PURSUING AN END TO FGM
MEDICAL INDEPENDENT
5 FEBRUARY 2018
Ms Ifrah Ahmed is one of the world’s foremost campaigners against female genital mutilation, having started her activism as a teenager in Ireland. Catherine Reilly spoke to Ms Ahmed and Irish healthcare and policy professionals about a worldwide problem that is hitting home
In Mogadishu’s corridors of power, Ms Ifrah Ahmed became known as the “Irish woman”. As an advisor to Somalia’s federal government, the Somali-Irish citizen petitioned ministers to “break the silence” on female genital mutilation (FGM), which is highly prevalent in the east African country. Worldwide, over 200 million women and girls are survivors of FGM, Ms Ahmed among them.
FGM comprises all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. It is usually carried out by local women using basic items. It has no health benefits and many negative immediate and long-term consequences, according to the World Health Organisation (WHO).
The commonly-cited motivations for the practice are social traditions, control over female sexuality, marriageability and religion, although no faith obliges FGM. Somalia, at 98 per cent, leads the countries with the highest prevalence among girls and women aged 15-to-49. Moreover, the most brutal form of FGM — type 3, or infibulation — is the most common in Somalia (see panel below). There is no legislation prohibiting FGM in Somalia and the practice is so deep-rooted that activists face an uphill struggle to encourage change.
But this has not dissuaded Ms Ahmed. When it comes to winning friends and influencing people, she has written the textbook. “Every minister has two or three police guards at the door, and the minister can hear me fighting with them, because they don’t allow anybody to enter to him,” Ms Ahmed tells the Medical Independent (MI) of her time as a gender and human rights advisor. “For me, always when I go, I say to the police guards ‘hey listen, this government kick out every minister after three months, so he will disappear soon, so let me go and see him’. The minister would hear me and say, ‘hey, let her in’… ”
Shunned
In 2006, Ms Ahmed arrived in Ireland as a lone teenage asylum-seeker; she was granted refugee status and later citizenship. In 2008, still aged in her teens, she told the multicultural newspaper Metro Éireann that Somali women were coming “under pressure” to send their young Irish raised daughters to Somalia for FGM. Thereafter, she was shunned and threatened by elements of her community.
Her motivation was born from the pain and trauma of peers, who at times endured ignorance and shock in healthcare settings.
From her small flat in Drumcondra, Dublin, she co-ordinated a growing band of supporters, bringing the worlds of fashion and politics together for awareness events. Her efforts were influential in ensuring the introduction in 2012 of legislation specifically outlawing FGM and the act of removing girls or women from the State, or attempting to remove them, for FGM. Her work was the focus of an RTÉ Would You Believe documentary in 2013. She is now an independent activist with the Ifrah Foundation, an Irish-registered charity that she founded. Her vision is that a campaign focused on FGM eradication will acquire a profile similar to that surrounding HIV/AIDS.
There is “a real steely determination behind what she is doing”, remarks Prof Chris Fitzpatrick, Consultant Obstetrician and Gynaecologist at the Coombe Women and Infants Hospital, Dublin, Clinical Professor at the School of Medicine, University College Dublin and an advisor to the Ifrah Foundation. “I think the momentum that has been generated by the #MeToo campaign has added extra impetus in relation to the significance of FGM, because it puts it into a context of violation of women’s rights. The local connection where somebody came here as an asylum-seeker to actually get to a position where you can found a foundation and advocate at many different levels is a phenomenal example of female empowerment.”
It is estimated that 5,795 women and girls living in Ireland have undergone FGM in their native countries, according to African and migrant women’s network Akidwa. In 2015, an EU-funded report found that between 1-to-11 per cent of the almost 14,600 girls under the age of 18 in Ireland, whose parents originate from practising countries, could be at risk of FGM.
A major risk factor is the girl being brought to the parental country of origin, where family members may arrange for the practice to take place, stated the report. In focus groups held as part of this report, “anecdotal cases” emerged of girls being taken from Ireland to “countries of origin” by their parents for FGM. There were no specific scenarios of it being performed in Ireland. “Participants had met or heard of parents in the direct provision system who wanted to cut their daughters, but this appeared to be rare. According to the groups, if parents or families really wanted to practise FGM, they would travel to their country of origin and possibly not return to Ireland.”
The issue of girls potentially being sent abroad remains a concern, according to Ms Alwiye Xuseyn, Manager at Akidwa. In discussions with some immigrant communities, “it will come up that, yes, the practice will still continue because it is deep-rooted,” says Ms Xuseyn, “but we don’t have the proof”. On 1 February, a man and woman were sent forward for trial accused of the genital mutilation of their daughter in Dublin. The couple cannot be named for legal reasons and have not indicated how they will plead.
A Garda spokesperson told MI that it has developed a crime classification code for FGM. However, this offence was only created in the coding system last year and no figures will be available until the end of 2018, they said.
“The Garda National Protective Services Bureau are currently engaged in training and awareness education programmes and deliver training to front-line operational personnel twice yearly. The bureau also engages with a wide range of agencies and law enforcement in presenting on the crime of FGM at national seminars,” added the spokesperson. Tusla said it does not have a specific category for FGM in respect of referral data.
‘No basis in Islam’
While FGM affects people of different religions, some members of Muslim communities argue an Islamic context to the practice. Shaykh Umar Al-Qadri, a progressive Imam in Dublin, strongly disputes an Islamic basis.
“In my view and the view of most Muslims, this is a cultural practice; it has no basis in Islam and no basis in Islamic law, and it is of course harmful and should not be practised. It should be discouraged. There is a minority view among some Muslims that there are, for example, some narrations that would not make it an obligation but would recommend such a practice, however these narrations have been proven to be unreliable, unauthentic, so therefore the majority of opinion is that it is a practice that has nothing to do with Islam.
“We do not find it in the time of the Prophet Muhammad, we do not find authentic sources, and also anything that is harmful for the body, anything that is harmful for one’s physical body and psychologically harmful, will always become harmful in Islam and always be discouraged because we in Islam are not allowed torture or physically harm ourselves; it is very much discouraged.” In 14 years here, he has not had an enquiry about undertaking FGM.
“We have had discussions [about the issue]; there were people from Somalia and Sudan, some of them that were sharing their views during the discussions, but again it was made clear to them and they also understood that it is a cultural thing, which is perceived by some as religious, but it isn’t. “They weren’t enquiring for their children but during discussions on this issue, they brought up that it is practised among their communities, among some members of the communities back home. [We were] discussing that there was no religious backing of it and they agreed on it.”
However, Dr Ali Selim (PhD), a senior figure in the Islamic Cultural Centre, Clonskeagh, has a different view. Some years ago, he put on record that the Centre opposed the proposed ban under the Criminal Justice FGM Act. In comments to Metro Éireann in 2010, he contended that the Centre was against FGM but not “female circumcision” (these terms are often used interchangeably). He referred to types of cutting to the female genitalia that are illegal under the legislation that commenced in 2012 and are commonly categorised within the definition of FGM.
Contacted by MI for the latest position, Dr Selim answered: “I believe you know my stand in this regard. I adhere to it. It cannot be banned but reasonably practised.” He believes a hadith (saying of the Prophet Muhammad) provides an Islamic context to “female circumcision”. “Female circumcision is a matter that should be determined by a medical doctor. If the doctor thinks there is a need for it, then do it and if otherwise, then otherwise. If it is done, then it should be done carefully and safely and should be limited to the amount needed,” Dr Selim informed MI.
Dr Selim said that “female circumcision is a matter that should not be banned nor haphazardly practised… it has to be sanctioned by a medical doctor who can recognise the need of that”. He was unable to identify any specific alleged medical needs (“sometimes you could have an abnormal part in your body and it will have to be treated”, he said). When asked if the alleged medical issues were a reference to matters around promiscuity, he said “no”.
Informed of some of Dr Selim’s comments, Prof Fitzpatrick stated: “Female genital mutilation is a crime against young girls and women. There are no health benefits — just misery, suffering and ill-health for millions. It is a criminal offence for a doctor to perform FGM. There is no such thing as ‘reasonable practice’ or ‘limited excision’.
