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Definition

Female genital mutilation (FGM) is a collective term for procedures, which include the removal of part or all of the external female genitalia for cultural or other non-therapeutic reasons. The practice is medically unnecessary, extremely painful and has serious health consequences, both at the time when the mutilation is carried out and in later life. The procedure is typically performed on girls aged between 4 and 13, but in some cases it is performed on new-born infants or on young women before marriage or pregnancy.

FGM has been a criminal offence in the U.K. since the Prohibition of Female Circumcision Act 1985 was passed. The Female Genital Mutilation Act 2003 replaced the 1985 Act and made it an offence for the first time for UK nationals, permanent or habitual UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where the practice is legal.

The rights of women and girls are enshrined by various universal and regional instruments including the Universal Declaration of Human Rights, the United Nations Convention on the Elimination of all Forms of Discrimination Against Women, the Convention on the Rights of the Child, the African Charter on Human and Peoples’ Rights and Protocol to the African Charter on Human and Peoples’ Rights on the rights of women in Africa. All these documents highlight the right for girls and women to live free from gender discrimination, free from torture, to live in dignity and with bodily integrity.

FGM has been classified by the World Health Organisation (WHO) into four types:

  • Type 1 - Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);
  • Type 2 - Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina);
  • Type 3 - Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and
  • Type 4 - Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area.

Multi-Agency Guidelines on Female Genital Mutilation

The non-statutory government Multi–agency Statutory Guidance on Female Genital Mutilation April 2016is a very useful resource for practitioners in all agencies to consider their role in identifying and addressing risk. This has step by step details of each agency’s responsibilities and what to do and practitioners are advised to read this to be familiar with the issues and before addressing a concern about FGM.

Children who have undergone FGM

If a child has already undergone FGM and this comes to the attention of any professional, a referral should be made to the police calling 101 or 999. Depending on the risk assessment, the police will link with social care or the child abuse investigation team. A strategy discussion will be convened to consider, how, where and when the procedure was performed and its implications for other female children in the family. If FGM has been undertaken in the UK or to a British National overseas after 2003, the police will investigate and prosecution will be considered.

A child who has undergone FGM will be seen as a child in need and offered services as appropriate. Medical assessment and both short term and long term therapeutic services are to be considered at the strategy meeting.

Click here to view Female Genital Mutilation: Flowchart & Practice Guidelines.

If a woman has already undergone FGM

If a woman has already undergone FGM and this comes to the attention of any professional e.g. midwife, GP or practice nurse, consideration needs to be given to any child protection implications e.g. for female siblings, their children and their family members. The professional must make a referral to social care and share and document information appropriately.

Click here to view Female Genital Mutilation: Flowchart & Practice Guidelines for Health Professionals upon identification of an adult female (age 18yrs and above) who has undergone FGM.

If the woman is the mother of a female child or has the care of female children, professionals need to assess the potential risk to female children in the family and need to identify the most appropriate way of informing parents of the legal and health implications of FGM. This should be done in consultation with police and social care and an appropriately trained interpreter who has an understanding of FGM, the law and cultural sensitivity if required.

It is important that any concerns in relation to FGM are referred to police who will link Children’s Social Care.

If you have concerns that a girl is at risk of FGM then you should make a referral to Police via 101 who will lead and link with Children’s Social Care.

As with any child protection concern a strategy meeting will be held. The specific issues to be discussed at a strategy meeting in relation to FGM would include:

  • Which professional is best placed to talk to the parents;
  • Whether there are likely to be language difficulties that require an interpreter;
  • Risk to any siblings either now or in the future;
  • Gathering information / intelligence on the person undertaking the FGM procedure;
  • Immediate health needs of the child.

Local Specialist Referral Centres

Deinfibulation:

Specialist paediatric / adolescent gynaecologists:
Referral can be made directly from consultant to consultant or via GP to specialist services.

Treatment is likely to be offered in Bristol or London at specialist centres.

