Female Genital Mutilation – A Nuanced Look at the First Trial

Dr Dhanuson Dharmasena is one of the first people to be charged in the UK under a landmark case allowing for the prosecution of people involved in aiding and abetting the crime of female genital mutilation.

Female Genital Mutilation is not a good practice. I have long stood against it. However I have had issues with the UK’s laws with regards to Female Genital Mutilation. Doctors were told to fight the practice with little or no training or worse? No idea of how to deal with children at risk.

The point is? We don’t want to take children away from parents. We don’t want young girls to get cut. We also don’t want parents to not bring their kids to see the doctor for fear of being arrested.

But that being said? Prosecutions need to occur.

Dr Dhanoun Dharmasena, 31, of Ilford, Essex, will be prosecuted for an alleged offence while working at the Whittington Hospital in London. Hasan Mohamed, 40, of Holloway, north London, faces a charge of intentionally encouraging female genital mutilation.

Dhanoun is alleged to have repaired a case of FGM (it can be done, the clitoris is not fully removed and more can be exposed to restore some pleasure) that he himself performed earlier. While Mohamed is believed to have tried to encourage the procedure and facilitate it.

There are other cases but the Crown Prosecution Service has not taken further action. These include a case where two parents arranged for a FGM while abroad. In another? A suspect contacted a FGM hotline to request the procedure.

Whatever happens it is a landmark case since it is the first case that has come to light since the new laws were put in place. However this needs to be coupled with education of children and adults with regards to the law and why the law exists. The campaign to halt female genital mutilation should also include our countries because it does happen even in the developed world

However this is not so cut and shut as it seems. It is easy to paint Dhanoun Dharmasena as a complete villain. But the reality seems to be a lot more grey. The issue seems to be that Dharmasena’s patient was injured during delivery due to the FGM done to her prior and that his efforts to correct the damage were seen as interventional and reported as FGM in itself.

In women who have suffered a FGM the pregnancy may be complicated by a narrow vaginal opening which may need widening to allow the baby out. If it is not done before labour it must be done during delivery. This leaves bleeding that needs to be repaired.

There is a world of difference between the practice of FGM an repairing an episiotomy. And Dr. Dharmasena’s generous episiotomy was indicated in cases of FGM where the vagina was “stitched” close reducing the elasticity of the opening.

The real problem here then is two fold.

1. This isn’t a case of prosecuting FGM where the real problem is the procedure being done both  abroad and in the UK

2. This will have knock on effects in preventing doctors from speaking out

The major issue here is that doctors are not encourage to correct the damage caused by FGM during child birth as it is seen as tampering and FGM in itself. It detracts from the real issue and punishes doctors trying to make the best of a terrible event to allow the victim of FGM a normal delivery.

In this case the victims of a FGM would be left to bleed “naturally” after a childbirth. Medics would be  penalised if they repair the damage in the wrong way. As the case details are released the opinion may change but from what we are seeing so far, the doctor is being penalised for repairing a vagina that was affected by FGM related damages during child birth.

Your prime objective as an Obs/Gyn is to reduce pain and bleeding,

“Your primary objective is to reduce the bleeding and pain and you are having to think about whether somebody is going to prosecute you for FGM. A lot of obstetricians and midwives right now will be feeling terrified about how to act. People will want to consult senior colleagues in FGM cases and women may be waiting and bleeding in the meantime.”

Tbe decision to charge a hospital doctor for the repair of FGM is idiotic, harmful and punishes the wrong people. It harms doctors and it harms the victims of FGM. It is easy to say “sod the law” and do the right thing but you cannot expect doctors to put their practice in jeopardy and take enormous risks solely to please people who aren’t taking the same risk.

Repairing a FGM should not be punished, doing one should. Treating this incident as a crime is daft. It’s like charging the trauma doctor with assault for repairing a stab injury.

I will rewrite and repost my primer on FGM to include how a FGM case is managed but roughly speaking the smaller opening has to be widened or cut to allow the delivery. Part of the reason for high African maternal/foetal mortality is the haemorrhage caused by tears and poor closure. There will be blood and stitches can reduce the bleeding.

The issue seems to be that this procedure restores the “FGM state” because it repairs the damage done. If the normal state of a FGM individual is a narrowed vaginal opening then restoring that would not be FGM in itself. The damage is already done, this is just preventing more of it.

The Crown Prosecution Service says there is an interest in this case and that the evidence exists but as of now there are fears that the UK’s anti-FGM law will prosecute those who try and help.

If there is more evidence to be released then by all means release it and set us straight, but right now there are a lot of fears among medics with regards to what this charge entails for us.


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  2. exi5tentialist says

    I’m glad you wrote this. You’d think that the CPS would want to prosecute FGM, not the subsequent treatment of FGM by a different surgeon. The CPS say all the facts will come out in the trial, at which point presumably all will be clear. Even if that is the case, medical staff in the meantime are left with confusion about whether they will lose their career and livelihood for treating the results of FGM, when they may not have actually carried out the offending operation in the first place.

  3. opposablethumbs says

    I did wonder about this – that the prosecution seems to be for repair rather than the FGM in the first place – when I first read about the case, and found it very confusing. I assumed I’d misunderstood … but your post suggests that maybe the CPS really has chosen almost the worst possible example for their first prosecution. They must have examined this from every angle, surely … ??? You’d think.

    Avi certainly seems to be right, in that medical staff in general will now be afraid to repair/do what they can to mitigate previous damage if it comes before them. And to think I’d thought the worst possible outcome was deterring parents from seeking medical care for their daughters – already a very real issue. And now this, an extra problem over and above the existing difficulties of prosecuting this kind of abuse. Sounds like a text-book example of picking the wrong case to prosecute.

    I very much hope to be proved wrong about that.

  4. Pen says

    Dhanoun is alleged to have repaired a case of FGM (it can be done, the clitoris is not fully removed and more can be exposed to restore some pleasure) that he himself performed earlier.

    I had previously missed that detail about him having performed the original FGM. If it’s true, that’s what he should be prosecuted for, not repairing the damage and it needs to be made clear. Otherwise, the way this case is being reported it could lead to all the problems you’ve mentioned and more.

    I suspect there is a desire by the legal system to go after a doctor here, rather than a family – on the basis, if nothing else that they are likely to be serial offenders. I hope they get the right target. In fact, there is no excuse for a British medical professional performing FGM but there is a moral and professional obligation to treat existing cases.

  5. says

    He is alleged to have done that. That’s the only rational reason as to why they would even push this case through. Although the genuine problem seems to be that on a patient with FGM having a delivery the standard procedure for correcting bleeding would be to restore to the FGM state.

    The thing is this may be for the purpose of precedent. One person’s guilty in this. The guy being tried for asking a FGM hotline where to get a FGM for his daughter since there is no way to avoid getting the book hurled at you.

    But the doctor may be for setting a precedent covering doctors.

  6. Helena D says

    surely he is being tried for not only performing the initial fgm, but then repairing the fgm, rather than trying to return it to as natural a state as possible (pre the initial fgm.) I seriously doubt they would wasting their time otherwise

  7. says

    He cannot restore it to a pre-FGM state since that is the purview of people in Plastic Surgery. I think he restored it to a FGM state to control haemorrhage. That’s what the “noises” coming from his camp seem to sound like.

    However that in itself is technically FGM but it is the only really way his skill set could control haemorrhage. And the damage is already done, this is just the path of least further damage.

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