“Phumzile Mlambo-Ngcuka, the Executive Director of UN Women, sums up the horror of this practice: ‘The cutting and sewing of a young girl’s private parts so that she is substantially damaged for the rest of her life, has no sensation during sex except probably pain, and may face further damage when she gives birth, is an obvious and horrifying violation of that child’s rights.’
“There are many, many Muslims who oppose this barbaric practice and there is, I believe, a moral imperative for Islamic religious leaders, as well as all politicians and other religious and secular leaders in countries where FGM is practised, to come out strongly and unequivocally in opposition to FGM and to support its total abolition.”
Dublin clinic
The extent of FGM in Ireland and its perpetration on Irish citizen girls is difficult to gauge. However, some women who suffered the practice in their native countries are presenting to health services. In mid-2014, the first specialist health clinic on FGM was opened by the Irish Family Planning Association (IFPA) at Cathal Brugha Street, Dublin. Policy Officer at the IFPA, Ms Alison Spillane, says the clinic has had less than 50 clients to date.
The number of clients is increasing year-on-year, however, and most attend on multiple occasions. The clinic provides free medical and psychological services, including interpreting support, if required. In 2017, it received HSE funding of €38,000, which “covers the clinical services and the outreach activities to both affected communities and front-line service providers”.
The IFPA raises awareness of the clinic during outreach information meetings at direct provision asylum-seeker centres. A clinical pathway has been established into Dublin’s Rotunda Hospital. In 2016, half of new clients had an onward referral to the Rotunda for consideration of deinfibulation.
“Because the client numbers are so small, the gynaecologist we work with in the Rotunda [Dr Maeve Eogan] is able to integrate those into her own caseload. I guess down the line, assuming the client numbers increase, we might need to look at that pathway again, and maybe develop a network of gynaecologists around the country who are able to provide the service,” stated Ms Spillane.
Dr Eogan, Consultant Obstetrician and Gynaecologist, says the IFPA clinic is a “holistic” service that provides a “huge benefit” for these women. The hospital sees women referred for sequelae of FGM. Around five-to-six women per year are referred for consideration of deinfibulation, which is a straightforward procedure. Surgical care and knowledge of FGM are part of basic and higher specialist training in obstetrics and gynaecology, confirms Dr Eogan.
It is underlined to trainees that women may not disclose a history of FGM due to fear, trauma, embarrassment or it may not be foremost in their mind during an antenatal visit. Affected women may present late to maternity services, “and that is why training is so important”, says Dr Eogan. On the hospital’s electronic health record, FGM can be noted “in the area where we document vaginal exam during labour”. This will relate to a minority of patients but is an important acknowledgment of such presentations, she adds.
Asked if patients ever ask for re-infibulation, which refers to the re-suturing (usually after childbirth) of the incised scar tissue and is illegal under the Criminal Justice FGM Act, Dr Eogan says: “No, that is not something I have come across. But whenever we are talking to trainees in this regard, we also ensure that we emphasise that repair of episiotomy or perineal tears still needs to be done in the usual fashion after childbirth; whatever suturing is required to achieve haemostasis is entirely appropriate.”
Currently, specialist services on FGM are Dublin-centric, an issue raised by the organisation Action Aid. It has called for additional resources to ensure the provision of medical treatment and psychosexual therapy for survivors of FGM in the Cork region. Prof Fitzpatrick says “there is significant awareness there [in healthcare]. I think there needs to be more awareness, and I think there needs to be ease of access into services. “My experience, and the numbers are very small, is that women with FGM have actually been identified early in the [maternity] services, but are often not identified until they actually attend a maternity service, so it is oftentimes the first point of contact.”
Akidwa has produced booklets on FGM for healthcare professionals and teachers; a guide for gardaí is under development.
Ms Xuseyn says Akidwa “would like to see” more State support for its work “other than the small bit we are receiving, because there’s a lot that needs to be done”. In 2017, the organisation received €70,000 from the HSE for its work on FGM. Akidwa wants to work more closely with people from FGM-practising countries to provide education on the health consequences of FGM and on the Criminal Justice FGM Act. It also wants to further engage with service providers to better equip them in supporting women affected by FGM, according to Ms Xuseyn. “We are doing all of that but in a very struggling situation because of lack of funding.”
Security risk
Over the last decade, Ms Ahmed was the principal driver of FGM awareness in Ireland. In 2013, she went back to Somalia on a short visit, which was her first since leaving the conflict-torn country. “I remember meeting with [a security advisor] and him explaining to me that anything can happen — you can be kidnapped, you can be killed, you can be recognised because you’ve been in the media,” she tells MI.
“But I felt, if I can do it in Ireland, why can I not do it in Somalia because I felt great when the FGM Bill passed in Ireland and I felt at least Ireland is a country with legislation, a country that is better than Somalia [in this respect] and where those who practise FGM can be facing the consequence of imprisonment. So it was not an easy decision to go back but I really wanted to make that journey and see how it is like as a grown woman to go back to my own country, because I came here when I was knowing nothing but I learned so much. I felt I had the power to speak to people, to influence, and knew how to communicate.”
She kept a low profile while meeting with family and visiting camps for internally-displaced people (IDP) in Somalia. She encountered three girls at an IDP camp at immediate risk of FGM and paid their families to not go through with it. “They started talking… they said ‘okay, we are not going to cut them, we are going to do sunna’… Sunna is that they cut it a little bit and make it bleed. I said ‘no, you take the 100 dollars and you leave the girls forever’.” The families took the money and swore on the Koran that the girls would not be touched.
On return to Ireland, she was depressed thinking of the poverty, hunger and insecurity she had witnessed. “But again, I said, my depression, me being sad about how people are living, I should start thinking positive; what can I do? I felt, you know what, if I went back to Somalia and started breaking the silence, that will help. But I meet with everyone, I see their life, the killing, the bombing, everything, I say okay, the country where there is a bomb every day and every single day people are killed, how would I make a change and how would I survive myself being in that situation? Then I said, ‘you know what, I am going back’.”
In 2014, she got the opportunity to advise the country’s Minister for Women and Human Rights Khadija Mohamed Dirie. In 2016, she persuaded Prime Minister Omar Abdirashid Ali Sharmarke to sign a petition calling for a ban on FGM in Somalia and worked as an advisor under his office.
She saw plenty of heartache. “I visited hospitals where I find that a lot of women have gone through fistula… I meet with women who cannot hold their urine and they have to be in hospital 24/7 with a tube, because the first child they gave birth to, it was very hard, then they have a fistula, now they have lost all their life. Where is the health?”
One girl she met, Hawa, faced renal failure arising from the consequences of FGM. Ms Ahmed enlisted the help of authorities and medics in a bid to save Hawa. Sadly, she did not survive.
FGM is entrenched in Somalia, but the country has many other problems. It is still emerging from conflict and routinely faces attacks from Islamists, notably al-Shabaab. This constitutes a very volatile climate for all human rights activists.
Currently, Ms Ahmed is focusing on her work as an activist through the Ifrah Foundation. It has been awarded a grant from Amplify Change to implement a pilot FGM eradication programme in the Gedo region of Somalia. The programme will be undertaken in collaboration with Trocaire and the Global Media Campaign to End FGM, founded by The Guardian.
The Ifrah Foundation has developed a National Action Plan study for Somalia, which targets eradication of FGM by 2030. The aim is to work in partnership with government and global stakeholders with a collective interest to eradicate FGM in Somalia using a sustained programme for change and collaborating with civil society and communities to achieve permanent change. In December 2017, the Ifrah Foundation worked with the Global Media Campaign to End FGM, local government and other partners to deliver training on ending the practice to media and religious leaders in Puntland. The buy-in of religious leaders will be key in ensuring legislation banning FGM can be instigated and respected, explains Ms Ahmed.
