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2.21 Female genital mutilation

Contents

Definition

The World Health Organisation (WHO) defines female genital mutilation (FGM) as: “all procedures which involve partial or total removal of the external female genitalia or injury to female genital organs whether for cultural or other non-therapeutic reasons” (WHO, 1996).

FGM is also known as female circumcision and female genital cutting. The reason for these alternative definitions is that it can be better received in communities which practise it, who do not see themselves engaging in mutilation. Each country/community may have a unique name for FGM, and further details can be found from FORWARD (Foundation for Women’s Health Research and Development).

Summary profile

It is illegal in the UK to subject a child to FGM or to take a child abroad to undergo FGM. It is also illegal to assist or encourage a child to perform FGM on themselves, or to aid, abet, counsel or procure a girl to have it done in the UK or abroad.

FGM is a form of violence against female children and women, it is a serious public health hazard and a human rights issue. Safeguarding and protecting children and mothers from FGM is everybody’s responsibility.

FGM cannot be left to personal preference or cultural custom as it is an extremely harmful practice which is illegal and violates basic human rights.

FGM constitutes child abuse and causes physical, psychological and sexual harm. It can be severely disabling and can be fatal.

Girls and women in the UK that have undergone FGM may be British citizens born to parents from FGM practicing communities or they may be women living in Britain who are originally from those communities, e.g. women who are refugees, asylum seekers, overseas students or the wives of overseas students.

It should be remembered that this is an act of abuse to a child, and will have long-term consequences being highly dangerous at the time of the procedure, and directly there afterwards.  The implications will be life-long.

Guidance

Professionals, volunteers and individuals coming across FGM for the first time can feel shocked, upset, helpless and unsure of how to respond appropriately to ensure that children are protected from harm. They may be afraid of tackling the issue due to perceived cultural sensitivities.

This procedure provides guidance for frontline professionals and their managers, individual’s in local communities and community groups such as faith and leisure groups on:

  • identifying when a child may be at risk of being subjected to FGM and responding appropriately to protect the child
  • identifying when a child has been subjected to FGM and responding appropriately to support the child
  • measures which can be implemented to prevent and ultimately eliminate the practice of FGM.

Legislation, policy and mandatory reporting of FGM

National legislation        

In England, Wales and Northern Ireland all forms of FGM are illegal under the Female Genital Mutilation Act 2003, and in Scotland it is illegal under the Prohibition of FGM (Scotland) Act 2005. (FGM has been a criminal offence in the UK since the Prohibition of Female Circumcision Act 1985 was passed).

A person is guilty of an offence if s/he excises, infibulates or otherwise mutilates the whole or any part of a girl’s labia majora, labia minora or clitoris except for operations performed on specific physical and mental health grounds by registered medical or nursing practitioners. It is also an offence to assist a girl to mutilate her own genitalia (see Types of FGM). The Act also includes anyone who may aid and abet any of the above. Professionals need to be aware of this, with the incidences of parents arranging for their children to travel abroad to have FGM done.

FGM is an offence which extends to acts performed inside AND outside of the UK. Any person found guilty of an offence under the Female Genital Mutilation Act 2003 will be liable to a fine or imprisonment up to 14 years, or both.

The Serious Crime Act 2015 amends the FGM Act 2003 to create a new offence of failing to protect a girl from FGM. This will mean that if an offence of FGM is committed against a girl under the age of 16, each person who is responsible for the girl at the time FGM occurred will be liable under this new offence.

To be ‘responsible’ for a girl, the person will either have parental responsibility for the girl and have frequent contact with her, or where the person is aged 18 or over they will have assumed responsibility for caring for the girl ‘in the manner of a parent’, for example family members to whom parents might send their child during the summer holidays.

Under the Children Act 1989, local authorities can apply to the courts for various orders to prevent a child being taken abroad for mutilation. These include an Emergency Protection Order; Interim Care Order; and Prohibited Steps Order.

The Serious Crime Act 2015 has amended the Female Genital Mutilation Act 2003 so that a Female Genital Mutilation Protection Order (FGMPO) can be taken out by applying to the court. The court may make a FGMPO on application by the girl who is to be protected or a third party. The court must consider all the circumstances including the need to secure the health, safety, and well-being of the girl. 

