Equal Opportunities Committee, 18 Jan 2005

Meeting date: Tuesday, January 18, 2005

Official Report 298KB pdf

---

Prohibition of Female Genital Mutilation (Scotland) Bill: Stage 1

Good morning and welcome to the second meeting in 2005 of the Equal Opportunities Committee. I remind members, witnesses and members of the public to ensure that all mobile phones are switched off, as they interfere with our sound system. We have received apologies from Frances Curran, Nora Radcliffe and Elaine Smith.

Item 1 on our agenda is consideration of the Prohibition of Female Genital Mutilation (Scotland) Bill. Many of our witnesses have travelled far to be here, which is humbling given the struggle and moans that we had when coming in through the snow this morning. I offer a warm welcome to Rosemary Burnett of Amnesty International Scotland, Susan Elsley of Save the Children Scotland, Simon Hodgson of the Scottish Refugee Council and Inge Baumgarten of the World Health Organisation. Before I give members an opportunity to put questions to you, I invite you to make statements on behalf of your organisations on the legislation that we are considering.

Thank you for inviting me to give evidence to the committee. Amnesty International broadly welcomes the legislation, which will have the effect of outlawing FGM on a similar basis throughout the United Kingdom. There are some points that we would like to cover.

We welcome the attention that has been given to scrutinising the bill, because we do not see the bill as standing by itself. We believe that it should be accompanied by sensitive approaches to providing information and education. That information and education should be targeted both at communities for whom the issue is relevant and at health and other professionals who work with them.

The Scottish Refugee Council welcomes the proposals. However, we are concerned that protection is not extended to asylum seeker children in Scotland and we would like that issue to be addressed.

We will pursue the matter in questioning.

Good morning. The World Health Organisation welcomes the committee's activity and believes that it is necessary to involve in a comprehensive, multisectoral way all the different stakeholders that are engaged in protecting children from this harmful traditional practice.

We will consider the bill and how it may be implemented, so there may be questions that it is not appropriate for the World Health Organisation, for example, to answer.

Do the witnesses have a view on the consultation process that the Scottish Executive carried out? We have heard that the consultation period was very short and covered a holiday period. Did you have enough time to respond to the consultation? Would you have responded differently if you had had more time?

Save the Children Scotland had enough time, as it was able to access information quite straightforwardly. However, I am concerned about whether there was sufficient opportunity for information to get out to communities that may be particularly affected by the bill and whether that information was presented to them in an appropriate form and in appropriate languages. Over the past few years, the Executive has shown a great deal of commitment to consulting children and young people on legislation that will apply to them. I wonder whether anything appropriate could have been done to explore the bill's impact on children and young people and their views on it.

Were you aware that information was available in languages other than English or that there was a process whereby translation could be sought? Over the past few weeks, we have heard that, although information was available to many communities, it was quite difficult to access. Do you think that there are better ways of ensuring that there is wide consultation?

One way of extending the consultation might have been to work orally with the groups of women and young girls who may be affected by the bill. In many communities, that is the traditional way of communicating. Had the consultation period been longer, more community work of that type could have been done.

The World Health Organisation was made aware of and invited to take part in this process only last week. That is very short notice and did not give us sufficient time to prepare and consult member states.

I notice that some important information is missing from the reading list that has been supplied to the committee by the Scottish Parliament information centre and in supporting materials. I highlight the fact that there has been a study of legislation in Europe regarding female genital mutilation and the implementation of the law in Belgium, France, Spain, Sweden and the United Kingdom. The study was produced by the international centre for reproductive health in Ghent. I offer that information so that the committee can include it in its further deliberations.

That is helpful. The information that you received last week came from the committee, rather than from the Executive. The committee thought that it needed to know what was happening elsewhere in Europe and the world. Your input this morning is very valuable. We will include the study that you have mentioned in our information gathering.

My question is directed specifically at Inge Baumgarten and the World Health Organisation. Estimates of the incidence of FGM in Africa show that it potentially affects a huge number of women. In some areas, more than 90 per cent of women may be affected. Are we winning the battle internationally to reduce the incidence of FGM? Is legislation of the sort that we are considering the right way in which to go about that? What effect do you think it will have on perceptions of FGM in the countries where it is prevalent?

Are you asking whether the legislation will have an impact on the perception of FGM in the countries from which people originate?

Yes. Is this the right way in which to affect how people think about FGM?

Since the 1990s, the world conference on women in Beijing in 1995 and the international conference on population and development in Cairo in 1994, it has been recognised globally that it is necessary to deal with FGM not just as a traditional practice that is harmful to the health of the women and girls affected but as a human rights issue. From the point of view of those who want to protect girls and women who are potential victims of the practice, it is helpful to have as much legislation as possible that aims to prevent them from being mutilated. However, it is important to educate people as well as to have legislation. If we aim to change perceptions in countries of origin, we are likely to need a network that links together activists, women's groups and national, regional and international non-governmental organisations, so that the legislation becomes known to people living in those countries, regardless of whether they migrate here or stay in their countries of origin.

Is the legislation having any effect yet, or is it too soon for that?

I presume that it is too soon, but I am not aware of any evidence on the matter.

What is the biggest challenge that we face when seeking to achieve our target of eradicating FGM?

The WHO's experience over the past few decades of supporting activists and countries that seek to abandon the practice suggests that if we address the issue only from a health education point of view, we miss important elements relating to culture, tradition and people's perception of gender and female and male roles in society. We need to co-operate closely with the practising communities so that we can understand why they practise FGM and we need to have strategies that are in harmony with their lines of thought.

Even if we are successful in reducing the incidence of FGM, many women will suffer from its consequences. In your experience, how much work needs to be done throughout all health service areas to ensure that effective and sensitive treatment is available to those women?

In the African region in which the WHO is most active in trying to prevent female genital mutilation, there is a big challenge in offering good-quality services to those who have been affected by the practice and who are suffering from long-term or immediate consequences. There must be trained experts and the maximum possible educational sensitisation of health providers so that they know what they must do if they are confronted with the difficulties and problems that are associated with female genital mutilation.

In Europe, we have become aware through consultative meetings with technical experts in the health field that health care providers in many countries—whether doctors, midwives, nurses, paediatric nurses or others—still have insufficient knowledge. They do not know what to do if they are confronted with FGM—they are embarrassed and afraid to take action that might result in their being labelled as having a racist attitude and they might not know how to deal with problems. It has been stated in your papers, rightly, that some people might try to organise a Caesarean section rather than a spontaneous delivery because they are embarrassed or do not know what to do. There is certainly a need for further sensitisation of health care providers and for educating them about the reasons for the practice being conducted in different communities in different countries. There is a need to understand better what the practice is about and how to deal with complications that may arise.

Are you aware of the extent to which legislation against FGM internationally depends on the World Health Organisation's definition of FGM?

I am not sure whether I understand your question. Would you rephrase it?

The bill is guided by the definition of FGM and its four types. Are other countries also guided by that definition?