Further developments are afoot. A film titled A Girl From Mogadishu, directed by Ms Mary McGuckian, will tell Ms Ahmed’s story. The project received funding from the Irish Film Board and will film scenes in Dublin shortly. The aim is to raise awareness of FGM and impact societies around the world, says Ms Ahmed.
The ‘Irish woman’ will surely see to it.
Types of FGM categorised by WHO
Female genital mutilation is classified into four major types.
Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris, and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, eg, pricking, piercing, incising, scraping and cauterising the genital area.
Source: World Health Organisation
In Mogadishu’s corridors of power, Ms Ifrah Ahmed became known as the “Irish woman”. As an advisor to Somalia’s federal government, the Somali-Irish citizen petitioned ministers to “break the silence” on female genital mutilation (FGM), which is highly prevalent in the east African country. Worldwide, over 200 million women and girls are survivors of FGM, Ms Ahmed among them.
FGM comprises all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. It is usually carried out by local women using basic items. It has no health benefits and many negative immediate and long-term consequences, according to the World Health Organisation (WHO).
The commonly-cited motivations for the practice are social traditions, control over female sexuality, marriageability and religion, although no faith obliges FGM. Somalia, at 98 per cent, leads the countries with the highest prevalence among girls and women aged 15-to-49. Moreover, the most brutal form of FGM — type 3, or infibulation — is the most common in Somalia (see panel below). There is no legislation prohibiting FGM in Somalia and the practice is so deep-rooted that activists face an uphill struggle to encourage change.
But this has not dissuaded Ms Ahmed. When it comes to winning friends and influencing people, she has written the textbook. “Every minister has two or three police guards at the door, and the minister can hear me fighting with them, because they don’t allow anybody to enter to him,” Ms Ahmed tells the Medical Independent (MI) of her time as a gender and human rights advisor. “For me, always when I go, I say to the police guards ‘hey listen, this government kick out every minister after three months, so he will disappear soon, so let me go and see him’. The minister would hear me and say, ‘hey, let her in’… ”
Shunned
In 2006, Ms Ahmed arrived in Ireland as a lone teenage asylum-seeker; she was granted refugee status and later citizenship. In 2008, still aged in her teens, she told the multicultural newspaper Metro Éireann that Somali women were coming “under pressure” to send their young Irish raised daughters to Somalia for FGM. Thereafter, she was shunned and threatened by elements of her community.
Her motivation was born from the pain and trauma of peers, who at times endured ignorance and shock in healthcare settings.
From her small flat in Drumcondra, Dublin, she co-ordinated a growing band of supporters, bringing the worlds of fashion and politics together for awareness events. Her efforts were influential in ensuring the introduction in 2012 of legislation specifically outlawing FGM and the act of removing girls or women from the State, or attempting to remove them, for FGM. Her work was the focus of an RTÉ Would You Believe documentary in 2013. She is now an independent activist with the Ifrah Foundation, an Irish-registered charity that she founded. Her vision is that a campaign focused on FGM eradication will acquire a profile similar to that surrounding HIV/AIDS.
There is “a real steely determination behind what she is doing”, remarks Prof Chris Fitzpatrick, Consultant Obstetrician and Gynaecologist at the Coombe Women and Infants Hospital, Dublin, Clinical Professor at the School of Medicine, University College Dublin and an advisor to the Ifrah Foundation. “I think the momentum that has been generated by the #MeToo campaign has added extra impetus in relation to the significance of FGM, because it puts it into a context of violation of women’s rights. The local connection where somebody came here as an asylum-seeker to actually get to a position where you can found a foundation and advocate at many different levels is a phenomenal example of female empowerment.”
It is estimated that 5,795 women and girls living in Ireland have undergone FGM in their native countries, according to African and migrant women’s network Akidwa. In 2015, an EU-funded report found that between 1-to-11 per cent of the almost 14,600 girls under the age of 18 in Ireland, whose parents originate from practising countries, could be at risk of FGM.
A major risk factor is the girl being brought to the parental country of origin, where family members may arrange for the practice to take place, stated the report. In focus groups held as part of this report, “anecdotal cases” emerged of girls being taken from Ireland to “countries of origin” by their parents for FGM. There were no specific scenarios of it being performed in Ireland. “Participants had met or heard of parents in the direct provision system who wanted to cut their daughters, but this appeared to be rare. According to the groups, if parents or families really wanted to practise FGM, they would travel to their country of origin and possibly not return to Ireland.”
The issue of girls potentially being sent abroad remains a concern, according to Ms Alwiye Xuseyn, Manager at Akidwa. In discussions with some immigrant communities, “it will come up that, yes, the practice will still continue because it is deep-rooted,” says Ms Xuseyn, “but we don’t have the proof”. On 1 February, a man and woman were sent forward for trial accused of the genital mutilation of their daughter in Dublin. The couple cannot be named for legal reasons and have not indicated how they will plead.
A Garda spokesperson told MI that it has developed a crime classification code for FGM. However, this offence was only created in the coding system last year and no figures will be available until the end of 2018, they said.
“The Garda National Protective Services Bureau are currently engaged in training and awareness education programmes and deliver training to front-line operational personnel twice yearly. The bureau also engages with a wide range of agencies and law enforcement in presenting on the crime of FGM at national seminars,” added the spokesperson. Tusla said it does not have a specific category for FGM in respect of referral data.
‘No basis in Islam’
While FGM affects people of different religions, some members of Muslim communities argue an Islamic context to the practice. Shaykh Umar Al-Qadri, a progressive Imam in Dublin, strongly disputes an Islamic basis.
“In my view and the view of most Muslims, this is a cultural practice; it has no basis in Islam and no basis in Islamic law, and it is of course harmful and should not be practised. It should be discouraged. There is a minority view among some Muslims that there are, for example, some narrations that would not make it an obligation but would recommend such a practice, however these narrations have been proven to be unreliable, unauthentic, so therefore the majority of opinion is that it is a practice that has nothing to do with Islam.
“We do not find it in the time of the Prophet Muhammad, we do not find authentic sources, and also anything that is harmful for the body, anything that is harmful for one’s physical body and psychologically harmful, will always become harmful in Islam and always be discouraged because we in Islam are not allowed torture or physically harm ourselves; it is very much discouraged.” In 14 years here, he has not had an enquiry about undertaking FGM.
“We have had discussions [about the issue]; there were people from Somalia and Sudan, some of them that were sharing their views during the discussions, but again it was made clear to them and they also understood that it is a cultural thing, which is perceived by some as religious, but it isn’t. “They weren’t enquiring for their children but during discussions on this issue, they brought up that it is practised among their communities, among some members of the communities back home. [We were] discussing that there was no religious backing of it and they agreed on it.”
However, Dr Ali Selim (PhD), a senior figure in the Islamic Cultural Centre, Clonskeagh, has a different view. Some years ago, he put on record that the Centre opposed the proposed ban under the Criminal Justice FGM Act. In comments to Metro Éireann in 2010, he contended that the Centre was against FGM but not “female circumcision” (these terms are often used interchangeably). He referred to types of cutting to the female genitalia that are illegal under the legislation that commenced in 2012 and are commonly categorised within the definition of FGM.
Contacted by MI for the latest position, Dr Selim answered: “I believe you know my stand in this regard. I adhere to it. It cannot be banned but reasonably practised.” He believes a hadith (saying of the Prophet Muhammad) provides an Islamic context to “female circumcision”. “Female circumcision is a matter that should be determined by a medical doctor. If the doctor thinks there is a need for it, then do it and if otherwise, then otherwise. If it is done, then it should be done carefully and safely and should be limited to the amount needed,” Dr Selim informed MI.
Dr Selim said that “female circumcision is a matter that should not be banned nor haphazardly practised… it has to be sanctioned by a medical doctor who can recognise the need of that”. He was unable to identify any specific alleged medical needs (“sometimes you could have an abnormal part in your body and it will have to be treated”, he said). When asked if the alleged medical issues were a reference to matters around promiscuity, he said “no”.