An FGMPO might contain such prohibitions, restrictions or other requirements for the purposes of protecting a victim or potential victim of FGM. This could include, for example, provisions to surrender a person’s passport or any other travel document; and not to enter into any arrangements, in the UK or abroad, for FGM to be performed on the person to be protected. 

The Act has also extended the extra-territorial reach of FGM offences to include ‘habitual residents’ of the UK and allows 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.

The Serious Crime Act 2015 also created a new duty of Mandatory reporting of FGM for regulated professionals in health, social care and teachers in England and Wales (see Mandatory reporting below).

International legislation

There are two international conventions and a declaration which contain articles that can be applied to FGM. Signatory states, including the UK, have an obligation under these standards to take legal action against FGM:

  • The UN Convention on the Rights of the Child
  • The UN Convention on the Elimination of All Forms of Discrimination against women
  • Universal Declaration of Human Rights

FGM is recognised internationally as a violation of the human rights of girls and women.  It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination and a complex form of social control against women.  It is nearly always carried out on minors and is a violation of the rights of children.  The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel and inhumane or degrading treatment and the right to life when the procedure results in death.

Mandatory reporting

The Children Act 2004 requires all statutory agencies to take responsibility for safeguarding and promoting the welfare of every child and within this legislative framework supported by statutory guidance (Working Together 2015) professionals and volunteers from all agencies have a responsibility to safeguard children from being abused through FGM.

NHS hospitals, GP practices and mental health trusts are required to record:

  • if a patient has had FGM
  • if there is a family history of FGM
  • if a FGM-related procedure has been carried out on a patient
  • type of FGM
  • if the patient has been re-sutured.

This data must be reported centrally to the Department of Health on a monthly basis. This is 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 FGM and actively support prevention.

The requirement to record FGM data has also been expanded to GP practices and mental health trusts, who will be required to submit information under the Enhanced Dataset when treating patients who have FGM. For further information, see Health and Social Care Information Centre Female Genital Mutilation Datasets/Information Standards Board for Female Genital Mutilation Prevalence Dataset Specification.

Regulated professionals in health and social care professions 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.

The appropriate response to FGM is to follow usual child protection procedures and a referral to children’s social care should be made in accordance with the Referrals procedure to ensure:

  • immediate protection and support for the child/ren
  • that the practice is not perpetuated.

Context in which FGM occurs

Prevalence

FGM is a deeply rooted tradition, widely practiced mainly among specific ethnic populations in Africa parts of Asia and the middle east. As a result of migration and refugee movements FGM is now being practised by ethnic minority populations in other parts of the world such as USA, Canada, Europe, Australia and New Zealand. FGM is practised around the world in various forms across all major faiths.

The World Health Organisation estimates that between 130–140 million girls and women in the world have experienced female genital mutilation and up to two million girls per year undergo some form of the procedure.

The great majority of affected women and girls live in sub-Saharan Africa, but the practice is also known in parts of the Middle East and Asia.

FGM is practiced in more than 28 countries in Africa and in some countries in Asia and the Middle East, however in each of those countries the extent of the practice varies. African countries with the highest likelihood of FGM being practiced are Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Guinea, Mali, Sierra Leone, Somalia and Sudan.  FGM has been found in communities in/from Iraq, Israel, Oman, United Arab Emirates, occupied Palestinian territories, India, Indonesia, Malaysia and Pakistan. A full list of practising countries is available from FORWARD.

It appears that the Democratic Republic of Congo (DRC), Ghana, Niger, Tanzania, Togo, Uganda, and Yemen have the lowest incidence of FGM. However, within each of these countries there are specific ethnic communities in which the incidence of FGM is high.

In England and Wales, women from non-African communities which are most likely to be affected by FGM include Yemeni, Iraqi Kurd, Indonesian and Pakistani women.

FGM is much more common than is generally realised both worldwide and in the UK.

Cultural underpinnings

Female genital mutilation is a complex issue – despite the harm it causes, many women from FGM practicing communities consider FGM normal to protect their cultural identity.

As a result of the beliefs of some practising FGM communities, many women who have undergone FGM may believe they appear more attractive than women who haven’t been infibulated, and that that normal female genitalia are both unattractive and unhygienic. In some communities it maybe considered that a girl who has not undergone FGM is unclean and not able to handle food or drink.