The WHO definition is internationally recognised as the standard definition of what we mean if we talk about female genital mutilation, female genital cutting or female circumcision. Usually, the countries that have legislation refer to that definition, although some countries make exceptions in respect of piercing in the area of the vagina, for example. However, they all refer to the four types of female genital mutilation.

Thank you. That is helpful.

What do you think about the terminology that is used? Some people would prefer that the word "circumcision" was used in the bill rather than "mutilation". Is it important to make that change? What effect would such a change be likely to have on the communities that practise FGM?

The World Health Organisation decided with other United Nations agencies to use the term "female genital mutilation" to highlight the human rights dimension of the practice. The WHO wanted to have a clear position. As an international agency, the WHO does not support any form of FGM being practised by a health care provider or any paramedical person in the health sector.

The term "female genital mutilation" is used at the policy level and to sensitise decision makers. However, one must start a dialogue at the community level, and if a term is used that is offensive to a community, it is likely that that community will react defensively and will not try to understand why FGM is being reasoned against. Communities usually use their own terms. One will say "l'excision" in a French-speaking country, or one may use the words "bolokoli" or "kene-kene" if one is using a native language.

Things vary according to the ethnic group to which one is talking. Somali people often use the word "sunna". The term that is most acceptable to the community is used in order to have a dialogue and to change things, but we have decided to use the term "female genital mutilation" at the policy level. Organisations that are based in the States also use the term "female genital cutting"—FGC—but the WHO, in line with other UN agencies, such as the United Nations Population Fund and the United Nations Children's Fund, uses the term "female genital mutilation".

Do other witnesses have views about the terminology? People have certainly raised the issue with the committee.

Save the Children works internationally, including in African countries, on issues relating to female genital mutilation and totally supports the WHO's position, which is that the phrase "female genital mutilation" should be used. However, people who work in communities must use sensitive language and terminology, although that should not undermine our concern about female genital mutilation.

Do the witnesses believe that the new law will protect girls and women from FGM? Will it provide more protection than the existing law does?

The new law will go a long way towards plugging some loopholes in the previous legislation, but I would like to make a suggestion. The committee might want to look into the UK's ratification of the UN convention against torture in order to cover situations in which, for example, a girl is sent back to stay with an aunt or grandmother and that aunt or grandmother allows or encourages the operation to go ahead. The UK's ratification of the convention allows the prosecution of any person of any nationality in the UK if they are shown to have committed, or to have aided and abetted, an act of torture anywhere in the world. The committee and the lawyers who are drafting the bill might want to consider that possibility as a way of extending the protection of girls.

That is something to consider.

The law has an important role to play in laying down principles and in creating a punitive position if the law is broken. However, it is important that the law is backed up by education and information to communities and that it is seen as having an educative lead.

I reiterate our point about who is protected. It seems to me that the bill still will not protect children who are seeking asylum. If the practice is regarded as a breach of human rights, those rights should be applied universally and not only to people who fall within a narrow definition of UK nationals. It is clear that it will be difficult for such things to be prosecuted in the future and that there are technical difficulties, but it seems bizarre to me that if, for example, I arranged a business to transport children who are seeking asylum out of the country in order for FGM to take place, I would not be guilty of any offence under the bill. I might be guilty of other offences such as those relating to immigration or people smuggling, but I would not be committing any offence under the bill, which seems me to be a human rights bill. I am sure that it would be possible to close that gap by recognising that a person's family still being in Scotland is sufficient connection for them to be protected under Scottish legislation. However, that seems to be specifically excluded.

That is an area of concern, and we will ask the Executive for a paper on it. Members have expressed concern about protection for the children of asylum seekers. The answer that we have received so far is that if the parents leave the country, they will no longer be asylum seekers. We are not sure whether that would be the case if people arranged for their children to be taken back to a family member in another country.

Surely the point is that if we are talking about a human right, that right must be universal—one cannot be selective and say that only some people have it.

The bill will cover some fairly unlikely scenarios. For example, it will deal with the scenario in which someone who has had a sex change operation might be subject to FGM. A scenario that is much more likely is that asylum seeker children from some of the communities that live in Scotland would need to be protected. That is the point that I addressed in my submission.

I think we all agree that the introduction of a law is an important step forward in reaching the objective of protecting girls from being the victims of FGM, but although having such a law is an important pillar, other activities are necessary. Enforcement of the law is a problem in many African countries in which, even though there is a law that prohibits FGM, the practice continues. The prevalence rates are still quite high; they are not dropping automatically.

For the law to be effective, sensitisation measures are necessary. There is a need to make the law known to the communities that practise FGM and to make them understand why it has been introduced. There needs to be multisectoral provision on how to identify cases of FGM and to find out who the victims and potential victims of the practice are. It is necessary to consider what other measures must be taken to accompany the law and to make it effective in the long run.

My first question is for Rosemary Burnett, as it is about Amnesty International's evidence. In your submission, you say:

"The Bill should make it an offence for a person to permit a woman or girl to be placed in a situation that poses a threat of the commission of FGM or any other offence under the proposed Bill or for a person to allow such commission or offence to take place."

Will you expand on that and tell us what situations you had in mind?

There might be occasions on which a young girl was sent abroad and the parents were not aware that while she was abroad, various relatives were thinking about having the operation done on her. That is the sort of situation that we had in mind.

Thank you for that clarification. The rest of my questions are open to the rest of the panel. Amnesty International suggests in its submission that the bill should include two additional offences: attempted FGM and incitement to FGM. What are the panel's views on that?

We believe that it is important to include in the bill a provision on incitement to FGM. "Incitement" is a very strong word. We are dealing with a cultural practice that has been deeply rooted in many communities for many generations. Many people, especially older people, in those communities are deeply committed to the practice—for very good reasons, as far as they are concerned.

I will illustrate my point with a story. I was working with an Amnesty International colleague in Ghana. His mother, who had suffered horrendous gynaecological complaints that could be traced back directly to the practice of FGM, asked him what his work in human rights meant—she wanted an example of it. He described to her the work that Amnesty was doing in Ghana to eradicate FGM. As it happened, she was the senior woman in her village and was responsible for guiding the other women in the village on the practices that they followed. In that village, the women believed that if a young girl had not been genitally mutilated, she would not get married and that any marriage that she might contract would result in deformed offspring. They also believed that if that cultural practice ceased, it might have an effect on the crops and the community's general well-being.

My colleague's mother went back to her village. That day, six girls were being prepared for the operation, but she put a stop to proceedings. She said that she now believed that the practice was wrong, because of the conversation that she had had with her son. The operations on the six girls did not go ahead, in spite of the complaints of the rest of their families. Within a year, three of the girls had got married and produced perfectly normal children, and the crop rotation had been perfectly normal. Within another year, the rest of the girls had got married and produced normal children. That had the effect of convincing the rest of the village that all the things that they had believed about FGM were false. They learnt through experience that not carrying out the practice did not lead to the consequences to which they had always believed that it would lead.

"Incitement" is the word that we have used to describe the very strong encouragement that older women in particular give to younger women or to their parents. They say things such as "Your daughter will never get married" and "You will ruin your daughter's life." As all members of the panel have said, the best way of eradicating the practice is through education and through the methods that were used in Ghana, which I have just described. However, to deal with situations in which someone is particularly insistent or in which a religious leader has directed that the practice should carry on, there should be an offence of incitement as a last resort.