Counselling / Psychological support:

Can also be commissioned via GP practices to specialist services.

Further psychological support via GP referral to Individual Treatment Panel (services provided by Rose Clinic, Bristol).

Other Resources:

Safeguarding women and girls at risk of FGM
This document provides practical help to support NHS organisations developing new safeguarding policies and procedures for female genital mutilation (FGM).

Commissioning services to support women and girls with FGM
This document sets out what some elements of a successful and safe service to support women and girls with female genital mutilation (FGM) might look like.

FGM: E-Learning to Improve Awareness and Understanding of FGM (e-Learning for Healthcare website)

NSPCC helpline number: 0800 028 3550.
Staff have now been trained by FGM health experts so that NHS staff can receive support from a 24/7 team of advisors who can discuss the often complex circumstances surrounding cases of FGM.

Information for families
Leaflets are available to download from www.nhs.uk/fgm or to order from www.orderline.dh.gov.uk in a wide range of languages.

‘Statement Opposing FGM’ leaflet (a wallet-sized document sometimes known as the “health passport”) for families travelling abroad who may be pressured to allow girls to undergo FGM.

Patient Information Leaflet More information about FGM - This leaflet is to be given to patients identified with FGM. It defines the different types of FGM, explains the health consequences and the help and support available, and provides information on the FGM data being collected in the NHS.


Indicators

FGM is often a hidden issue as there are rarely reasons to examine a child’s genitalia and children will be conscious of negative consequences for their family if they disclose.

Suspicions may arise in a number of ways that a child is being prepared for FGM to take place abroad. 

Consider whether any other indicators exist that FGM may have or has already taken place, for example:

  1. Preparations are being made to take a long holiday - arranging vaccinations or planning an absence from school;
  2. The child has changed in behaviour after a prolonged absence from school;
  3. The child has health problems, particularly bladder or menstrual problems;
  4. The child has health problems, particularly bladder or menstrual problems;
  5. Visitors to the family;
  6. Children disclosing that a ‘special procedure’ is to happen.

There may be older women in the family who have already had the procedure and this may prompt concern as to the potential risk of harm to other female children in the same family.

Appendix B of the Multi-Agency Guidelines on FGM sets out the terms used for FGM in other languages which will help practitioners identify FGM when children and young people or family members refer to it in their own language.

If you are worried about a girl under 18 who is either at risk of FGM or who you suspect may have had FGM, you should share this information with Children’s social care or the police immediately, whichever is most appropriate. See Protection and Action to be Taken below.

Professionals must take into consideration that by alerting the girl’s or woman’s family to the fact that she is disclosing information about FGM may place her at increased risk of harm and professionals should therefore take sufficient steps to minimise this risk.

It should not be assumed that families from practising communities will want their girls and women to undergo FGM.

From the 31st October 2015, regulated professionals in health and social care and teachers in England and Wales have a duty to report ‘known’ cases of FGM in under 18s to the police see Mandatory Reporting of FGM.


Protection and Action to be Taken

Practice Guidelines

New referrals should be police led and managed jointly according to the following guidelines:

  • An appropriately qualified female interpreter, if required, who is skilled in addressing issues of language, race and culture must be used. It is important to gauge the views of the interpreter towards FGM before they are used to support families;
  • Every attempt should be made to work with parents on a voluntary basis to prevent the abuse. It is the duty of the investigating team to look at every possible way that parental co-operation can be achieved. Working sensitively within cultural and language parameters is also a priority;
  • If no agreement is reached, the first priority is the protection of the child and the least intrusive legal action should be taken to ensure the child’s safety;
  • A child thought to be in immediate danger of FGM and where the parents are unable to ensure the safety of the child, legal advice will be sought;
  • A Prohibited Steps Order can be sought to stop parents who have decided to send the child overseas and mutilation is likely to take place;
  • Where there is no immediate danger to the child, counselling and education clarifying the dangers and legal issue related to FGM for parents should be arranged;
  • Wherever possible the child would remain in the family and all the principles of good child protection work apply equally to this situation;
  • The primary focus is to prevent the child undergoing any form of FGM rather than removal from the family.

