Table 1 United Kingdom – when does a medical procedure become FGM/C?

In the United Kingdom (UK), FGM/C has been illegal since 1985 when the Prohibition of Female Circumcision Act became law. In 2003 the law was amended under the FGM Act (2003) to include an extra-territorial clause. In 2015 provisions were strengthened under the Serious Crime Act, which extended the scope of extra-territorial offences, granted victims of FGM lifelong anonymity; and introduced a new offence of failing to protect a girl at risk of FGM (Crown Prosecution Service, nd). The law states it is a criminal offence to excise, infibulate or otherwise mutilate the whole or any part of a female’s labia majora, labia minora or clitoris. However no offence is committed by a registered healthcare professional who performs: a surgical operation on a female which is necessary for her physical or mental health; or a surgical operation on a female who is in any stage of labour, or has just given birth, for purposes connected with the labour or birth. It is also an offence to aid, abet, counsel or procure FGM [17].

After 30 years with no prosecutions under the FGM/C legislation, the first prosecution was brought to court in January 2015. It was a high profile case involving an alleged medicalized re-infibulation by a doctor in a Maternity Unit of a National Health Service (NHS) hospital in London. The alleged offence took place in November 2012 when a 24-year-old woman was brought into the Maternity Unit in labour with her first child. It was apparent to the midwife in attendance that she had been subjected to type 3 FGM infibulation (which had been performed on her at the age of 6 in her home country, Somalia) and that this had not been picked up earlier in her pregnancy and was making the birth difficult [18, 19]. The doctor was called in and he cut the woman to facilitate the safe birth of her child [18]. Following the delivery of the child, the doctor, allegedly encouraged by her husband [18], sutured the woman, to stop excessive bleeding. However it was claimed by the prosecution that the suturing exceeded that which was medically required and thus constituted re-infibulation [20]. The case thus revolved around whether a figure of eight suture constituted re-infibulation [19]. In the period between when the alleged FGM took place and the court case, the woman had delivered a second child with no need for surgical intervention and she declined to give evidence in court [19, 21]. The defendants (the doctor and the woman’s husband) were both acquitted of the offence by the jury after only 25 min of deliberation [20, 21].

The case has thrown up a number of issues most notably how re-infibulation is defined, i.e. when does a medical procedure become FGM/C. In this prosecution the case consisted of debates and expert witness evidence concerning one suture (in a figure of eight, part of which involved the stitching of the labia). The prosecution claimed this one stitch constituted FGM. This argument was supported by expert evidence from health professionals including the midwife involved in the delivery room at the time [18]. Other health professionals argued otherwise, stating that as the woman had given birth to a second child without having to be surgically cut then the suturing could not be labeled as reinfibulation. The debate on when a medical procedure crosses the legal line to become FGM has not been resolved. However, whilst the prosecution did not result in a conviction, it did raise the issue of the medicalization of FGM/C in the UK, whether this was inadvertent or deliberate. It is not known if any or how many health professionals are engaged in medicalized FGM/C in the UK, but this highly publicized case provided a stark warning to the medical profession that medicalized FGM will not be tolerated in the UK.