Do other panel members have a view on that?

Save the Children broadly supports Amnesty's position, with the codicil that we always highlight, which is that it is important to work closely with communities. Legislation should not be seen as punitive or as failing to understand the long tradition of cultural practices. It is a question of working with communities.

We, too, broadly support Amnesty's position.

The policy memorandum notes that there is anecdotal evidence that FGM is practised by members of the Somali community in Glasgow. Are you aware of any other groups or communities in Scotland in which the practice is likely to be carried out?

I got notice of the question yesterday, so I tried to do a bit of checking with our community workers in Glasgow. It is unfortunate that the statistics that the Convention of Scottish Local Authorities publishes on the breakdown of asylum seekers in Glasgow by nationality are a couple of years out of date. Although it is not impossible to get the latest figures, they are not published on COSLA's website. Recently, such a breakdown has been done by council ward but not by nationality.

A few years ago, there were groups of about 50 or 60 such families in Scotland from African countries, such as Ghana, Liberia, Kenya and Cameroon. I tried to find out whether there were any other groups. I know that the Somali women's action group assisted by coming to give evidence and that there is a Cameroonian association. To return to the first question, we have not had time to do a lot of work on FGM with all those groups. If we had a bit more time, we might be able to go back to some of the other community groups to ask them whether FGM is practised. Other than that, the answer is that I do not know.

All the evidence shows that refugee flows come from areas in which there have been wars and disasters. The present situation in Sudan means that it is probably reasonable to assume that in the future there could be a refugee flow from Sudan, where FGM is practised.

I talked about this to my colleagues who work with young asylum seekers and refugees in Glasgow, but they have no evidence on the subject. That flags up the need for some sensitive research to be undertaken; there is a lack of information on the practice in Scotland.

The explanatory notes to the bill say that there have been no prosecutions under the existing legislation and that the Scottish Executive does not expect many prosecutions under the new law. What are your views on that subject?

That shows how difficult it is to get the evidence that is required to bring successful prosecutions. I have read about some cases in other countries that have come to light as a result of difficult hospital births, for example. Those examples have been used as test cases and learning opportunities for communities, with the aim of highlighting the potential for someone to get into trouble if they do something wrong. I recognise how difficult it is to get evidence in these cases.

If the bill is enacted, will it act as a huge deterrent?

Yes.

Does Inge Baumgarten know of prosecutions in other countries?

The international centre for reproductive health, which I mentioned at the beginning of my evidence, studied five countries—Spain, France, the United Kingdom, Sweden and Belgium—that have specific FGM legislation. Its report found that those countries are no more successful in punishing FGM offences than are countries who try to do so under more general criminal law provisions.

The bill includes a proposal to increase the level of punishment by increasing the length of sentences. Will that have an impact?

It is important to send out a signal that the practice is wrong. We need to be clear that the practice constitutes torture and that it will not be countenanced in Scotland. The bill sends out that signal. Although the difficulty of bringing a prosecution under the bill is a factor, the most important factor is the deterrent effect that the bill will have.

From the material on the bill that I downloaded from the internet, I can see that the intention is not to increase the number of court cases but to protect girls from being victimised. I agree with Rosemary Burnett that the bill sends out an important signal. It should act as the basis for further action and activity by women's groups, public health authorities and so on.

I have a follow-up question. I presume that the study document of which I have a copy is the report to which you referred. France is the one country that stands out in the report as having had some success with prosecutions. Do you know how that was achieved in France?

From the WHO perspective, and given that we are not a legal agency, I am unable to comment. I am happy to hand over the document to the committee for further reading. The committee could get in touch with the contacts in the report—some contacts are given for France, for example—and find out how they went about it.

Thank you; that is helpful.

In its submission to the Scottish Executive, Glasgow City Council mentioned the pressure on African women who live in Glasgow to send their daughters abroad to have FGM carried out. What difference will the bill make to those women?

I return to the point that panel members have mentioned in our contributions this morning, which is that the bill gives an important lead in flagging up the legal position in Scotland. If it also provides councils with the impetus to work more closely with communities on the issue, it will be a productive step forward in banning the practice of FGM in communities. Again, I agree that the bill sends out a clear signal and that that needs to be backed up by some good work in communities.

In common with the evidence from previous witnesses, panel members have talked a lot about education and how the debate on that subject has to go hand in hand with the debate on the bill. All committee members are supportive of that suggestion and are aware of the reasons that lie behind it. However, how do we publicise the issue to relevant communities in Scotland? How do we reach those communities and let them know about the change in the law so that people know that they are committing a punishable offence if they send a child abroad to undergo the procedure? Panel members have stressed the importance of getting the message out to communities, but what is the best way in which to reach them?

I spoke to one of our community development workers yesterday on the subject. We have a network of groups across Glasgow, including women's groups, groups from different nationalities and local area groups, some of which come together already. Therefore, we can access the networks that exist through us and others who work with groups in Glasgow. For example, Glasgow City Council also knows where the asylum seekers are and which countries they come from.

In the past, we have managed to send out letters to individuals in their own language. For example, we have sent letters to every household in an area, inviting people to come to specific meetings. There are fundamental things that we could do in that respect. We have also discussed whether information on the subject should be put into the welcome pack that people receive when they arrive in Scotland. Instead of producing lots of leaflets and leaving them in the places that people might go to—which we can do as well—we can communicate directly with people. Given that we are not talking about hundreds of thousands of people or about doing things in loads of different languages, we can identify the people whom we need to reach and their language.

I am aware that, when we produce material in different languages, it should be produced not only in written form but in tape and video format. That would allow material to be shown to groups, for example.

Given that the WHO has some experience in the field of health promotion, we know about how to reach communities and convey messages to them. One of the lessons that we have learned in the context of FGM from our experience in European as well as African countries is that the message is more effective if it is integrated in strategies for sexual and reproductive health or child and adolescent health. Instead of focusing only on FGM, it is more effective for an integrated approach to be taken, as the subject of FGM can be integrated into a broader package.

A woman from an ethnic minority community who is living in a European region could have a variety of health needs: she might need to attend sexual health, reproductive health or antenatal clinics. Ample opportunities exist for an issue such as FGM to be addressed in such a context without simply confronting women with information about a special service only for FGM. The lesson that we have learned is to take an integrated approach.

The WHO has collaborating centres in the field of women's health and gender mainstreaming, one of which is at the University of Glasgow. If required, the centre could support any further work that the committee might undertake on identifying appropriate measures. The committee is about to hear evidence from Comfort Momoh that will include information on the African well woman clinic in London. She can tell the committee about her experience of good practice in reaching ethnic minority women and girls.

Finally, how should the information on good practice be made available to the services and professionals who deal with communities in Scotland that are affected by FGM?