Informed of some of Dr Selim’s comments, Prof Fitzpatrick stated: “Female genital mutilation is a crime against young girls and women. There are no health benefits — just misery, suffering and ill-health for millions. It is a criminal offence for a doctor to perform FGM. There is no such thing as ‘reasonable practice’ or ‘limited excision’.
“Phumzile Mlambo-Ngcuka, the Executive Director of UN Women, sums up the horror of this practice: ‘The cutting and sewing of a young girl’s private parts so that she is substantially damaged for the rest of her life, has no sensation during sex except probably pain, and may face further damage when she gives birth, is an obvious and horrifying violation of that child’s rights.’
“There are many, many Muslims who oppose this barbaric practice and there is, I believe, a moral imperative for Islamic religious leaders, as well as all politicians and other religious and secular leaders in countries where FGM is practised, to come out strongly and unequivocally in opposition to FGM and to support its total abolition.”
Dublin clinic
The extent of FGM in Ireland and its perpetration on Irish citizen girls is difficult to gauge. However, some women who suffered the practice in their native countries are presenting to health services. In mid-2014, the first specialist health clinic on FGM was opened by the Irish Family Planning Association (IFPA) at Cathal Brugha Street, Dublin. Policy Officer at the IFPA, Ms Alison Spillane, says the clinic has had less than 50 clients to date.
The number of clients is increasing year-on-year, however, and most attend on multiple occasions. The clinic provides free medical and psychological services, including interpreting support, if required. In 2017, it received HSE funding of €38,000, which “covers the clinical services and the outreach activities to both affected communities and front-line service providers”.
The IFPA raises awareness of the clinic during outreach information meetings at direct provision asylum-seeker centres. A clinical pathway has been established into Dublin’s Rotunda Hospital. In 2016, half of new clients had an onward referral to the Rotunda for consideration of deinfibulation.
“Because the client numbers are so small, the gynaecologist we work with in the Rotunda [Dr Maeve Eogan] is able to integrate those into her own caseload. I guess down the line, assuming the client numbers increase, we might need to look at that pathway again, and maybe develop a network of gynaecologists around the country who are able to provide the service,” stated Ms Spillane.
Dr Eogan, Consultant Obstetrician and Gynaecologist, says the IFPA clinic is a “holistic” service that provides a “huge benefit” for these women. The hospital sees women referred for sequelae of FGM. Around five-to-six women per year are referred for consideration of deinfibulation, which is a straightforward procedure. Surgical care and knowledge of FGM are part of basic and higher specialist training in obstetrics and gynaecology, confirms Dr Eogan.
It is underlined to trainees that women may not disclose a history of FGM due to fear, trauma, embarrassment or it may not be foremost in their mind during an antenatal visit. Affected women may present late to maternity services, “and that is why training is so important”, says Dr Eogan. On the hospital’s electronic health record, FGM can be noted “in the area where we document vaginal exam during labour”. This will relate to a minority of patients but is an important acknowledgment of such presentations, she adds.
Asked if patients ever ask for re-infibulation, which refers to the re-suturing (usually after childbirth) of the incised scar tissue and is illegal under the Criminal Justice FGM Act, Dr Eogan says: “No, that is not something I have come across. But whenever we are talking to trainees in this regard, we also ensure that we emphasise that repair of episiotomy or perineal tears still needs to be done in the usual fashion after childbirth; whatever suturing is required to achieve haemostasis is entirely appropriate.”
Currently, specialist services on FGM are Dublin-centric, an issue raised by the organisation Action Aid. It has called for additional resources to ensure the provision of medical treatment and psychosexual therapy for survivors of FGM in the Cork region. Prof Fitzpatrick says “there is significant awareness there [in healthcare]. I think there needs to be more awareness, and I think there needs to be ease of access into services. “My experience, and the numbers are very small, is that women with FGM have actually been identified early in the [maternity] services, but are often not identified until they actually attend a maternity service, so it is oftentimes the first point of contact.”
Akidwa has produced booklets on FGM for healthcare professionals and teachers; a guide for gardaí is under development.
Ms Xuseyn says Akidwa “would like to see” more State support for its work “other than the small bit we are receiving, because there’s a lot that needs to be done”. In 2017, the organisation received €70,000 from the HSE for its work on FGM. Akidwa wants to work more closely with people from FGM-practising countries to provide education on the health consequences of FGM and on the Criminal Justice FGM Act. It also wants to further engage with service providers to better equip them in supporting women affected by FGM, according to Ms Xuseyn. “We are doing all of that but in a very struggling situation because of lack of funding.”
Security risk
Over the last decade, Ms Ahmed was the principal driver of FGM awareness in Ireland. In 2013, she went back to Somalia on a short visit, which was her first since leaving the conflict-torn country. “I remember meeting with [a security advisor] and him explaining to me that anything can happen — you can be kidnapped, you can be killed, you can be recognised because you’ve been in the media,” she tells MI.
“But I felt, if I can do it in Ireland, why can I not do it in Somalia because I felt great when the FGM Bill passed in Ireland and I felt at least Ireland is a country with legislation, a country that is better than Somalia [in this respect] and where those who practise FGM can be facing the consequence of imprisonment. So it was not an easy decision to go back but I really wanted to make that journey and see how it is like as a grown woman to go back to my own country, because I came here when I was knowing nothing but I learned so much. I felt I had the power to speak to people, to influence, and knew how to communicate.”
She kept a low profile while meeting with family and visiting camps for internally-displaced people (IDP) in Somalia. She encountered three girls at an IDP camp at immediate risk of FGM and paid their families to not go through with it. “They started talking… they said ‘okay, we are not going to cut them, we are going to do sunna’… Sunna is that they cut it a little bit and make it bleed. I said ‘no, you take the 100 dollars and you leave the girls forever’.” The families took the money and swore on the Koran that the girls would not be touched.
On return to Ireland, she was depressed thinking of the poverty, hunger and insecurity she had witnessed. “But again, I said, my depression, me being sad about how people are living, I should start thinking positive; what can I do? I felt, you know what, if I went back to Somalia and started breaking the silence, that will help. But I meet with everyone, I see their life, the killing, the bombing, everything, I say okay, the country where there is a bomb every day and every single day people are killed, how would I make a change and how would I survive myself being in that situation? Then I said, ‘you know what, I am going back’.”
In 2014, she got the opportunity to advise the country’s Minister for Women and Human Rights Khadija Mohamed Dirie. In 2016, she persuaded Prime Minister Omar Abdirashid Ali Sharmarke to sign a petition calling for a ban on FGM in Somalia and worked as an advisor under his office.
She saw plenty of heartache. “I visited hospitals where I find that a lot of women have gone through fistula… I meet with women who cannot hold their urine and they have to be in hospital 24/7 with a tube, because the first child they gave birth to, it was very hard, then they have a fistula, now they have lost all their life. Where is the health?”
One girl she met, Hawa, faced renal failure arising from the consequences of FGM. Ms Ahmed enlisted the help of authorities and medics in a bid to save Hawa. Sadly, she did not survive.
FGM is entrenched in Somalia, but the country has many other problems. It is still emerging from conflict and routinely faces attacks from Islamists, notably al-Shabaab. This constitutes a very volatile climate for all human rights activists.
Currently, Ms Ahmed is focusing on her work as an activist through the Ifrah Foundation. It has been awarded a grant from Amplify Change to implement a pilot FGM eradication programme in the Gedo region of Somalia. The programme will be undertaken in collaboration with Trocaire and the Global Media Campaign to End FGM, founded by The Guardian.
The Ifrah Foundation has developed a National Action Plan study for Somalia, which targets eradication of FGM by 2030. The aim is to work in partnership with government and global stakeholders with a collective interest to eradicate FGM in Somalia using a sustained programme for change and collaborating with civil society and communities to achieve permanent change. In December 2017, the Ifrah Foundation worked with the Global Media Campaign to End FGM, local government and other partners to deliver training on ending the practice to media and religious leaders in Puntland. The buy-in of religious leaders will be key in ensuring legislation banning FGM can be instigated and respected, explains Ms Ahmed.