Infibulation (see Types of FGM) is strongly linked to virginity and chastity and it is believed that it can safeguard girls from sex outside marriage and from having sexual feelings. In more traditional cultures it is considered necessary at marriage for the husband and his family to see evidence of the procedure. In some instances mothers will take the girl to be cut open in order for them to be able to have sex. Women also have to be cut open to give birth. The consequences of this are pain, bleeding, varying degrees of incapacity and psychological trauma.

Although FGM is practiced by secular communities, it is most often claimed to be carried out in accordance with religious beliefs. However, there is NO religious justification for this abhorrent practice - NOT one holy book condones the practice. All faiths are against FGM.

Parents who support the practice of female genital mutilation say that they are acting in the child’s best interest. The reasons they give include that it:

  • brings status and respect to the girl
  • preserves a girl’s virginity/chastity
  • is part of being a woman
  • is a rite of passage
  • gives a girl social acceptance, especially for marriage
  • upholds the family honour
  • gives the girl and her family a sense of belonging to the community
  • fulfils a religious requirement mistakenly believed to exist
  • perpetuates a custom/tradition
  • helps girls and women to be clean and hygienic
  • increasing sexual pleasure for the male
  • is cosmetically desirable.

It is because of these beliefs that girls and women who have not undergone FGM are usually considered by practicing communities to be unsuitable for marriage. Women who have attempted to resist exposing their daughters to FGM report that they and their families were ostracised by their community and told that nobody would want to marry their daughters.

 FGM cannot be left to personal preference or cultural custom as it is an extremely harmful practice which violates human rights. 

Cultural change in the UK

There are increasing instances where young men and women who have grown up in the UK are experiencing their own difficulties in relation to this practice. For example young men rejecting girlfriends when they discover she was subjected to FGM as a child or a female child/young person discovering that not all girls are subjected to FGM. Young people who resist FGM can also experience conflict within their family and community.

Also see Consequences of FGM.

Principles supporting this procedure

The following principles should be adopted by all agencies in relation to identifying and responding to children (and unborn children) at risk of, or who have experienced female genital mutilation and their parent(s):

  • The safety and welfare of the child is paramount.
  • All agencies act in the interests of the rights of the child as stated in the U.N. Convention on the Right of the Child (1989).
  • FGM is illegal and is prohibited by the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005, as well as the Serious Crime Act 2015.
  • It is acknowledged that some families see FGM as an act of love rather than cruelty. However, FGM causes significant harm both in the short and long term and constitutes physical and emotional abuse to children.
  • All decisions or plans for the children should be based on good quality assessments and be sensitive to the issues of race, culture, gender, religion and sexuality, and avoid stigmatising the child or the practicing community as far as possible. However, this is an issue by it’s very nature which involves questioning culture, and professionals should not be afraid to tackle the issues for fear of offending the family – FGM is against the law, and is child abuse.
  • The Serious Crime Act 2015 amends the FGM Act 2003 to prohibit the publication of any information that would be likely to lead to the identification of a person against whom an FGM offence is alleged to have been committed. Anonymity will commence once an allegation has been made and will last for the duration of the victim’s lifetime. (Except in some specific circumstances to do with court cases).
  • Accessible, acceptable and sensitive health, education, police, children’s social care and voluntary sector service provision must underpin this procedure.

All agencies should work in partnership with members of local communities, to empower individuals and groups to develop support networks and education programmes.

Description of FGM

Types of FGM                                

FGM has been classified by the WHO into four types:

  • Type 1: Excision of the prepuce with or without excision of part or the entire clitoris
  • Type 2: Excision of the clitoris with partial or total excision of the labia minora (small lips which cover and protect the opening of the vagina and the urinary opening). After the healing process has taken place, scar tissue forms to cover the upper part of the vulva region.
  • Type 3: Infibulation. This is the most severe form of female genital mutilation. Infibulation often (but not always) involves the complete removal of the clitoris, together with the labia minora and at least the anterior two-thirds and often the whole of the medial part of the labia majora (the outer lips of the genitals). The two sides of the vulva are then sewn together with silk, catgut sutures, or thorns leaving only a very small opening to allow for the passage of urine and menstrual flow. This opening is often preserved during healing by insertion of a foreign body.
  • Type 4: Unclassified. This includes all other operations on the female genitalia including pricking, piercing or incising of the clitoris and or labia; stretching of the clitoris and or labia; cauterisation by burning of the clitoris and surrounding tissues; scraping of the tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purposes of tightening or narrowing it; and any other procedure that falls under the definition of female genital mutilation given above.