Such information should be incorporated in training for gynaecologists and other health professionals who work with women. The subject should also form part of continuing professional development for doctors, as it is an important element of delivering women who have had FGM practised on them. I know that at a previous evidence session the committee discussed what impact the legislation would have in the circumstances of a doctor being asked to reinfibulate a woman who had just delivered. That is part of the training that would need to be given to doctors.

We have been talking a lot about girls and women, but Save the Children's experience is that it is also important that boys and men are able to access health and information. Working with health professionals in the integrated way that Inge Baumgarten mentioned and getting information to male members of communities is important as well.

There is lots of community pressure.

I have three points to make quickly so I do not forget them. It is important to involve men rather than focusing only on women and girls. That is the lesson that we have learned. In the end women always say, "We do it for the men." We have to convince community leaders and fathers and ensure that we do not forget them.

The WHO has a clear policy that no medical personnel at any level should carry out reinfibulation. From a UN-agency point of view, reinfibulation should not be supported in any country that is aiming to end FGM.

I wanted to answer Marilyn Livingstone's question, but I have forgotten it.

I asked how we should disseminate information to services and professionals who deal with affected communities in Scotland.

The WHO has produced three brochures that are aimed specifically at midwives and nurses. One is a teacher training manual, the second is a student manual and the third contains policy guidelines for nurses and midwives and information on international human rights instruments relating particularly to the right to health. Those three important manuals, which can be downloaded, have been produced in consultation with people in African and European countries. The WHO is more than happy to support you in educating medical students, midwives and nurses and in providing on-going in-service training and support.

My first question is for Susan Elsley of Save the Children, but other witnesses can comment if they wish. The Save the Children submission refers to article 12 of the United Nations Convention on the Rights of the Child, which states that it is a child's right to express an opinion in matters affecting them and to have that opinion heard. The submission adds that the provision of appropriate information and education is essential. What action would you ask of the Scottish Executive in that regard?

In relation to article 12?

Yes.

Article 12 is one of many articles in the convention; other articles also apply to children and young people in relation to FGM, including the right to protection. On article 12, our experience, and my colleagues' international experience in particular, is that girls who experience FGM often do not have their views taken into account. They do not know what is going to happen to them and they do not have access to information. We are saying clearly that it needs to be seen as essential that young girls have the opportunity to express their views and have them taken into account.

I have brought along a piece of research, which I have not forwarded to the committee, called "Rights of Passage: Harmful cultural practices and children's rights", which contains the views of girls who have experienced female genital mutilation and describes their shock and horror because they had no idea what they were about to undergo. The issue is highly sensitive and we have raised the complex issues of working closely with communities and young people on their sexual health, to which article 12 is relevant.

We should see the legislation as the apex of the pyramid; it should be part of an integrated strategy to protect girls and young women from harmful cultural practices. It will not work in isolation but will be part of an integrated approach from the Scottish Executive.

It has been interesting to hear from Inge Baumgarten how much information is available. From a health point of view, do you think that we have enough people in Scotland with the experience to carry out the type of work that is required to raise awareness and be involved with the women concerned?

I am not sure whether I am in a position to judge what expertise you have in this country. My impression is that a lot of groups here are active on the issue and there is a lot of experience at UK level. Support from the WHO or other active and experienced agencies would make it easier for you to develop your own strategy that could be adapted to your needs and qualifications and the setting here.

Inge Baumgarten is right that there is loads of expertise in Scotland, although the practice is a relatively new thing for us to deal with, particularly in relation to the numbers. As a Glasgow resident, I know that there have been big changes in relation to the new communities arriving in Scotland that were not here in significant numbers before—apart from students at universities. Previous witnesses gave you lots of information about experiences in England, which I am sure can be shared. There is enough knowledge about community development and medical knowledge; we just have to put it all together, which is not impossible.

My final question is about information gathering. The policy memorandum states:

"There is no evidence that this practice is widespread within communities in Scotland, although evidence is hard to establish because FGM is a private practice".

It is clearly not easy to gather information on FGM in Scotland. How should the Executive approach that?

The WHO has a lot of experience in that field, not in Scotland but in African countries where female genital mutilation is a concern. There are various possible approaches. One is through KAB studies—studies into the knowledge, attitude and behaviour of people—which can be carried out with students or women for example. We interview them about what they think of the practice, why they are undertaking it, whether they intend to have their youngest daughter cut and their plans for the future. In that way we are able to inquire about people's attitudes and the knowledge that they have about the negative impacts of female genital mutilation. If the outcome of the survey is that they do not know about the negative impacts, we can say, "Okay, we need more health education messages at community level." If we find that they still support the practice, we take what we call a behaviour-change approach, which involves dialogue and finding out why they do the practice and whether it is possible to change their cultural practices. If that is possible, the question then is how they want the strategies to be designed.

The other opportunity, of course, which I am sure we will hear about later from Comfort Momoh, arises in antenatal clinics, in which gynaecological examinations can ascertain what type of FGM has been conducted on a woman. Therefore, it is possible to integrate our survey with the standard procedure of clinical examinations in antenatal clinics, which can inform us about the number of women from particular communities who are affected by FGM. There is much discussion in France about whether girls should be gynaecologically examined in their school medical check-ups. No agreement has been reached on that yet, as far as I am aware.

There are examples, therefore, that make it possible for you, in your Scottish setting, to decide what is appropriate in your country and how you want to go about making more information available. From a public health point of view, if you want to design strategies, you must have more information to be able to design them appropriately.

I have listened intently to the evidence and I want to ask about two particular issues regarding penalties, which I think were referred to earlier. I believe that you all agree that it is acceptable that the maximum penalty should be raised from five to 14 years' imprisonment. However, I am interested in Amnesty International's written submission and its reference to situations in which parents or relatives do not know that FGM is going to be carried out when a child is taken abroad. Does Rosemary Burnett think that the penalties should apply to such a situation, which Amnesty regards as a crime? Does Amnesty believe that the penalties should be wider than just raising the maximum possible term of imprisonment from five to 14 years and that they should deal with what Amnesty regards as incitement and coercion?

I do not know that I am qualified to say what the penalties should be. We are merely trying to point out that it would be possible to put in place an offence of incitement and that such an offence should be included in the bill. The bill should say not only that it is wrong to practise FGM, but that it is wrong to encourage and incite others to practise it. I remember that the committee received information from some Somali women who said that they believed that the practice of FGM was tied up with their religion, and you can imagine that there might encouragement by religious leaders to continue the practice. If it were an offence to incite the practice, we might not reach the stage at which prosecution was necessary. The possibility of prosecution might act as a disincentive to any incitement.

I understand your point, which is that although you would like a law against incitement, you would rather speak to people and try to stop the incitement or encouragement of FGM and its practice without parents' knowledge. You mentioned religious issues, which leads me on to the exemption for mental health reasons and the age of consent. I have read what the panels' written submissions, including Amnesty's, say on exemptions. Do you think that the proposed exemption for reasons of physical or mental health is reasonable?

As we have heard, many mothers are under a great deal of pressure to carry out the operation on their children. They could cite mental health as a reason for ensuring that the practice was carried out, or the children themselves could be encouraged or incited to claim that. We need to be very careful that the bill's wording ensures that mental health actually means mental health and not such pressure.