Further developments are afoot. A film titled A Girl From Mogadishu, directed by Ms Mary McGuckian, will tell Ms Ahmed’s story. The project received funding from the Irish Film Board and will film scenes in Dublin shortly. The aim is to raise awareness of FGM and impact societies around the world, says Ms Ahmed.
The ‘Irish woman’ will surely see to it.
Types of FGM categorised by WHO
Female genital mutilation is classified into four major types.
Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris, and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, eg, pricking, piercing, incising, scraping and cauterising the genital area.
Source: World Health Organisation
Jockeying in the race for health
Medical Independent
11 August 2016
The unique demands of elite horse racing — notably weight-making — can have detrimental effects on jockeys’ physical and mental health. Catherine Reilly reports on reforms being pursued by health and sports science professionals
A young jockey, sweating in the sauna, watched bewildered as a seasoned rider ate incessantly.
“I saw him coming into the sauna and the next minute he would be eating, eating and eating, and I would be thinking ‘mother of God, I am in the sauna trying to lose weight, he is eating away at the same time’,” Mr Warren O’Connor, a former professional jockey, recalls for the Medical Independent (MI).
The reality soon crystallised: the seasoned rider was “throwing everything back up again”. Self-induced vomiting (known as ‘flipping’) has long been used by some jockeys to meet horse racing’s restrictive weight demands.
“When I saw that I was young at the time, and I copied it. But I will tell you one thing, it was the sorriest thing I’ve ever done,” reflects Mr O’Connor.
Champion Apprentice in 1990, Mr O’Connor’s career wins included the Irish 1,000 Guineas at The Curragh, the Coronation Stakes at Royal Ascot, both in 1991, and the Eclipse Stakes at Sandown Park the following year. His talent was curtailed by a number of health challenges, often closely connected with the demands of the sport. He regularly competed two stone below his natural weight of 10 stone.
He got trapped in a destructive cycle of vomiting and binge-eating: “I would be sitting here after going into the sauna — after sweating — and the next minute, I would go down and get a McDonald’s. An hour later — literally an hour later — I would go get a Chinese, then I would go make a sandwich… ”
There was a ‘buzz’ after vomiting; an illusion of energy to an exhausted and dehydrated rider. Even the good times became a mirage. “I rode three winners one day at The Curragh and got beat — finished second — on the other,” he remembers. “I didn’t even enjoy the three winners that I had. I beat myself up over the one I got beat on…
“You can be over-driven too and that was my biggest problem; I was over-driven.”
When his dieting had totally gotten out of control, his body started shutting down, his energy “completely gone”.
In time, Mr O’Connor began using cocaine, believing it gave him the lift he required. On one level, he knew he would get caught; on another, there was a sense of invincibility.
Cocaine was introduced to him while riding abroad and was part of keeping his weight down.
In 2006, however, he tested positive for a metabolite of cocaine after competing in The Curragh. Shortly prior to the positive test he had retired in the midst of a battle with other health issues.
These days, fortunately, Mr O’Connor’s career is more evocative of a redemption story than mere cautionary tale, although both narratives hold important lessons. He is one of two jockey coaches in Ireland to have qualified from a prestigious coaching course run by the British Horseracing Authority (BHA).
Mr O’Connor describes a determination to ensure young jockeys avoid the same pitfalls and have access to holistic supports. He credits the support of the Irish Jockeys’ Trust in helping him to rebuild his career.
“I started up my own business [as a jockey coach]. Touch wood, it is going very well. The feedback from the trainers is they see the difference in it as well. I manage them, look after them and treat them like my own kids. I am passionate about racing. I left racing in shame and I am grateful to be back again.”
There is “a lot more support” for jockeys these days. However, they still face many of the same pressures in respect of dieting and competing. Their size has grown, yet competition weights have not altered proportionately.
“I am five-foot-seven and I was tall for a flat jockey. But they are even bigger now; you don’t find that small little fella anymore,” notes Mr O’Connor. In that respect, he would agree with some rise in the weight structure. He is encouraged by news of the new Horse Racing Ireland (HRI) helpline and plans for greater holistic support for jockeys.
“I don’t want them to go down the road I went, because it is not a nice place to go,” he adds. “I am just grateful to have come out the other side of it.”
Hectic
Mr Andrew Coonan, Secretary of the Irish Jockeys Association, says poor nutrition is still a big problem but flipping has decreased significantly. He describes jockeys’ hectic schedule of riding out in the mornings, racing in the afternoons and travelling to and from race meetings. The reality is that dietary guidance is difficult to implement and not all racecourses have nutritionally adequate food, despite improvements.
The dominant emerging issue is mental ill health. It is “a significant problem” and something “we are only really beginning to identify now”, outlines Mr Coonan.
Recent research found that 57 per cent of Irish professional jockeys displayed symptoms of depression, compared with 32 per cent of amateurs. In contrast, a similar study in Australia reported that just 27 per cent of elite athletes displayed symptoms of depression. Some 116 Irish jockeys (74 amateur and 42 professional) aged over 18 years participated in the research carried out by exercise physiologist Dr SarahJane Cullen and exercise psychologist Dr Ciara Losty, both lecturers at Waterford Institute of Technology (WIT). Drs Cullen and Losty found that 64 per cent of professional jockeys with no diet plan had symptoms of depression, compared to 47 per cent of those with a diet plan.
Moreover, 67 per cent of professionals who had difficulty making weight suffered from symptoms of depression, whereas of those who didn’t have difficulty making weight, this figure was 52 per cent. The online anonymous survey assessed different psychological health parameters of Irish jockeys and was commissioned by Irish horse racing’s regulatory body, the Turf Club.
The decisions of high-profile figures such as Mr Mark Enright and Mr Kieren Fallon to disclose their own experiences of depression has brought the issue into wider public consciousness. There are signs the industry is responding to some degree.
Last month, governing body HRI launched an ‘Industry Assistance Programme’ for the Irish thoroughbred industry; it will provide free and confidential telephone and online supports.
Weighty issue
The Turf Club has been highly active in health-related research, predominantly led by Senior Medical Officer Dr Adrian McGoldrick and Senior Lecturer in Sport and Exercise Physiology at the University of Limerick Dr Giles Warrington. The pair have been joint Co-ordinators of the Turf Club Research Team since 2005.
Research backed by the Turf Club has led to changes on health grounds: a 4lb rise in the minimum flat racing weight to the current 8 stone 4lbs took effect from the start of the 2006 flat racing season (it is eight stone in the UK). Moreover, minimum riding weights for apprentices were introduced by the Turf Club in 2013. These are the lowest riding weight at which an individual rider may ride in any race.
Weights are, in fact, assigned to the horses based on their ability under the handicapping system that is a key facet of an industry that contributed almost €1.1 billion to the Irish economy in 2012.
Weight allocations in Irish horse-racing currently range from 8 stone 4lbs to 10 stone in flat racing, and 9 stone 10lbs to 12 stone for national hunt jockeys. These are inclusive of the saddle and protective wear.
Dr McGoldrick, a highly-respected figure among riders, has striven for reforms since assuming his current role in 2008.
In respect of the recent research on depression that he commissioned, Dr McGoldrick has asked colleagues in the UK and France if they would consider repeating the study to see if they elicit similar findings.
“Potentially, if we could get the data replicated in France and England, and came up with similar stats and similar causes, and particularly if making weight was one of the reasons why they were depressed, well, obviously we must look at upping the weight structure in racing, if that is one of the causes.”
Dr McGoldrick, who is a specialist in occupational health and sports medicine and also works as a GP in Newbridge, is frank in his views on the weight issue. Further reforms in this area are on his agenda, as well as ensuring the advancement of a jockey pathway that would enhance educational, nutritional, fitness and sports science supports.
He feels it is “unnatural to have somebody riding two stone below their natural weight”. However, as he acknowledges, significant changes to weights would require some form of pan-European consensus.
“I would love to see weight structures go up significantly,” says Dr McGoldrick. He points out that the average population is increasing by a pound every three years and racing hasn’t kept pace.