Age and procedure

The age at which girls are subjected to female genital mutilation varies enormously according to the community. The procedure may be carried out when the girl is newborn, during childhood or adolescence, at marriage or during the first pregnancy. However, the majority of cases of FGM are thought to take place between the ages of 5 and 8, and therefore girls within that age bracket are at a higher risk (see Multi-agency statutory guidance on female genital mutilation).

FGM is usually carried out by the older woman in a practicing community, for whom it is a way of gaining prestige and can be a lucrative source of income. It is believed that foreign nationals may be flown into the UK to perform a number of circumcisions to cut costs for families; it is also believed that children are flown out to their home countries, or other countries that perform this procedure to have this carried out, usually at the beginning of the summer holidays to allow the wounds to heal before the new school term.  However, the procedure can be carried out at any time of the year. It is also believed that there are ‘cutters’ available within the communities here in the UK.

The arrangements for the procedure usually include the child being held down on the floor by several women and the procedure carried out without medical expertise, attention to hygiene and anaesthesia. The instruments used include un-sterilised household knives, razor blades, broken glass and stones. In addition the child is subjected to the procedure unexpectedly. In some cases the child might be told that they are to have a party or celebration, and a party will in fact take place. If professionals are told this by a child from a practicing community, careful questioning should take place and caution given.

Names for FGM

FGM is known by a number of names, including female genital cutting or circumcision. The term female circumcision is unfortunate because it is anatomically incorrect and gives a misleading analogy to male circumcision. The names ‘FGM’ or ‘cut’ are increasingly used at the community level, although they are still not always understood by individuals in practising communities, largely because they are English terms.

For further information, see the FORWARD website.

Consequences of FGM

Many women in practising communities appear to be unaware of the relationship between female genital mutilation and its harmful health and welfare consequences, in particular the implications affecting sexual intercourse and childbirth, which occur many years after the mutilation has taken place.

The health implication of the FGM procedure can be severe to fatal for a child, depending on the type of FGM carried out.

As with all forms of child abuse or trauma, the impact of the FGM on a child will depend upon such factors as:

  • the severity and nature of the violence
  • the individual child’s innate resilience
  • the warmth and support the child receives in their relationship with their parent/s, siblings and other family members
  • the nature and the quality of the child’s wider relationships and social networks
  • previous or subsequent traumas experienced by the child
  • Particular characteristics of the child’s gender, ethnic origin, age, (dis)ability, socio-economic and cultural background.

Short-term implications for a child’s health and welfare

Short-term health implications can include:

  • severe pain
  • emotional and psychological shock (exacerbated by having to reconcile being subjected to the trauma by loving parents, extended family and friends)
  • haemorrhage
  • wound infections including Tetanus, and blood borne viruses (including HIV and Hepatitis B and C)
  • urinary retention
  • injury to adjacent tissues
  • fracture or dislocation as a result of restraint
  • damage to other organs
  • death.

Long-term implications for a girl or woman’s health and welfare

The longer term implications for women who have been subject to FGM Types 1 and 2 are likely to be related to the trauma of the actual procedure. Nevertheless, analysis of World Health Organisation data has shown that, as compared to women who have not undergone FGM, women who had been subject to any type of FGM showed an increase in complications in childbirth, worsening with Type 3. Therefore, although Type 3 creates most difficulties, professionals should respond proactively for all FGM types.

The health problems caused by FGM Type 3 are severe – urinary problems, difficulty with menstruation, pain during sex, lack of pleasurable sensation, psychological problems, infertility, vaginal infections, specific problems during pregnancy and childbirth, including flashbacks.

Women with FGM Type 3 require special care during pregnancy and childbirth.

The long-term health implications of FGM include:

  • chronic vaginal and pelvic infections
  • difficulties in menstruation
  • difficulties in passing urine and chronic urine infections
  • renal impairment and possible renal failure
  • damage to the reproductive system, including infertility
  • infibulation cysts, neuromas, abscesses and keloid scar formation
  • complications in pregnancy and delay in the second stage of childbirth
  • maternal or foetal death
  • psychological damage; including a number of mental health and psychosexual problems including depression, anxiety, and sexual dysfunction
  • increased risk of HIV and other sexually transmitted infections
  • increased risk of vaginal fistula
  • sexual dysfunction.