I do not have a legal background, so I am not sure that I understand the bill perfectly. However, I have a couple of concerns about it. The first relates to section 1(2), which states that

"an approved person who performs … a surgical operation on another person who is in any stage of labour or has just given birth, for purposes connected with the labour or birth"

should be excluded from punishment. It is likely that the clitoris is included in that provision, but I am not aware of any surgical operation in relation to labour and delivery that would justify the excision of the clitoris.

My other concern is about the mental health aspect and whether the bill would offer a loophole that would, for example, allow a woman to get a certificate from a doctor that stated that, for mental health reasons, she would have to have FGM. We do not have any evidence that the excision of the clitoris, the labia minor or whatever has any benefits for a woman's mental health. Perhaps it has such benefits for the mental health of a man, such as the woman's husband, but it certainly does not for the mental health of the woman or girl concerned.

I am also concerned about another aspect; I am not sure whether you have covered it, but you might intend to discuss it later. In Africa, there is an increasing problem with what we call medicalisation, when skilled personnel—whether doctors, midwives or nurses—offer services and perform FGM. That happens partly because the education strategies that have been conducted over past decades focused only on the health aspects of FGM. Those strategies said that FGM was bad for children's health because it is conducted in very unhygienic settings, with unclean knives and so on. People decided that they did not want to expose their daughters to unhygienic conditions and have them fall ill, so they went to health care providers and had FGM done with anaesthesia and disinfectant. Therefore, there are now health care providers—paramedical staff—who conduct FGM.

Section 3(2) of the bill states:

"No offence under section 1 is committed by a person who … in relation to the operation, provides services corresponding to those of an approved person."

Irrespective of the definition of "approved person", somebody from an African country could say that a medical doctor conducted the operation. However, from our international point of view, FGM would still be a human rights violation even if a doctor conducted it. Those are my concerns about the bill, not only as a public health person but, from the legal point of view, as a lay person.

The bill would impose an age limit of 18 for the offence of FGM, which is the age limit that most other countries have imposed. If a qualified medical person performed FGM on a girl under 18, that would be wrong under our bill.

To return to the mental health issue, do the panel members have concerns regarding young girls being pressurised by their communities into having FGM? Is there a danger that a girl herself could say that, because of pressure from her community, it would cause her mental health problems if she did not get FGM carried out?

In many communities, FGM is regarded as a rite of passage and a girl is not regarded as a woman until she has had the operation. It is probably fairly easy to extrapolate from that that if a girl is regarded by her community as a girl, even though she is 20, because she has not had the operation done, it is not impossible that that could lead to feelings of low self-esteem and mental health concerns. As I said, the mental health exemption is a loophole in the bill as drafted.

I have a point that is not totally connected with Sandra White's question, but which follows on from Rosemary Burnett's point about the rite of passage. It must be strongly acknowledged that FGM plays a role in girls' rites of passage in their communities, which are about giving them access to rights as young women. Our colleagues at Save the Children Canada have explored alternative rites of passage and different ways of looking at moving to young adulthood in the communities with which they work. The communities accepted those new rites of passage, which became an alternative to FGM.

My final question is on the age limit. In most countries that have laws against FGM, the age limit is 18, but you have questioned whether that will suffice. An issue arises in relation to consenting adults having cosmetic surgery. Should the law in Scotland contain an age limit in relation to female genital mutilation? Should cosmetic surgical procedures be regarded as a separate issue? When we first looked at the bill, we talked about the distinction between cosmetic surgery and female genital mutilation, which is entirely different. There are two questions. Should there be a cut-off point at 18 years of age? Also, where should we go on the cosmetic surgery issue, which could be used as an excuse for FGM?

We are talking about harmful cultural practices that are normally done to girls. In international law, when a girl reaches 18, she is no longer a girl and she has the right to decide what she wants to do with her own body. That is the international legal take on the matter.

The WHO says that the practice should not be supported in any way—that is its clear position. I am aware that in some countries, such as Ethiopia, there is a wide range of practices in relation to female genital mutilation. It might be done in one ethnic group at the age of 1 month, in another group at seven to nine years of age and in a third group after marriage and prior to delivery. There might be women who are older than 18 who are put under a lot of pressure by their mother-in-law or their family to have the practice conducted close to delivery so that the family is satisfied that things are being done according to their cultural values. There are cases of FGM in women who are over 18 years of age, but it is not easy for the law to cover everything.

The WHO does not have a stance on surgical operations yet. I think that the issue could be raised by the UK's health delegation to the WHO's regional committee meeting in August. The UK could ask the WHO to consider the issue and to hold a consultative meeting on what it understands by FGM. At the moment, with UNFPA and UNICEF, we are in the process of rethinking and reformulating the type I to IV definitions of FGM and it might be the right time to consider whether vaginal surgeries fall under the definition of female genital mutilation, which is an issue that the Scottish Parliament and other organisations have identified.

My first question is on costs to local authorities. It is anticipated that the bill will not create any additional costs for local authorities' social work systems, but we are all agreed that, following enactment of the legislation, there will be a need for education and guidance on matters that include but are not limited to child protection measures. What is your view on the cost implications of the production and provision of such education and guidance? Do you envisage that local authorities will incur any other costs in relation to the legislation?

Obviously, there will be some costs for producing materials and bringing in expertise, as has been mentioned, but I do not think that they need be immense. We are not saying that the whole population of Scotland needs to be briefed immediately on all the details. At the moment, the requirement is focused in Glasgow, although a little bit of work needs to be done outside Glasgow.

I do not have a figure for how much it will cost to build certain aspects into the basic training of doctors, nurses, gynaecologists and so on, if that is what members are looking for, but clearly there will be some additional costs. However, it would make sense for such measures to be part of a wider, integrated, public health programme. After all, broader issues such as the integration of new communities need to be addressed, and it should not be hugely expensive to make them part of a package. Additional translation of material might be required, but we and the Executive already carry out much of that work. We would not be talking about vast amounts of money.

I support those comments. It is unrealistic to assume that we will be able to do what needs to be done without any additional funding. For example, if we want to know more about the prevalence of the practice in Scotland, we will need to carry out research, which will require money. If we want to train people, we will need money. An integrated approach that brings together representatives from the various sectors will need time and resources to be allocated to it to ensure that people can attend meetings, for example. Producing material will also require funding.

The WHO regularly holds consultations with member states on sexual and reproductive health issues. It might be interesting to hold a consultative meeting on the sexual and reproductive health needs of immigrant women in Europe to harmonise legal, community and health sector strategies. The committee could certainly make its interest known and ask formally for some support in that area.

I thank the witnesses for their helpful evidence this morning. I know that Inge Baumgarten in particular has travelled some distance to be here.

I suspend the meeting for five minutes.

Meeting suspended.

On resuming—

We continue our evidence gathering on the Prohibition of Female Genital Mutilation (Scotland) Bill. Our second panel of witnesses is now seated and I thank them for coming along. They are Dr Pamela Buck and Comfort Momoh. I understand that Comfort was up at 4 o'clock this morning, so a big thank you for getting here. Your evidence is important to us. If you wish, will you both outline your views before we go to questions?

