UK. The impression gained from reading the paper is that these African women suffered mutilation mostly in Somalia and then came to Britain, where their damaged genitalia presented significant problems at childbirth, leading to de-infibulation, the practice of surgical intervention to open up the vagina prior to delivery, thus significantly improving the outcome of the pregnancy for mother and child. Cultural practices be damned.

Here are the scraps of information for the Bayesians among you. The number of African women delivered at Northwick Park Hospital has risen from 1.23% in 1988 to 5.79% in the first seven months of 1994. Fifty women have attended the clinic in the first six months. (Not clear how many African women in total attended maternity services at Northwick Park). Thirteen of the women were non-pregnant, 14 were primagravid, and 23 were multigravid. The main reason for attendance of the non-pregnant women was a request for de-infibulation. In addition, three patients had been victims of sexual assault (two children and one adult), and one patient had a painful vulva swelling. Where information on age at the time of circumcision was available, the mean age of infibulation was 6.7 years (range: birth to 13 years). The ages of the pregnant patients ranged from 17 to 34 years (mean age 26 years). Those who were not pregnant ranged in age from 14 to 33 years (mean age 23.3 years).

All this tells you very little about how many African women have their genitalia messed about with, and how many suffered this in the UK.

Summary: FGM is apparently still rife in Africa, but if modernity, globalisation and education for girls has any effect then it should be dying out, which is what African women want. There is no hard evidence it is being done in the UK, but it is worth investigating, so long as the indigenous white locals can bear to think that some aspects of their culture are better than some aspects of other people’s cultures. 

So, is Female Genital Mutilation the tip of the iceberg or the skin of an onion? I tried to explain these two conflicting analogies on 6 December 2012. It is an argument which rages about many a human behaviour and presumed epidemic disorder.

http://drjamesthompson.blogspot.co.uk/2012/12/icebergs-and-onions.html

If we really want to get an estimate of FGM rates we will have to do some examinations at gynaecology clinics, STD clinics and maternity wards in specified populations. Then, by checking names, we should be able to get capture/re-capture/re-capture numbers within a year, from which much better estimates might be derived. Then we have to do the hardest thing: we have to say that not mutilating genitalia is a better policy than taking out razor blades. How shall we explain that?

Suttee or sati is the Indian practice of widows immolating themselves on their dead husband’s funeral pyre. Initially British rulers in India tried to regulate the process by requiring it to be supervised by local religious authorities (sounds familiar, doesn’t it?) but eventually banned it. There were protests from Hindu priests in 1859 who complained to General Sir Charles James Napier, the Commander-in-Chief in India about the prohibition of sati by British authorities.

"Be it so. This burning of widows is your custom; prepare the funeral pile. But my nation has also a custom. When men burn women alive we hang them, and confiscate all their property. My carpenters shall therefore erect gibbets on which to hang all concerned when the widow is consumed. Let us all act according to national customs.

I doubt we have the self-assurance to do anything remotely like that now.

5 comments:

  1. Similar situation here in Sweden - no data to make a meaningful estimate of prevalence from. In one school class all the girls were recently found to have had the procedure. One woman said they had gone to London to do the procedure, no idea of whether that's common or not though. The PC establishment just isn't very keen on finding out. For all their talk of tolerance and compassion those girls don't mean much to them.

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  2. This article mentions a Dr Comfort Momoh, a specialist in treating FGM who runs the African Well Woman’s Clinic at St Thomas’ Hospital : http://www.standard.co.uk/news/health/true-number-of-fgm-victims-in-capital-is-far-more-than-figures-show-8801826.html

    Maybe she would be interested in hearing from someone who's looking for data, maybe there's a bit of funding somewhere that could be used for data collection.

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  3. I just noticed this, may be of interest, published a couple of days ago. http://www.pulsetoday.co.uk/news/political-news/mps-call-for-doctors-to-be-empowered-to-tackle-female-genital-mutilation/20007196.article#.U7maEZRdWuo

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    Replies
    1. Thank. Getting prevalence estimates is a first step, so I will wait to see what further information I receive.

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