In addition there are also psycho-sexual, psychological and social consequences of FGM.

Mental health problems

In FGM practising communities, the procedure is usually performed without anaesthetics and with instruments such as razor blades as noted above. Case histories and personal accounts from women note that FGM is an extremely traumatic experience for girls and women that stay with them for the rest of their lives.

Young women receiving psychological counselling in the UK report feelings of betrayal by parents, incompleteness, regret and anger. It is possible as young women become more informed about FGM and/or cross the threshold from traditional/practising communities to the modern sector this problem may be more frequently identified. There is increasing awareness of the severe psychological consequences of FGM for girls and women, which became evident in mental health problems.

The results from research in practising African communities are that women who have undergone FGM have the same levels of Post Traumatic Stress Disorder as adults who have been subject to early childhood abuse, and the majority of the women (80%) suffer from affective (mood) or anxiety disorders.

The fact that FGM is ‘culturally embedded’ in a girl or woman’s community appears not to protect her against the development of Post Traumatic Stress Disorder and other psychiatric disorders.

Professional response

There are three circumstances related to FGM which require identification and intervention:

  • Where a child is at risk of FGM.
  • Where a child has been abused through FGM.
  • Where a prospective mother has undergone FGM.

Identifying a child who has been subject to FGM or who is at risk of being abused through FGM

A child at risk of FGM

Professionals in all agencies, and individuals and groups in the community, need to be alert to the possibility of a child being at risk of or having experienced female genital mutilation. There are a range of potential indicators that a child may be at risk of FGM, but this is not an exhaustive list.

Indications that FGM may be about to take place include:

  • The family comes from a community that is known to practice FGM, e.g. Somalia, Sudan and other African countries (see Context in which FGM occurs) as well as increasingly from places such as Iran and Iraq. It may be possible that they will practice FGM if a female family elder is around.
  • Parents state that they or a relative will take the child out of the country for a prolonged period.
  • The family makes preparations for the child to take a holiday to their country of origin or another country where the practice is prevalent e.g. arranging vaccinations, planning an absence from school.  This does not necessarily mean FGM will take place – more information needs to be gained.
  • A child may talk about a long holiday to her country of origin or another country where the practice is prevalent, including African countries and the Middle East.
  • A child may confide to a professional that she is to have a ‘special procedure’ or to attend a special occasion/ceremony.
  • A professional hears reference to FGM in conversation, for example a child may tell other children about it.
  • A child may request help from a teacher or another adult.
  • An awareness by a midwife or obstetrician that the procedure has already been carried out on a mother, or on other women or older girls in the family prompting concern for any daughters, girls or women in the family.  Again work with the family is needed to gain more information.
  • Any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family. However, it must not be assumed that just because a mother has undergone FGM that she will automatically do this to her child.
  • Any female child who has a sister who has already undergone FGM must be considered to be at risk, as must other female children in the extended family.
  • The early part of the school summer holiday is the time when girls are most at risk of having the procedure carried out in the UK or being sent abroad to have it carried out.  As this allows for the recovery period over the school break.  Consequently a change in a child’s behaviour in the lead up to school holidays or on return to school maybe significant. (FGM can however, be carried out at any time of the year).
  • Where a girl from a practising community is withdrawn from sex and relationship education they maybe at risk from their parents wishing to keep them uninformed about their body and rights.
  • Repeated failure to attend or engage with health and welfare services or the mother of a girl is very reluctant to undergo genital examination.
  • If a female family elder is present, particularly when she is visiting from a country of origin, and taking a more active and influential role in the family.
  • The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children.
  • The socio economic position of the family and the level of integration within UK society can increase risk.

Indication that FGM may have already taken place include:

  • A child may spend long periods of time away from the classroom during the day with bladder or menstrual problems/has frequent days off from school with urinary tract infections.
  • There may be prolonged absences from school.
  • A prolonged absence from school with noticeable behaviour changes on the girl’s return could be an indication that a girl has recently undergone FGM.
  • Professionals also need to be vigilant to the emotional and psychological needs of children who may/are suffering the adverse consequences of the practice, e.g. withdrawal, depression.
  • A child may confide in a professional.
  • A professional overhears a conversation amongst children about a special procedure that took place, whilst on holiday.
  • A child requiring to be excused from physical exercise lessons without support of her GP.
  • A child may ask for help.
  • A child has returned from a holiday with fractured/bruised limbs.
  • A child has difficulty walking, sitting or standing and may appear to be uncomfortable.
  • Recurrent UTI (urinary tract infection) or complaints of abdominal pain.