“And as a result, we are seeing the problems we are seeing, with bone thinning etc, so it is trying to get the balance.”
Some 59 per cent of flat and 40 per cent of national hunt jockeys showed osteopaenia in one or more of the total body, hip or spine scans, according to research co-authored by Dr McGoldrick.
This study of 27 elite male jockeys in the Journal of Sports Science (Warrington et al, 2009) also reported marked dehydration on an official race day, while 64 per cent of participants cited a current injury at the time of assessment.
Dr McGoldrick has secured funding from the Irish Injured Jockeys Fund for a DEXA scanner so that riders can be tracked more regularly. The plan is to scan all 170 professional riders as well as 350 amateurs and monitor bone health annually.
“That is one of the studies that we are looking at: DEXA-scanning them and then looking at an intervention study — so jockeys who are found [to have] bone thinning, putting them on high-dose vitamin D, plus an exercise regimen, and seeing what the benefit is from either the vitamin D or the combination of vitamin D and exercise. That is one of the studies we are looking at.”
Common weight-making practices in Ireland include use of sweat suits and/or exercise, saunas, hot baths and fluid/energy restriction. Drug testing takes place in-competition and rarely produces positives for diuretics. Dr McGoldrick says flipping occurs in Ireland but “not to a great extent”, although it appears to be a particular problem in the UK.
UK
BHA Chief Medical Adviser Dr Jerry Hill says prevalence of flipping is incredibly difficult to assess, mainly as it is something jockeys tend not to self-disclose.
“There seems to be a definite feeling that, yes, it is happening,” says Dr Hill of the UK situation. “It is probably happening in the younger jockeys; it is quite patchy throughout the country, it tends to be more the flat guys than the jump jockeys. But absolute numbers? It is an imponderable.
“The approach we are trying to take is much more to make it unnecessary — so you change the culture. If you want to perform well — you are an athlete, you love your sport — these are the things you will do to do well and achieve your weights.
“The hope is that those people who are flipping will begin to realise that there are better ways [of making weight] and also if they continue to do it, their performance will be affected. In practical terms, if your performances are not very good, you are going to get less rides over time.”
In this respect, he believes sports science and nutrition support for jockeys are key.
“If we get all our athletes doing the right thing and there is still a challenge with them making weights, then that is the time to look at the weights. The danger is if you say the solution is to just increase the weight, you may perpetuate bad habits and they will just be at a slightly higher weight than they were beforehand... ”
Dr Hill adds that “just changing the weights might end up not giving us the result we want. I think it is part of it, don’t get me wrong, but I don’t think it is the quick, easy solution that it is often bandied around to be.”
PathwayIn Ireland, a holistic approach to jockey health, wellbeing, safety and performance has been in-development at the Turf Club: the aforementioned jockey pathway envisages placing Ireland at the forefront of jockey development.
Dr Cullen has been pivotally involved in developing this pathway, with Dr McGoldrick and colleagues. She has worked with the Turf Club on providing sports science support to jockeys, particularly to ensure better knowledge of healthier weight-making practices.
Having undertaken a PhD scholarship in DCU in conjunction with the Turf Club on jockey health and performance, Dr Cullen noted a lack of structured support and pathway for jockeys as professional athletes in the form of long-term athlete development. This infrastructure has been slow to develop in Irish horse racing and elsewhere for a variety of reasons.
The pathway proposal originated in the Turf Club, with the input and involvement of the Racing Academy and Centre of Education (RACE).
A spokesperson for the HRI says it has been working closely with this group to “explore the feasibility” of such a programme and to ensure industry stakeholders “agree and support” the pathway. “This process is currently ongoing, with consultation meetings scheduled with jockeys and trainers in the coming weeks.”
Dr Cullen says the core idea of the pathway is to “give the right education and support at the right stage of their development”.
The approach incorporates technical, tactical, physical, mental, lifestyle and personal capacities.
It proposes that pre-licence jockeys would do modules on areas like weight management, nutrition and hydration. Professional jockeys would be required to undertake continuing professional development (CPD). The DEXA-scanning referenced by Dr McGoldrick would form another component.
An online element will be important to ensure jockeys can fulfil some of these commitments, due to their often unpredictable working lives. Nutrition will be a core part of the jockey pathway, including individual diet consultations. The idea is that, initially, there will be compulsory modules for those on the cusp of professionalism.
Dr Cullen suggests that a radical change is required in how jockeys approach nutrition and exercise. Many “never go to the gym” and when they do, their programme is rudimentary: running on a treadmill in a sweat-suit.
It certainly is not “going to the gym to do a structured training session with an S&C coach to improve their performance on the horse,” she observed.
There is access to dietary, S&C and sports psychology expertise via the Turf Club. However, jockeys can be resistant to engagement. After all, they have observed successful older jockeys moving through the sport without these supports, and using the traditional means of making weight. The medium-to-long-term health consequences are unseen or just overlooked.
“We are just trying to let jockeys know you can eat little and often, and train, and keep your weight down. Whereas what they do, as you can imagine, is often keep eating high-fat foods and then starve themselves when necessary for racing,” noted Dr Cullen.
Jockeys are also anxious about the idea of going to the gym and doing weights, not realising that it can help keep their body fat down. In fact, jockeys often have a high body fat percentage in comparison with other elite athletes.
“I’d say it is literally not eating, and then eating rubbish, high-fat foods and then not doing any other exercise,” explained Dr Cullen.
Commonly, jockeys do not warm-up before a race and their schedule leaves little scope for rest and recovery.
Further research is being planned at the Turf Club. It will advertise for a PhD student to explore the effects of chronic dehydration on cognition and balance. Previous smaller-scale research found that the effects were highly individualised. “Some jockeys really went downhill in their reaction time and their balance was completely off; others were fine,” noted Dr Cullen.
There could be a protocol in the future whereby a jockey would need to pass certain tests on cognitive stability as well as fitness before being allowed out to race, she speculated.
“Sometimes you have a jockey who falls off and then they are called into the Stewards’ room and they don’t remember being where they were when they fell off, they are so dehydrated.”
There are also plans to have another PhD student undertake research on the physical demands of the sport, with a view to developing a fitness protocol.
Concussion
There is an inherent danger in the activity of horse racing. Thoroughbred racehorses weigh up to 500kg and can run at speeds of more than 60km per hour.
The recent passing of the much-admired JT McNamara was a poignant reminder of the risks faced by jockeys. The late Mr McNamara had fractured C3 and C4 vertebrae after a fall at the 2013 Cheltenham Festival.
Dr McGoldrick considers the adoption of a more sophisticated Concussion Protocol in 2009 as vitally important.
The 170 professional and 350 amateur riders have undergone baseline neuropsych testing.
“Say they are concussed, they have to pass that test again and plus they are assessed by a sports physician independently and must pass that test, so they have two independent tests which report back to me before they can be cleared to ride again.”
There are about 30 concussions per year arising from approximately 2,000 falls between national hunt point-to-point and flat racing. Dr McGoldrick notes that no system is in place for people who are riding-out in the morning time, so potentially jockeys could be having concussion off-track. However, advice is provided on this issue.
Dr McGoldrick has a particular interest in concussion and acknowledges that the science is in its infancy, with a vast reservoir of unknowns.
On an anecdotal level, he has seen nothing to suggest that the rate of dementia among retired jockeys is higher than in the overall population.
“I have lived here in The Curragh for 32 years and I am surrounded by retired jockeys and there is no more dementia among retired jockeys than in the normal population that I would certainly see.”
Knowledge is accumulating on concussion. The Turf Club is considering compulsory gum-shields, as there is now research that shows this reduces the risk.
“Up until now, I always personally believed they reduced concussion because I had never seen a jockey wearing gum-shields have a concussion. But there was no scientific data to support it. But there have been two papers this year stating that gum-shields, if they are custom-made, will reduce concussion, so that is another area we are looking at.”
The Turf Club is also participating in an international long-term study to investigate the extent of the link between concussion and chronic traumatic encephalopathy.
