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21.21 Female genital mutilation

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The World Health Organisation (WHO) defines female genital mutilation (FGM) as: “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” (WHO, 2000).

FGM is also known as female circumcision or initiation, 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).

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.

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, individuals 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.

This procedure should be read in conjunction with the Child Protection Procedures.

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 became law).

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). Section 6(1) of the 2003 Act provides that the term “girl” includes “woman” so the offences in sections 1 to 3 apply to victims of any age. 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.

National Legislation, Policy and Mandatory Requirements

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 2018) professionals and volunteers from all agencies have a responsibility to safeguard children from being abused through FGM.

It became mandatory in 2014 for any NHS healthcare professional to record within a patient’s clinical record if they identify through the delivery of healthcare services that a woman or girl has had 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 an FGM-related procedure has been carried out on a patient
  • type of FGM
  • if the patient has been re-sutured.

NHS Digital collects data on FGM within the NHS in England on behalf of the Department of Health (DH). The data collected is used to produce information that helps to:

  • improve how the NHS supports women and girls who have had or who are at risk of FGM
  • plan the local NHS services needed both now and in the future
  • help other organisations e.g. local authorities to develop plans to stop FGM happening in local communities

Data is collected from NHS Acute Trusts, Mental Health Trusts and GP practices and reports are published as an official statistic every quarter. For further information, see Health and Social Care Information Centre Female Genital Mutilation Datasets/Information Standards Board for Female Genital Mutilation Prevalence Dataset Specification.

Mandatory Reporting of FGM

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.

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.

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.

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 https://www.gov.uk/government/publications/fact-sheet-on-mandatory-reporting-of-female-genital-mutilation Fact sheet on mandatory reporting of female genital mutilation - GOV.UK (www.gov.uk) to Police.

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.

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 exact number of girls and women alive today who have undergone FGM is unknown, however, UNICEF estimates that over 200 million girls and women worldwide have undergone FGM. 

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.

HM Government Multi-agency statutory guidance on female genital mutilation lists 27 countries in Africa where FGM is practiced, and also 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 Cameroon, Ghana, Niger, Tanzania, Togo, and Uganda, 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. HM Government guidance quotes a 2015 study estimating that approximately 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM, and approximately 103,000 women aged 15-49 and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM. In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM.

NHS Digital, which is part of the Government Statistical Service, has produced data which shows that since the collection began in 2015, NHS trusts and GP practices have reported information about 28,035 individual women and girls. Between April 2015 and June 2021 there were a total of 65,800 attendances for these individuals where FGM was identified. A link to full report can be found here. Female Genital Mutilation (FGM) - April to June 2021 - Report.pdf (digital.nhs.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 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, and none of the main religious texts advocate or justify 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.

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.
  • FGM is an extremely harmful practice - responding to it cannot be left to personal choice.
  • 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 high quality assessments based on Working Together to Safeguard Children (2018) 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 its 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.

Types of FGM                                

FGM has been classified by the WHO into four types:

  • Type 1: Cliteridectomy. Excision of the prepuce with or without excision of part or the entire clitoris
  • Type 2: Excision. 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: Other. 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, it is usually carried out on young girls between infancy and the age of 15, most commonly before puberty starts. (see HM Government - Multi-agency statutory guidance on Female Genital Mutilation (publishing.service.gov.uk), and Female genital mutilation (FGM) - NHS (www.nhs.uk).

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.

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 are likely to be related to the trauma of the actual procedure. The World Health Organisation highlight that generally speaking, risks from FGM increase with increasing severity (which here corresponds to the amount of tissue damaged), although all forms of FGM are associated with increased health risk. 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. (ehrendt, A. et al, 2005, ‘Posttraumatic Stress Disorder and Memory Problems after Female Genital Mutilation’, Am J Psychiatry 162:1000-1002, May)

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.

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.