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

Professionals and volunteers from all agencies responding to concerns

Overview of professional response

Any information or concerns that a child is at risk of, or has undergone female genital mutilation should result in a child protection referral to LA Children’s Social Care/Police in line with the Referral procedure. As noted above, Regulated professionals in health and social care professions 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.

Where a child is thought to be at risk of FGM, practitioners should be alert to the need to act quickly - before the child is abused through the FGM procedure in the UK, or taken abroad to undergo the procedure.

Screening or risk assessment tools may be used and may include:

The tools are to aid an initial assessment of risk, and then support the on-going assessment of individuals who are potentially subject to or are at risk of FGM. However, this should not prohibit delays in reporting and referral as identified above when the need to act quickly to safeguard and protect a child will take priority, as multi-agency safeguarding intervention needs to happen quickly.

Education/leisure and community and faith groups

Teachers, other school staff, volunteers and members of community groups may become aware that a child is at risk of FGM through a parent/other adult, a child or other children disclosing that:

  • The procedure is being planned
  • An older child in the family has already undergone FGM.

School nurses are in a particularly good position to identify FGM or receive a disclosure about it.

A professional, volunteer or community group member who has information or suspicions that a child is at risk of FGM should consult with their agency or group’s designated child protection adviser (if they have one) and should make an immediate referral to LA Children’s Social Care, in line with relevant Referral procedures.

The referral should not be delayed in order to consult with the designated child protection adviser, a manager or group leader, as multi-agency safeguarding intervention needs to happen quickly.

If there is a concern about one child, consideration must be given to whether siblings are at similar risk. Once concerns are raised about FGM there should also be consideration of possible risk to other children in the practising community.

Concerns that a child has already undergone FGM

Teachers, other school staff, volunteers and members of community groups may become aware that a child has been subjected to FGM though:

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.

A professional, volunteer or community group member who has information or suspicions that a child has been subjected to FGM should consult with their agency or group’s designated child protection adviser (if they have one) and make a referral to LA Children’s Social Care.

If the child appears to be in acute physical and emotional distress, they should make an immediate referral to LA Children’s Social Care and to the local health service.

If there is a concern about one child, the child’s siblings and the children in the extended family should be considered to be at risk.

Once concerns are raised about FGM in relation to one child/family there should also be consideration of possible risk to other children in the practising community.

Health

Health professionals encountering a girl or a woman who has undergone FGM should be alert to the possible risk of FGM in relation to her:

  • siblings
  • daughters or daughter she may have in the future
  • extended family members.

The on-going health needs of those who have undergone FGM should be carefully considered and appropriate referrals made. Health professionals are the most likely to encounter a girl or woman who has been subjected to FGM. All girls and women who have undergone FGM should be given information about the legal and health implications of practising FGM (this should be fully recorded in records). Professionals in health and social care 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.  For health professionals there is also a requirement to for recording in both the ‘red book’ and discharge summaries from maternity if FGM has been performed on the mother in the past.

Health visitors are in a good position to reinforce information about the health consequences and the law relating to FGM. Currently, FGM advice is not always provided on post-natal discharge reports and is not recorded routinely in health visiting records. Health professionals should ensure this information is recorded.

If a girl or woman who has been de-infibulated requests re-infibulation after the birth of a child, where the child is female or there are daughters in the family, health professionals should consult with their designated child protection adviser and make a referral to LA Children’s Social Care.

After childbirth a girl/woman who has been de-infibulated may request and continue to request re-infibulation. This should be treated as a child protection concern. This is because, whilst the request for re-infibulation is not in itself a child protection issue, the fact that the girl or woman is apparently not wanting to comply with UK law and/or consider that the process is harmful raises concerns in relation to female child/ren she may already have or may have in the future.

If the girl or woman is mother or prospective mother, the child/ren or unborn child should be considered at risk of significant harm. The health professional should consult with their designated child protection adviser and should make a referral to LA Children’s Social Care.