Given how vocal he is on a range of health issues, one wonders how this ‘goes down’ in the industry.
“I am in the very lucky situation in that I am a GP, I am contracted to the Turf Club so I can walk away in the morning if people don’t like what I say. I have very strong support from the Turf Club and Horse Racing Ireland. I have never, ever had anybody rap me over the knuckles.”
So Dr McGoldrick’s work continues in earnest. There is still “a heck of a lot to do”.
“I saw him coming into the sauna and the next minute he would be eating, eating and eating, and I would be thinking ‘mother of God, I am in the sauna trying to lose weight, he is eating away at the same time’,” Mr Warren O’Connor, a former professional jockey, recalls for the Medical Independent (MI).
The reality soon crystallised: the seasoned rider was “throwing everything back up again”. Self-induced vomiting (known as ‘flipping’) has long been used by some jockeys to meet horse racing’s restrictive weight demands.
“When I saw that I was young at the time, and I copied it. But I will tell you one thing, it was the sorriest thing I’ve ever done,” reflects Mr O’Connor.
Champion Apprentice in 1990, Mr O’Connor’s career wins included the Irish 1,000 Guineas at The Curragh, the Coronation Stakes at Royal Ascot, both in 1991, and the Eclipse Stakes at Sandown Park the following year. His talent was curtailed by a number of health challenges, often closely connected with the demands of the sport. He regularly competed two stone below his natural weight of 10 stone.
He got trapped in a destructive cycle of vomiting and binge-eating: “I would be sitting here after going into the sauna — after sweating — and the next minute, I would go down and get a McDonald’s. An hour later — literally an hour later — I would go get a Chinese, then I would go make a sandwich… ”
There was a ‘buzz’ after vomiting; an illusion of energy to an exhausted and dehydrated rider. Even the good times became a mirage. “I rode three winners one day at The Curragh and got beat — finished second — on the other,” he remembers. “I didn’t even enjoy the three winners that I had. I beat myself up over the one I got beat on…
“You can be over-driven too and that was my biggest problem; I was over-driven.”
When his dieting had totally gotten out of control, his body started shutting down, his energy “completely gone”.
In time, Mr O’Connor began using cocaine, believing it gave him the lift he required. On one level, he knew he would get caught; on another, there was a sense of invincibility.
Cocaine was introduced to him while riding abroad and was part of keeping his weight down.
In 2006, however, he tested positive for a metabolite of cocaine after competing in The Curragh. Shortly prior to the positive test he had retired in the midst of a battle with other health issues.
These days, fortunately, Mr O’Connor’s career is more evocative of a redemption story than mere cautionary tale, although both narratives hold important lessons. He is one of two jockey coaches in Ireland to have qualified from a prestigious coaching course run by the British Horseracing Authority (BHA).
Mr O’Connor describes a determination to ensure young jockeys avoid the same pitfalls and have access to holistic supports. He credits the support of the Irish Jockeys’ Trust in helping him to rebuild his career.
“I started up my own business [as a jockey coach]. Touch wood, it is going very well. The feedback from the trainers is they see the difference in it as well. I manage them, look after them and treat them like my own kids. I am passionate about racing. I left racing in shame and I am grateful to be back again.”
There is “a lot more support” for jockeys these days. However, they still face many of the same pressures in respect of dieting and competing. Their size has grown, yet competition weights have not altered proportionately.
“I am five-foot-seven and I was tall for a flat jockey. But they are even bigger now; you don’t find that small little fella anymore,” notes Mr O’Connor. In that respect, he would agree with some rise in the weight structure. He is encouraged by news of the new Horse Racing Ireland (HRI) helpline and plans for greater holistic support for jockeys.
“I don’t want them to go down the road I went, because it is not a nice place to go,” he adds. “I am just grateful to have come out the other side of it.”
Hectic
Mr Andrew Coonan, Secretary of the Irish Jockeys Association, says poor nutrition is still a big problem but flipping has decreased significantly. He describes jockeys’ hectic schedule of riding out in the mornings, racing in the afternoons and travelling to and from race meetings. The reality is that dietary guidance is difficult to implement and not all racecourses have nutritionally adequate food, despite improvements.
The dominant emerging issue is mental ill health. It is “a significant problem” and something “we are only really beginning to identify now”, outlines Mr Coonan.
Recent research found that 57 per cent of Irish professional jockeys displayed symptoms of depression, compared with 32 per cent of amateurs. In contrast, a similar study in Australia reported that just 27 per cent of elite athletes displayed symptoms of depression. Some 116 Irish jockeys (74 amateur and 42 professional) aged over 18 years participated in the research carried out by exercise physiologist Dr SarahJane Cullen and exercise psychologist Dr Ciara Losty, both lecturers at Waterford Institute of Technology (WIT). Drs Cullen and Losty found that 64 per cent of professional jockeys with no diet plan had symptoms of depression, compared to 47 per cent of those with a diet plan.
Moreover, 67 per cent of professionals who had difficulty making weight suffered from symptoms of depression, whereas of those who didn’t have difficulty making weight, this figure was 52 per cent. The online anonymous survey assessed different psychological health parameters of Irish jockeys and was commissioned by Irish horse racing’s regulatory body, the Turf Club.
The decisions of high-profile figures such as Mr Mark Enright and Mr Kieren Fallon to disclose their own experiences of depression has brought the issue into wider public consciousness. There are signs the industry is responding to some degree.
Last month, governing body HRI launched an ‘Industry Assistance Programme’ for the Irish thoroughbred industry; it will provide free and confidential telephone and online supports.
Weighty issue
The Turf Club has been highly active in health-related research, predominantly led by Senior Medical Officer Dr Adrian McGoldrick and Senior Lecturer in Sport and Exercise Physiology at the University of Limerick Dr Giles Warrington. The pair have been joint Co-ordinators of the Turf Club Research Team since 2005.
Research backed by the Turf Club has led to changes on health grounds: a 4lb rise in the minimum flat racing weight to the current 8 stone 4lbs took effect from the start of the 2006 flat racing season (it is eight stone in the UK). Moreover, minimum riding weights for apprentices were introduced by the Turf Club in 2013. These are the lowest riding weight at which an individual rider may ride in any race.
Weights are, in fact, assigned to the horses based on their ability under the handicapping system that is a key facet of an industry that contributed almost €1.1 billion to the Irish economy in 2012.
Weight allocations in Irish horse-racing currently range from 8 stone 4lbs to 10 stone in flat racing, and 9 stone 10lbs to 12 stone for national hunt jockeys. These are inclusive of the saddle and protective wear.
Dr McGoldrick, a highly-respected figure among riders, has striven for reforms since assuming his current role in 2008.
In respect of the recent research on depression that he commissioned, Dr McGoldrick has asked colleagues in the UK and France if they would consider repeating the study to see if they elicit similar findings.
“Potentially, if we could get the data replicated in France and England, and came up with similar stats and similar causes, and particularly if making weight was one of the reasons why they were depressed, well, obviously we must look at upping the weight structure in racing, if that is one of the causes.”
Dr McGoldrick, who is a specialist in occupational health and sports medicine and also works as a GP in Newbridge, is frank in his views on the weight issue. Further reforms in this area are on his agenda, as well as ensuring the advancement of a jockey pathway that would enhance educational, nutritional, fitness and sports science supports.
He feels it is “unnatural to have somebody riding two stone below their natural weight”. However, as he acknowledges, significant changes to weights would require some form of pan-European consensus.
“I would love to see weight structures go up significantly,” says Dr McGoldrick. He points out that the average population is increasing by a pound every three years and racing hasn’t kept pace.
“And as a result, we are seeing the problems we are seeing, with bone thinning etc, so it is trying to get the balance.”
Some 59 per cent of flat and 40 per cent of national hunt jockeys showed osteopaenia in one or more of the total body, hip or spine scans, according to research co-authored by Dr McGoldrick.
This study of 27 elite male jockeys in the Journal of Sports Science (Warrington et al, 2009) also reported marked dehydration on an official race day, while 64 per cent of participants cited a current injury at the time of assessment.