Chapter four of the Government Multi-Agency Guidelines on FGM (see Further Information below) sets out Good Practice to happen in any case of concern about FGM.

Chapter six to ten set out the different roles for Health, Police, Social Workers, Schools, Colleges and Universities (see Further Information below).

Where concerns about the welfare and safety of a child or young person have come to light a referral to police (101 or 999) should be made in accordance with the Referrals Procedure.

Telephone referrals should be followed up formally in writing with 24hours.

Police and Children’s Social Care jointly with the referrer will undertake a Strategy discussion if there is reason to believe that a child is likely to suffer or has suffered FGM. This strategy discussion must include health professionals and education services to be able to plan the response.

Where a child appears to be in immediate danger of mutilation, legal advice should be sought and consideration should be given, for example, to seeking a Female Genital Mutilation Protection Order, an Emergency Protection Order or a Prohibited Steps Order, making it clear to the family that they will be breaking the law if they arrange for the child to have the procedure.

The 2003 Female Genital Mutilation Act makes it illegal for any residents of the UK to perform FGM within or outside the UK. The punishment for violating the 2003 Act carries 14 years imprisonment, a fine or both.

Children’s Social Care will liaise with Paediatric services where it is believed that FGM has already taken place to ensure that a Medical Assessment takes place (see Investigating Child Protection Concerns Procedure, Medical Assessments).

It should be remembered that FGM will have lifelong consequences, and can be highly dangerous at the time of the procedure and directly afterwards.


NHS Actions

Since April 2014 NHS hospitals have been required to record:

  • If a patient has had Female Genital Mutilation;
  • If there is a family history of Female Genital Mutilation;
  • If a Female Genital Mutilation-related procedure has been carried out on a patient.

Since September 2014 all acute hospitals have been required to report this data centrally to the Department of Health on a monthly basis. This was the first stage of a wider ranging programme of work in development to improve the way in which the NHS will respond to the health needs of girls and women who have suffered Female Genital Mutilation and actively support prevention.

Any Medical professional / midwife/obstetrician/gynaecologist/General Practitioner may become aware that Female Genital Mutilation has occurred when treating a female patient. This should trigger concern for other females in the household.

If a health professional encounters a woman who has experienced cutting they will follow the guidance and discuss risks with the woman to her own children and make a referral to CSC.

Female Genital Mutilation: Flowchart & Practice Guidelines for for Maternity, Obstetrics & Gynaecology.

For further information, see Information Standards Board for Health and Social Care Female Genital Mutilation Prevalence Dataset Specification.


Mandatory Reporting of FGM

From the 31st October 2015, regulated professionals in health and social care and teachers in England and Wales have a duty to report ‘known’ cases of FGM in under 18s which they identify in the course of their professional work to the police. Following consultation with social care professionals as well as other relevant professionals, only then will the police take action to ensure the girl/young woman is safe and her needs are prioritised.

‘Known’ cases are those where either a girl informs the person that an act of FGM – however described – has been carried out on her, or where the person observes physical signs on a girl appearing to show that an act of FGM has been carried out and the person has no reason to believe that the act was, or was part of, a surgical operation within section 1(2)(a) or (b) of the FGM Act 2003.

A failure to report the discovery in the course of their work could result in a referral to their professional body. The Home office has produced guidance Mandatory Reporting of Female Genital Mutilation – procedural information to support this duty and a Fact sheet on the New Duty for Health and Social Care Professionals and Teachers to Report Female Genital Mutilation (FGM) to Police. See Fact sheet on Mandatory Reporting of Female Genital Mutilation.