If the girl or woman has the care of female children, these children should be considered children at risk of significant harm. The designated child protection adviser should be consulted and referral made to LA Children’s Social Care, as above.

The police

The police have a key role in the investigation of serious crime.

All Child Abuse Investigation Teams (CAITs) in the West Midlands should have an awareness of FGM and specific policy to deal with allegations of FGM. The police response recognises the need for an effective investigative response to what is regarded as an extremely severe form of child abuse, recognising the immediate and long term pain, suffering and risks to health associated with this practice.

Where FGM has been practiced, CAIT will take a lead role in the investigation of this serious crime, working to common joint investigative practices and in line with strategy agreements. Professionals in health and social care as well as 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, the police will take appropriate action to ensure the girl/young woman is safe and her needs are prioritised.

The police investigation will extend to identifying established excisors and investigating these with a view to identifying further victims and closing down these networks.

Intelligence, however small needs to be sent into the police from statutory agencies, community and faith groups who are working within the communities.  It is vital that this information is fed into the police intelligence systems and sharing of this information is a multi-agency responsibility.

Adult social care

When information is received by Adult Social Care, in relation to an adult with care and support needs the referral must be discussed with the relevant Team Manager, who will inform the appropriate team in line with Safeguarding Adults and Childrens policies and procedures. In all cases, professionals should not discuss the referral with the parents/carers/family until a multi-agency action plan has been agreed.

On receipt of the referral a planning meeting should be convened within a maximum of 5 days, involving the police and any other relevant agency. If a referral is received concerning one female in a family, consideration must be given to whether other females in that family are also at similar risk, particularly children.  There should be consideration of other females from other associated families once concerns are raised about an incident or the perpetrator of FGM. Where there are also children at risk, a referral must be made to Children’s Social Care.

Local authority children’s social care

Children’s social care will investigate (initially) under Section 47 of the Children’s Act (1989).

If a referral is received concerning one child, consideration must be given to whether siblings are at similar risk.

Once concerns are raised about FGM, there should also be consideration of possible risk to other children in the practising community as well as adults with care and support needs. Professionals should be alert to the fact that if one of the female children amongst these could be identified as being at risk of FGM they will then need to be responded to as a child in need or a child in need of protection.

Regulated professionals in social care 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.

Working Together 2015 “If at any time it is considered that the child maybe a Child In Need as defined in the Children Act 1989, or that the child has suffered Significant Harm or is likely to do so, a referral should be made immediately to Local Authority Children’s Social Care.”

Strategy Meeting

On receipt of a referral, a Strategy Meeting must be convened as soon as practicable and within 2 days to agree any immediate steps for protection of a child, and will involve representatives from the police, children’s social care, education, health and other bodies as appropriate, including Voluntary Services. Health providers or voluntary organisations with specific expertise, e.g. FGM, domestic violence and/or sexual abuse, should be invited; and consideration may also be given to inviting a legal advisor. (Dependant upon the assessment the meeting may need to take place immediately).

In addition to the issues considered at all strategy meetings, the strategy meeting will consider:

  • How best to approach the family and seek their cooperation. If either parents or child has had access to information about the harmful aspects of FGM and the law in the UK. If not, the parents/child should be given appropriate information regarding the law and harmful consequences of FGM.
  • What action may be necessary in response to an attempt to remove the child from the UK.
  • Whether a medical examination is required and if so for what purpose.

If an interpreter is needed, caution is needed in selecting an appropriate person.  They should be appropriately trained in all aspects of FGM, and used in all interviews with the family. A female interpreter should be used who is not a relative, known to the family, or in a position within the community.

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, including the use of community organisations and/or community leaders to facilitate the work with parents/family. However, the child’s interests are always paramount, and the first priority is the protection of the child.

If no agreement is reached, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child’s safety.  Furthermore reference should be made to the LSCB Escalation Policy and appropriate action taken accordingly.

The primary focus is to prevent the child undergoing any form of FGM, rather than removal of the child from the family; however this may sometimes be necessary. It is important to have an open mind as it will be unlikely for the family to admit being in favour of FGM.

Child at immediate risk of harm

If the Strategy Meeting decides that the child is in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, then an Emergency Protection Order should be sought.  The Police also have protection powers where there is a reasonable cause to believe the child is at immediate risk.