Dr McGoldrick has secured funding from the Irish Injured Jockeys Fund for a DEXA scanner so that riders can be tracked more regularly. The plan is to scan all 170 professional riders as well as 350 amateurs and monitor bone health annually.
“That is one of the studies that we are looking at: DEXA-scanning them and then looking at an intervention study — so jockeys who are found [to have] bone thinning, putting them on high-dose vitamin D, plus an exercise regimen, and seeing what the benefit is from either the vitamin D or the combination of vitamin D and exercise. That is one of the studies we are looking at.”
Common weight-making practices in Ireland include use of sweat suits and/or exercise, saunas, hot baths and fluid/energy restriction. Drug testing takes place in-competition and rarely produces positives for diuretics. Dr McGoldrick says flipping occurs in Ireland but “not to a great extent”, although it appears to be a particular problem in the UK.
UK
BHA Chief Medical Adviser Dr Jerry Hill says prevalence of flipping is incredibly difficult to assess, mainly as it is something jockeys tend not to self-disclose.
“There seems to be a definite feeling that, yes, it is happening,” says Dr Hill of the UK situation. “It is probably happening in the younger jockeys; it is quite patchy throughout the country, it tends to be more the flat guys than the jump jockeys. But absolute numbers? It is an imponderable.
“The approach we are trying to take is much more to make it unnecessary — so you change the culture. If you want to perform well — you are an athlete, you love your sport — these are the things you will do to do well and achieve your weights.
“The hope is that those people who are flipping will begin to realise that there are better ways [of making weight] and also if they continue to do it, their performance will be affected. In practical terms, if your performances are not very good, you are going to get less rides over time.”
In this respect, he believes sports science and nutrition support for jockeys are key.
“If we get all our athletes doing the right thing and there is still a challenge with them making weights, then that is the time to look at the weights. The danger is if you say the solution is to just increase the weight, you may perpetuate bad habits and they will just be at a slightly higher weight than they were beforehand... ”
Dr Hill adds that “just changing the weights might end up not giving us the result we want. I think it is part of it, don’t get me wrong, but I don’t think it is the quick, easy solution that it is often bandied around to be.”
PathwayIn Ireland, a holistic approach to jockey health, wellbeing, safety and performance has been in-development at the Turf Club: the aforementioned jockey pathway envisages placing Ireland at the forefront of jockey development.
Dr Cullen has been pivotally involved in developing this pathway, with Dr McGoldrick and colleagues. She has worked with the Turf Club on providing sports science support to jockeys, particularly to ensure better knowledge of healthier weight-making practices.
Having undertaken a PhD scholarship in DCU in conjunction with the Turf Club on jockey health and performance, Dr Cullen noted a lack of structured support and pathway for jockeys as professional athletes in the form of long-term athlete development. This infrastructure has been slow to develop in Irish horse racing and elsewhere for a variety of reasons.
The pathway proposal originated in the Turf Club, with the input and involvement of the Racing Academy and Centre of Education (RACE).
A spokesperson for the HRI says it has been working closely with this group to “explore the feasibility” of such a programme and to ensure industry stakeholders “agree and support” the pathway. “This process is currently ongoing, with consultation meetings scheduled with jockeys and trainers in the coming weeks.”
Dr Cullen says the core idea of the pathway is to “give the right education and support at the right stage of their development”.
The approach incorporates technical, tactical, physical, mental, lifestyle and personal capacities.
It proposes that pre-licence jockeys would do modules on areas like weight management, nutrition and hydration. Professional jockeys would be required to undertake continuing professional development (CPD). The DEXA-scanning referenced by Dr McGoldrick would form another component.
An online element will be important to ensure jockeys can fulfil some of these commitments, due to their often unpredictable working lives. Nutrition will be a core part of the jockey pathway, including individual diet consultations. The idea is that, initially, there will be compulsory modules for those on the cusp of professionalism.
Dr Cullen suggests that a radical change is required in how jockeys approach nutrition and exercise. Many “never go to the gym” and when they do, their programme is rudimentary: running on a treadmill in a sweat-suit.
It certainly is not “going to the gym to do a structured training session with an S&C coach to improve their performance on the horse,” she observed.
There is access to dietary, S&C and sports psychology expertise via the Turf Club. However, jockeys can be resistant to engagement. After all, they have observed successful older jockeys moving through the sport without these supports, and using the traditional means of making weight. The medium-to-long-term health consequences are unseen or just overlooked.
“We are just trying to let jockeys know you can eat little and often, and train, and keep your weight down. Whereas what they do, as you can imagine, is often keep eating high-fat foods and then starve themselves when necessary for racing,” noted Dr Cullen.
Jockeys are also anxious about the idea of going to the gym and doing weights, not realising that it can help keep their body fat down. In fact, jockeys often have a high body fat percentage in comparison with other elite athletes.
“I’d say it is literally not eating, and then eating rubbish, high-fat foods and then not doing any other exercise,” explained Dr Cullen.
Commonly, jockeys do not warm-up before a race and their schedule leaves little scope for rest and recovery.
Further research is being planned at the Turf Club. It will advertise for a PhD student to explore the effects of chronic dehydration on cognition and balance. Previous smaller-scale research found that the effects were highly individualised. “Some jockeys really went downhill in their reaction time and their balance was completely off; others were fine,” noted Dr Cullen.
There could be a protocol in the future whereby a jockey would need to pass certain tests on cognitive stability as well as fitness before being allowed out to race, she speculated.
“Sometimes you have a jockey who falls off and then they are called into the Stewards’ room and they don’t remember being where they were when they fell off, they are so dehydrated.”
There are also plans to have another PhD student undertake research on the physical demands of the sport, with a view to developing a fitness protocol.
Concussion
There is an inherent danger in the activity of horse racing. Thoroughbred racehorses weigh up to 500kg and can run at speeds of more than 60km per hour.
The recent passing of the much-admired JT McNamara was a poignant reminder of the risks faced by jockeys. The late Mr McNamara had fractured C3 and C4 vertebrae after a fall at the 2013 Cheltenham Festival.
Dr McGoldrick considers the adoption of a more sophisticated Concussion Protocol in 2009 as vitally important.
The 170 professional and 350 amateur riders have undergone baseline neuropsych testing.
“Say they are concussed, they have to pass that test again and plus they are assessed by a sports physician independently and must pass that test, so they have two independent tests which report back to me before they can be cleared to ride again.”
There are about 30 concussions per year arising from approximately 2,000 falls between national hunt point-to-point and flat racing. Dr McGoldrick notes that no system is in place for people who are riding-out in the morning time, so potentially jockeys could be having concussion off-track. However, advice is provided on this issue.
Dr McGoldrick has a particular interest in concussion and acknowledges that the science is in its infancy, with a vast reservoir of unknowns.
On an anecdotal level, he has seen nothing to suggest that the rate of dementia among retired jockeys is higher than in the overall population.
“I have lived here in The Curragh for 32 years and I am surrounded by retired jockeys and there is no more dementia among retired jockeys than in the normal population that I would certainly see.”
Knowledge is accumulating on concussion. The Turf Club is considering compulsory gum-shields, as there is now research that shows this reduces the risk.
“Up until now, I always personally believed they reduced concussion because I had never seen a jockey wearing gum-shields have a concussion. But there was no scientific data to support it. But there have been two papers this year stating that gum-shields, if they are custom-made, will reduce concussion, so that is another area we are looking at.”
The Turf Club is also participating in an international long-term study to investigate the extent of the link between concussion and chronic traumatic encephalopathy.
Given how vocal he is on a range of health issues, one wonders how this ‘goes down’ in the industry.
“I am in the very lucky situation in that I am a GP, I am contracted to the Turf Club so I can walk away in the morning if people don’t like what I say. I have very strong support from the Turf Club and Horse Racing Ireland. I have never, ever had anybody rap me over the knuckles.”
So Dr McGoldrick’s work continues in earnest. There is still “a heck of a lot to do”.