As you said, I had to wake up at 4 o'clock to be here, which is very early, but I am pleased that I am here. Thank you for inviting me to provide evidence. Before I begin, may I say that the building is lovely? It is great and unique.

As you said, my name is Comfort, and I am an FGM specialist midwife and public health specialist based at Guy's and St Thomas' hospitals. I chair an organisation called Black Women's Health and Family Support, which enables me to work in the community, and I am also the vice-president of the European network on FGM, of which I am sure you are aware.

I know that members are aware of FGM and its complications. FGM has no medical or health benefits. It is irreversible, and its effects last a long time. I know that because I work closely with women and children with FGM. FGM denies a child her fundamental human right, hence it is a cause for concern, and has resulted in working together to safeguard children within the UK. FGM is commonly performed by traditional birth attendants, and can be performed by anybody within the community, as well as by professionals.

It is important that the law is revisited. I am happy to take questions and to comment on my experience.

I reiterate what Comfort said: there is no medical foundation for FGM. It is condemned by medical practitioners in this country, and in particular by the Royal College of Obstetricians and Gynaecologists, whose representative I am today. Our college is currently reviewing its curriculum and syllabus, such that FGM will have an even higher profile than it has had in the past. Female genital mutilation is covered in our training, as is the current legislation in England and Wales. The forthcoming Scottish act will be incorporated, because we train Scottish obstetricians as well.

I will start by asking about terminology. What is your view on the change of terminology in the law, from the use of "circumcision" to "mutilation"? Is it important to make that change? How is it likely to affect communities that practise FGM?

Changing the terminology is important. Some people will argue against it. However, you have heard from the WHO about its stance on female genital mutilation. From my experience of working with the community and as a professional, I know that it is important to call a spade a spade.

Many activists have been campaigning for many years and have been using the softer phrase. We have gone into the community and have tried to sensitise it for more than 25 years. It is about time that we changed the terminology. When we are with the community, we have to use the terminology that people are comfortable with. It is important to acknowledge that. We cannot go into the community and say, "Have you been mutilated?", because the community sees FGM as an act of love; it does not see it in the way that western communities see it—as barbaric and a human rights issue. The committee needs to understand that.

For people's attitudes to be changed, they need to understand why FGM is performed in the first place, so the proper terminology should be used. I am sure that the WHO rightly mentioned that it is called "sunna" in Somali languages, and many other languages use the term "infibulation", while some people feel more comfortable using the term "circumcision". However, it is important that the professional uses the term "female genital mutilation", so that people are aware of the extent of damage to the vulva. From my experience of running conferences and seminars, I am sad to say that only about 70 per cent of professionals in the UK are aware of FGM even if they are not aware of the law. If we so-called professionals are not aware, how do we expect the community to be aware of FGM?

I agree; it should be called female genital mutilation and not circumcision. There is one variety of FGM that is comparable to male circumcision where only the prepuce of the clitoris is removed—that would be the nearest equivalent. However, those patients are in the minority in this country. The majority of patients in this country have type III infibulation, which is far more mutilating than male circumcision and has more profound health impacts, so it is not appropriate to call it circumcision. It is a mutilating procedure and it should be called that.

I agree that when we are talking to communities and individual patients, we need to be a little bit more sensitive. The majority of the patients that I see are Somali and they call it "cutting". In the group that I meet, we ask, "Have you been cut?" and they know exactly what is meant.

Will the new law protect girls and women from FGM and will it provide more protection than the existing law does?

Yes, but only when the law is combined with education. It will happen not just because of the law, but because of everything the law will bring with it.

That is why we are taking the evidence that we are taking; we want to raise the issue to encourage people to consider their role in promoting education.

My answer to your question is yes as well. The law will be used as a deterrent for the practising community. Many women who come to the clinic say that they are against FGM and do not want to circumcise their daughters, but they get lots of pressure from back home. Those women will be able to fall back on the law. However, as Pamela Buck said, we need to have other strategies. The act alone will not help; we need to educate and raise awareness, and we need to collaborate and work with the community.

In its submission, Amnesty International suggested including in the bill two additional offences—attempted FGM and incitement to FGM. Do you have any views on including those two additional offences in the bill? I am thinking particularly of incitement.

I am not a legal person, but if a parent or a grandparent takes a child to Somalia, for example, with the intention of having FGM performed on that child—even though they do not perform it—and the child comes back mutilated, and if the parent or grandparent knew about it or if it was the purpose of the visit, then that parent or grandparent should be punished as well as the so-called surgeon.

As long as the community is well informed, people should take responsibility for their actions.

The explanatory notes to the bill say that there have been no prosecutions under the existing law and that the Scottish Executive does not expect there to be many prosecutions under the new law. Do you have views on the lack of prosecutions?

It is a disgrace. There have been successful prosecutions in France, which is the only country that I know about. I think that there have been some attempts at prosecution in England and Wales, but they have fallen foul of there being a lack of evidence because the child and/or the parent or guardian needs to stand up in court and name a certain man or woman and say what they did. That is the point at which the attempts to secure prosecutions fall flat.

It is easy to say that, because there are no prosecutions, genital mutilation is not happening, but that is not the case; we know that it is happening.

I believe that it is happening.

We know that it is happening. The law in the United Kingdom is not being taken seriously. Last year, I was part of a team that was working on a case in Sheffield but, because of a lack of evidence, among other things, nothing was done. The police and enforcement teams were unable to do anything. People in the UK have not been taking the matter seriously.

Yesterday, a policeman from Scotland Yard came to see me about some cases that involve a bogus doctor. He wanted my advice on how to tread sensitively around the area, which seems to be the right way to go about things. Not until we start working with the police, child protection teams and others in the community to raise awareness of the law will we be able to prosecute anybody.

I assume that there was a considerable amount of publicity around the case in Sheffield. Did that have a beneficial effect in the community? What was the response?

The media tend to blow things out of proportion, but the communities were made aware of the situation because of that. However, because of the sensitivity of the issue, no one was willing to come forward as a witness.

That is interesting.

Last week, we took evidence from Glasgow City Council, which said that it believes that there is pressure on African women who live in Glasgow to send their daughters abroad for the purposes of undergoing female genital mutilation. What difference would the legislation make to those women? If it will make a difference, how should we get out information about the law?

As I said, the law on its own will not put an end to FGM; we will need to use other strategies. However, a deterrent is lacking. If the bill becomes law, a woman will know that she is in a country that has a law and that the situation is not like the situation back home, where there is no law or where nobody abides by the law. That will be a good step.

To raise the community's awareness, the community must be involved. I know that the committee has involved the community in the consultation process, but more needs to be known about the prevalence of the practice in Scotland. Proper data and knowledge of where the women are from are required. Are they from Ghana or Somalia? That information will help in working with them. You need to find out what languages they speak as well. The mistake that was made in respect of the Prohibition of Female Circumcision Act 1985 was that the communities were not aware of it because it was not translated into different languages. I have been working closely with Black Women's Health and Family Support and, together, we have been able to translate the Female Genital Mutilation Act 2003 into different languages. You need to be able to give the translations to all relevant organisations and communities in Scotland.