If there are suspicions that a girl under the age of 18 years may have undergone FGM or is at risk of FGM professionals must still report the issue by following their internal safeguarding procedures. Professionals must share the information about their concerns, potential risk and/or the actions which are to be taken. Next steps should be discussed with the safeguarding lead and if necessary a social care referral made.


Issues

Where is FGM Practised?

As a result of immigration and refugee movements, FGM is now being practiced by ethnic minority populations in other parts of the world, such as USA, Canada, Europe, Australia and New Zealand. FORWARD estimates that as many as 6,500 girls are at risk of FGM within the UK every year.

There is no Biblical or Koranic justification for FGM and religious leaders from all faiths have spoken out against the practice.

Consequences of FGM

Depending on the degree of mutilation, FGM can have a number of short-term health implications:

  1. Severe pain and shock;
  2. Infection;
  3. Urine retention;
  4. Injury to adjacent tissues;
  5. Immediate fatal haemorrhaging.

Long-term implications can entail:

  1. Extensive damage of the external reproductive system;
  2. Uterus, vaginal and pelvic infections;
  3. Cysts and neuromas;
  4. Increased risk of Vesico Vaginal Fistula;
  5. Complications in pregnancy and child birth;
  6. Psychological damage;
  7. Sexual dysfunction;
  8. Difficulties in menstruation.

In addition to these health consequences there are considerable psycho-sexual, psychological and social consequences of FGM.

Justifications of FGM

The justifications given for the practise are multiple and reflect the ideological and historical situation of the societies in which it has developed. Reasons include:

  1. Custom and tradition;
  2. Religion, in the mistaken belief that it is a religious requirement;
  3. Preservation of virginity/chastity;
  4. Social acceptance, especially for marriage;
  5. Hygiene and cleanliness;
  6. Increasing sexual pleasure for the male;
  7. Family honour;
  8. A sense of belonging to the group and conversely the fear of social exclusion;
  9. Enhancing fertility.

FGM is a complex and sensitive issue that requires professionals to approach the subject carefully. An accredited female interpreter may be required. Any interpreter should ideally be appropriately trained in relation to FGM, and in all cases should not be a family member, not be known to the individual, and not be someone with influence in the individual’s community.

In light of this, professionals must give careful thought and consideration to developing a safety and support plan for the girl/woman prior to meeting with her. If a girl/woman is seen by someone within the community who she perceives as ‘hostile’ this may pose a risk to her safety. By mutually agreeing in advance another reason why they are there and/or why they are meeting could potentially minimise this risk.



Amendments to this Chapter

This chapter was updated in August 2017 when the definition of FGM by the World health organisation was added to the introduction.


Law

The Female Genital Mutilation (FGM) Act was introduced in 2003 and came into effect in March 2004. The act:

  1. Makes it illegal to practice FGM in the UK;
  2. Makes it illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in that country;
  3. Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;
  4. Has a penalty of up to 14 years in prison and, or, a fine.

The Serious Crime Act 2015 has amended the Female Genital Mutilation Act 2003

  1. Creating a new offence of failing to protect a girl from FGM with a penalty of up to 7 years in prison or a fine or both. - A person is liable if they are “responsible” for a girl at the time when an offence is committed. This will cover someone who has “parental responsibility” for the girl and has “frequent contact” with her and any adult who has assumed responsibility for caring for the girl in the manner of a parent. This could be for example family members, with whom she was staying during the school holidays;
  2. Introduced Female Genital Mutilation Protection Orders (“FGMPO”) - breaching an order carries a penalty of up to five years in prison. The terms of the order can be flexible and the court can include whatever terms it considers necessary and appropriate to protect the girl or woman;
  3. Allowing for the anonymity of victims of FGM – prohibiting the publication of any information that could lead to the identification of the victim. Publication covers all aspects of media including social media;
  4. Extended the extra-territorial reach of Female Genital Mutilation (FGM) offences to include “habitual residents” of the UK.

End.