Additionally other remedies can be used as a form of legal protection. For example a Prohibited Steps Order to prevent the parents/family removing the child, and making it clear to them that they will be breaking the law if they arrange for the child to have the procedure.

If a child has already undergone FGM

A Strategy Meeting must be convened within 2 days. The Strategy Meeting will consider how, where and when the procedure was performed and the implication of this. A police investigation will commence and this will take precedence over any other investigation. (Dependant upon the assessment the meeting may need to take place immediately).

Consideration should be given to any other female children who may be at risk, or who may have also had the procedure carried out.

If the child has already undergone FGM, the Strategy Meeting will need to consider carefully whether to continue enquiries or whether to assess the need for support services. If any legal action is being considered, legal advice must be sought.

A second Strategy Meeting may be required, and this should be held within 10 working days. This meeting must evaluate the information collected in the enquiry and recommend whether a Child Protection Conference is necessary.

A girl who has already undergone FGM should not normally be subject to a Child Protection Conference or Child Protection Plan unless additional child protection concerns exist. However, she should be offered counselling and medical help. Consideration must be given to any other female siblings or children at risk of FGM, as well as the family’s willingness to co-operate with the agencies concerned.

A Child Protection Conference should only be considered necessary if there are any unresolved child protection issues once the initial investigation and assessment have been completed.

If the strategy meeting concludes that there is no clear evidence of risk to a child, children’s social work services should:

  • consult the child’s GP about the conclusion and invite him/her to notify children’s social care if any information arises which challenges this decision or gives rise to further concerns
  • notify other appropriate professionals involved with the family, of the reasons why the enquiry was concluded, as well as the family and the referrer
  • support the affected girl to deal with the consequences of FGM
  • offer the family appropriate support and preventatives services, health, education and other work prevention to reduce risk to others or themselves.

Reducing the prevalence of FGM

The role of Local Safeguarding Children Boards

Local Safeguarding Children Boards’ (LSCBs) duties and responsibilities include promoting activity amongst local agencies and in the community to:

  • identify and prevent maltreatment or impairment of health or development, and ensure children are growing up in circumstances consistent with safe and effective care
  • safeguard and promote the welfare of groups of children who are potentially more vulnerable than the general population
  • increase understanding of safeguarding children issues in the professional and wider community, promoting the message that safeguarding is everybody’s responsibility.

The LSCB should undertake initiatives in relation to FGM which fulfil these duties and responsibilities.

The LSCBs are responsible for ensuring that single agency and inter-agency training on safeguarding and promoting welfare is provided in order to meet local needs, i.e. child protection procedures in relation to FGM and are confident working with local preventative programmes relating to FGM.

Information sharing

Professionals in all agencies need to be confident and competent in sharing information appropriately, both to safeguard children from being abused through FGM to receive physical, emotional and psychological help.

Regulated professionals in health and social care professions 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 (see Legislation, policy and mandatory reporting of FGM). 

Further information

Agencies offering help and advice

  • Female Genital Mutilation Helpline - 0800 028 3550; fgmhelp@nspcc.org.uk
  • BCC Health Education Service - 0121 303 8200
  • Birmingham Against FGM – 0121 4641131
  • West Midlands Police - Investigative Training - 0121 626 5573
  • West Midlands Police - Public Protection Unit HQ - 0121 609 6909
  • African Well Woman’s Clinic - 07817 534274 or 0121 424 3909
  • Muslim Women’s Network – National Helpline 0800-999-5786/0303-999-5786
  • Birmingham and Solihull Women’s Aid – Helpline 0808 800 0028
  • ChildLine 0800 1111 (24 hour helpline for children)
  • NSPCC 24 hour helpline to protect children and young people affected by FGM – 0800 028 3550

There are also a number of NHS clinics across the UK which are supporting women who have undergone FGM.

It is recognised that the above is not an exhaustive list for the West Midlands and as a consequence this will need to be populated for the region.

Note

With acknowledgement to London Safeguarding Children Board for sharing their FGM procedure, which has informed this document, along with West Midlands Metropolitan Safeguarding Boards, West Mercia and Staffordshire and Stoke On Trent.

This page is correct as printed on Friday 18th of August 2017 07:00:49 PM please refer back to this website (http://westmidlands.procedures.org.uk) for updates.
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