Somebody on the first panel talked about producing packs for asylum seekers. That would be a useful way of ensuring that people are aware of the laws—not only those relating to FGM—when they get to this country. It would also be useful to disseminate information during seminars, conferences and women's days, such as the one that we have on 6 February, which is zero tolerance day for FGM. One could use such days as opportunities to disseminate information to the community, because most organisations hold events on those days.

An increasing number of women from communities do not want to have their children taken back home for the FGM procedure. They would be able to use the legislation as an excuse because they could say, "In times gone by, I would have sent my daughter back to you, grandma or uncle, but now, unfortunately, a law prevents me from doing so." The law would enable them to present the situation as not being their fault, which women have told me they would like to be able to do. That is another benefit.

Dr Buck, you talked about the training for gynaecologists and paediatricians that is being rolled out and you mentioned that Scottish professionals were involved in that. How would we be able to roll out such training to other professionals who will be working with those communities? Do you have any examples of best practice that you can share with us?

There is information in the submission by the Royal College of Obstetricians and Gynaecologists that I sent to Roy McMahon in advance of this meeting. Furthermore, parts of the WHO manuals and technical reports are public health oriented, although parts of them are designed more for use in Africa than in cities in Scotland, which have a relatively small number of people to whom they would apply. In London, there is an enormous number of such women; there are also large numbers in Birmingham and Manchester, which are the second and third largest English cities. From what one of the previous witnesses said this morning, I understand that there is a large number in Glasgow as well.

General practitioners need to know about the subject, as do health visitors, midwives and nurses—the latter three professions being the first port of call because they are the ones who get involved with families. The next port of call is the general practitioners. Most GPs' training will involve some time in obstetrics and gynaecology. Nearly all GPs now get a family planning certificate, within which context FGM is mentioned, although not at any great length. As time goes on and more GPs do such diplomas, we will be able to get through to more of them.

It is likely that GPs of the future will not spend a formal period of six months doing obstetrics and gynaecology in a hospital but will have training that is more oriented towards women's health in a global sense. The Department of Health is introducing a foundation programme for GPs, which will involve a post-registration year made up of four-month modules. We are trying to introduce women's health modules as part of that. They are being piloted from August 2005 and will come into force officially in August 2006. Of course, however, not everyone will do a women's health module.

In general, the subject should form part of the curriculum for all professionals if we are looking to raise awareness of FGM and to put an end to it. At Guy's and St Thomas' hospitals, where I work, we have effectively incorporated FGM into the orientation pack. Whenever new midwives, doctors or senior house officers start, they have to see me and I talk to them about the clinic and about how important it is that they are aware of FGM. I tell them of the importance of identifying FGM during a woman's pregnancy, especially in labour. I suggest that that approach be adopted here, too.

It is clear that work is going on among health professionals, but what about other professionals working in the community? Is there a lot going on in the communities where you work for other professionals who might come into contact with children in particular?

I work with everybody, but I alone cannot be everywhere at the same time. I do a lot of work with teachers, health visitors and child protection teams. Tomorrow, I have a seminar with my local GPs from the Stockwell practice, some of whom are not aware of FGM—I will have a two-hour talk with them, with a video and question time. I do a lot of training to raise awareness and to educate professionals. We need to train more people to train others—we need training for trainers. We have in-house training and seminars for medical students and other professionals and I do a lot of work with teachers and school nurses.

The policy memorandum says:

"There is no evidence that this practice is widespread within communities in Scotland".

However, we know that it is going on and we have to put a stop to it. One of our problems is that it is not easy to collect information on the subject in the community. What is the best way for the Scottish Executive to go about gathering information from communities in order to get enough evidence of the practice and to put a stop to it?

The Executive would need to go to the communities. As a member of the first panel said this morning, in Glasgow there is a network of contacts with various ethnic groups and country groups in different situations. That is where you need to start. I can speak only about Manchester, but our Somali women have a group called Haween, which is the Somali for "women". The group got some funding from Manchester City Council and it holds a monthly luncheon club. The women do the cooking and they invite speakers from the medical profession, the Benefits Agency and child welfare agencies, for example. The group chooses whom it invites to speak on a topic. I have been to speak to Haween twice, on antenatal care and FGM.

In the hospital setting, we have link workers, who act as translators. They do more than that, however; they are also cultural setters of scenes. They have contacts with the language groups that they serve. We can get out into the community through those various groups.

It is important to work with the community. I see a lot of Somali women and they form an oral community. It is important to inform them about your work at the beginning—to introduce yourself, tell them what you are doing and involve them. When I started the clinic, I had to go to mosques, look for women's organisations and find out what women's views were. You need to do some research, as the woman from the WHO said earlier, and you need to look into people's attitudes. You need to work with people and get them involved at the start. If you do not do that, the word will go around: people in those communities will say, "We do not know what the Government is doing; the law is supposed to protect our children and yet nobody has told us about this new act." Because those communities are oral communities, word will get around very quickly. It is important that communities are involved in the legislation.

We have heard evidence from other groups about the medical effects that can result from FGM. What is the panel's view on that subject?

The initial problems are caused at the time of the operation: some girls die of shock because the operation is done without anaesthesia. Other immediate health effects include shock, haemorrhage and infection. Traditionally, when the operation is carried out abroad, it is done neither with the use of sterile instruments nor in an operating theatre. As the committee heard this morning, the increasing tendency, especially in southern Egypt, Somalia and Sudan, is to medicalise FGM. The same procedure is carried out but with sterile scalpels and surgical techniques and not with the blunt knives that are used traditionally, shall we say.

In this country, we mainly see the longer-term effects: the physical health problems and emotional and psychosexual problems, including difficulties with relationships and sexual intercourse. Those problems are common. However, because of the sensitivity of the issue and its taboo nature, the effects on women and girls do not come to the fore. Once we have got to know a patient and we are sitting down with them and having a chat, they will tell us about the difficulties, but they will not go to a GP and say, "I have a psychosexual problem; I am not reaching orgasm," or whatever—people just do not do that.

The facilities that we have in Scotland and in England and Wales are not very good for dealing with psychosexual problems or with people from other cultures. There are subtleties of language and of the cultural aspects of relationships and, in general terms, they are not well dealt with. There are also physical problems: about 5 per cent of FGM cases present with retention cysts where the mutilation has been done; others have problems passing urine or a problem with acute retention of urine.

We see women when they want to marry, prior to which Comfort Momoh and I open up the infibulation. We do not have to do that in all cases: some women do not need opening up because the infibulation has broken down to a degree that allows penetration to take place. We also see them for opening either prior to childbirth or in the late stages of labour when we can see the baby's head. That said, it is better to open up the infibulation earlier in the pregnancy.

Pregnancy can bring flashbacks and memories, which can cause anxiety for the expectant mother. It is important that professionals are aware of the issue. Some women need a lot of support. Their pregnancy may be the first time that anyone has raised the issue of FGM. In most cases, given that the women had it done when they were aged five or six and that the subject is taboo, nobody has talked to them about it. Some of the women are extremely anxious during their pregnancy and labour.

I have a short follow-up question about the long-term consequences of FGM, which is an issue that Marilyn Livingstone raised earlier. Are we doing enough to educate doctors, nurses and community health workers in this country about the long-term effects of FGM?

Although we are doing something, we are not doing enough. Before I began working at Guy's and St Thomas' hospitals about eight years ago, I had done a lot of work around FGM and, since then, I have been involved in many conferences locally, nationally and internationally. Whenever I go to big conferences, especially here in the UK, I do an exercise to find out how many of the, say, 100 participants are aware of the legal issues or of how to care for women who have experienced FGM. It is sad that only a handful will raise their hands to say that they are aware of the matter, because I have been doing lots of training and other people in the community and other professionals have been raising awareness. We are not doing enough; it is unfortunate that we are not reaching the people whom we are supposed to be reaching. The Government and policy makers need to look into that and provide funding for training and for raising awareness in the community.

My question is on penalties. The new law will increase the possible term of imprisonment for FGM from five to 14 years. Do you have a view on that change? Might it help the issue to be taken more seriously?

That is an indication of Parliament's view. Increasing the sentence from five to 14 years sends the message that Parliament sees FGM as a serious offence that will incur a sentence comparable to that for manslaughter. That is a good idea.

I, too, think that it is a good idea, because it sends a strong message. It shows that the Parliament has strong views about putting an end to FGM and protecting children. However, at the same time, we need to educate people and raise awareness.

I will deal with the proposed exceptions and the age of consent. Do you think that the proposed exception for reasons of physical or mental health is reasonable? We have read in submissions that there are concerns about the mental health exception.

The only potential argument for the exception for mental health reasons is that, if a young woman has been denied FGM, she might be ostracised in her community; she might not be deemed marriageable should she go back home—although I do not think that that would be the case in Scotland or England—and would therefore be socially outcast and suffer emotional and mental trauma. However, the physical and mental disadvantages of FGM greatly outweigh that. It is rather perverse, but I have heard it argued that FGM has to be carried out because otherwise the girl in question will not be deemed marriageable and will be socially outcast in her village or town.

We should look into the exception carefully, because it could be open to interpretation.

Some countries with laws against FGM have an age limit of 18, which allows for consenting adults to have the relevant procedure carried out. Do you think that we should have such an age limit in our law?

No. The law should cover all women and girls.

Do you have any idea how common such cosmetic procedure is in the UK?

No. I do not have any information on that.

Cosmetic procedures are common in London. I know that people go to Harley Street to have their labia reduced. People also go to Harley Street to have their perineum tightened—for example, following three or four deliveries.

Do you think that such practices are increasing?

Yes, but we cannot give you any figures. Such procedures are more common in London than elsewhere, but they are becoming fashionable. As a gynaecologist, I think that it is perfectly reasonable for someone whose perineum is slack as a consequence of their having had three or four children to want to have it tightened to improve sexual function.

I would have thought that that was more a medical than a cosmetic reason.

That is right.

I have problems with some procedures to reduce the labia. I do some such procedures on the national health service—usually on girls who are in their teens or early twenties, who have gross elongation of the labia. Their labia are so big that they catch on clothes and they dare not wear a bathing suit. However, I get requests from people who merely perceive that their labia are big. If I think that the labia look normal, I will not carry out the procedure. Some of those people may go to the private sector; as I do not practise in the private sector at all, I do not know whether that is the case.

The question is about drawing the line between medical and cosmetic reasons.

That is right. Some people would argue that if an adult woman wants smaller labia—labia that she thinks are prettier—that is no different from wanting a face-lift, an operation to have her nose changed or a breast augmentation or reduction. Those are all image things. The feature that a person wants to change might not be abnormal. If someone has been born with a crooked nose, for example, they might not find it acceptable, even though it is just a variation on what is normal. We would not argue if they wanted to have their nose straightened—as long as they were an adult.

That is where informed choice and consent come in.

At conferences, many African women ask me why what the WHO defines as type IV FGM, which includes what we have been talking about, is not seen as mutilation by the western community when the procedures that African women perform are seen as mutilation. Some will say that the western community is practising double standards.

The issue is informed choice and consent. Someone who has reached the age of consent can get their breasts inflated or do anything that they want to their body. As long as they are aware of the consequences, they have the right to do that. However, when it comes to FGM, it is vital to consider the position of children.

The bill does not contain an age limit. Given that it is not an objective of the bill to outlaw such procedures, should the bill make specific provision to allow elective cosmetic surgery to be carried out?

I do not think that we can say to adults that they cannot have cosmetic surgery done on the vulva when they can have it done on the breast.

How do you feel about the fact that the bill will probably outlaw a fair amount of cosmetic surgery?

Personally, I do not have a problem with that, but I am not in private practice.

I do not have a problem with it, either.

There are some individuals who genuinely have hypertrophied labia, which are a nuisance because of rubbing or friction, or because they catch on clothing. I have no problem about dealing with that, but I do not do procedures on people who have normal labia but who want them to be smaller or slimmer, and I cannot argue very strongly for those who perform such operations.

In your book, Comfort, you refer to WHO figures from 1997; the other figures are from 1993 and 1998. I take on board your point about straw polls and the lack of awareness, but do you get the feeling from discussions—particularly the work of Amnesty International—that you are beginning to see a reduction in the incidence of FGM here and abroad?

Yes, definitely, among the second generation. I was in Somalia about three years ago to research current attitudes. I chose Somaliland because 92 per cent of the women whom I see are from Somalia and I felt that it was important for me to go there and meet the people to find out what their attitudes were. It was interesting to note that, although attitudes are changing in the cities, they are still the same in rural areas and villages.

The bill does not anticipate any additional costs to the local authority social work system. However, given the likely need for education and guidance following enactment of the bill—not only in relation to child protection measures—what is your view of the potential cost implications of the production of guidance and the provision of education?

Why does the bill not anticipate any costs? With any attitude change, you need to think about the cost. You need to provide funds for the community and to give support for people who will raise awareness and campaign. There should be costs, because you need to raise awareness and provide leaflets and other tools and resources. There will be cost implications.

So you challenge the explanatory notes. That is helpful.

The impact of costs could be minimised. FGM education should be carried out in the context of reproductive health education. With such a package, it would be a question of introducing or strengthening the FGM component within the teaching material, perhaps when it is being reprinted, so that you do not need to scrap all your educational material and start again. That could be phased in, but somebody will have to write the material, somebody will have to translate it and somebody will have to devise and deliver the module on FGM in other health education packages. From colleagues, I have gained some idea of the community gynaecology services in Glasgow, which seem pretty well geared up to deliver.

You can also tap into other resources that are already available, instead of reinventing them, such as the WHO, us at Guy's and St Thomas', and other organisations. I am happy to come back to provide educational support to professionals or to raise awareness at any time. Feel free to call me.

We may well call you. Thank you for your evidence this morning. It has been very helpful.

Meeting suspended.

On resuming—