Factors which suggest a child may be 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:

Potential risk factors may include:

  • a female child is born to a woman who has undergone FGM;
  • a female child has an older sibling or cousin who has undergone FGM;
  • a female child’s father comes from a community known to practise FGM;
  • the family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
  • a woman/family believe FGM is integral to cultural or religious identity;
  • a girl/family has limited level of integration within UK community;
  • parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
  • a girl confides to a professional that she is to have a ‘special procedure’ or to attend a special occasion to ‘become a woman’;
  • a girl talks about a long holiday to her country of origin or another country where the practice is prevalent (see Section 2.3 for the nationalities that traditionally practise FGM);
  • parents state that they or a relative will take the girl out of the country for a prolonged period;
  • a parent or family member expresses concern that FGM may be carried out on the girl;
  • a family is not engaging with professionals (health, education or other);
  • a family is already known to social care in relation to other safeguarding issues;
  • a girl requests help from a teacher or another adult because she is aware or suspects that she is at immediate risk of FGM;
  • a girl talks about FGM in conversation, for example, a girl may tell other children about it (see Annex G for commonly used terms in different languages) – it is important to take into account the context of the discussion;
  • a girl from a practising community is withdrawn from Personal, Social, Health and Economic (PSHE) education or its equivalent;
  • a girl is unexpectedly absent from school;
  • sections are missing from a girl’s Red book; and/or
  • a girl has attended a travel clinic or equivalent for vaccinations / anti-malarials.

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 mother/family member discloses that female child has had FGM;
  • A family/child is already known to social services in relation to other safeguarding issues;
  • 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.
  • A child finds it hard to sit still for long periods of time, and this was not a problem previously;
  • A child spends longer than normal in the bathroom or toilet due to difficulties urinating;
  • Recurrent UTI (urinary tract infection) or complaints of abdominal pain.
  • A girl asks for help, but is not be explicit about the problem;
  • A girl talks about pain or discomfort between her legs, and/or
  • A girl is reluctant to undergo any medical examinations;

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

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. This should include unborn children whose mothers are known to have undergone FGM. 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.

If indicators of FGM exist then it may not necessarily be appropriate to make a referral to Children's Social Care immediately, although a multi-agency response might be required to ensure that information is shared and that agencies have access to the most up to date information on which to assess the risk.   If the only risk factor is that a child's mother has undergone FGM this does not necessarily mean that there is a significant risk that the child will also be subjected to FGM and this would need to be explored with the family.  Professionals should remember that FGM can be carried out at any age and so identifying a risk at birth means that the risk may need to be reviewed over the course of her childhood.  As part of the assessment professionals should make sure that the child and/or appropriate family members understand:

  • That FGM is illegal in the UK
  • The possible consequences of FGM
  • Any actions taken
  • That information will be shared as appropriate

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/Early Years/leisure and community and faith groups

Teachers and nursery workers are in a particularly strong position to identify when a child or young person is at risk of, or has been subject to FGM, as they have ongoing relationships with girls and their families. They are well placed to identify any changes in behaviour or physical wellbeing, and also to recognise other possible indicators such as planned holidays to high risk countries. Education staff also have an important role in protecting children and young people from FGM through information provided as part of the curriculum.

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.

See Female Genital Mutilation: Guidance for Schools.

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/safeguarding lead (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/safeguarding lead, 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. It will be rare for teachers to see visual evidence, and they should not be examining pupils or students, but the same definition of what is meant by “to discover that an act of FGM appears to have been carried out” is used for all professionals to whom the mandatory reporting duty applies.

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/safeguarding lead (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

Concerns in relation to a mother who has undergone FGM:

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.

When health professionals identify that the woman has or may have been mutilated they should carry out a risk assessment using, 'Annex 1 of 'Female Genital Mutilation Risk and Safeguarding: Guidance for professionals (May 2016)'. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/525390/FGM_safeguarding_report_A.pdf#page=25

It is critical that risk assessments are undertaken and that assessments are combined with supportive and educative work to assist women and their families to understand the legal framework and physical, sexual and psychological harm caused by FGM.

Health professionals should refer to CSC if their assessment raises concerns that a female child may have had, or be at risk of, FGM. They should also refer to CSC when they are unable to gather sufficient information to adequately assess the risk.

If indicators of FGM exist then it may not necessarily be appropriate to make a referral to Children's Social Care immediately, although a multi-agency response might be required to ensure that information is shared and that agencies have access to the most up to date information on which to assess the risk.   If the only risk factor is that a child's mother has undergone FGM this does not necessarily mean that there is a significant risk that the child will also be subjected to FGM and this would need to be explored with the family.

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 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. FGM advice  should be provided on post-natal discharge reports and recorded routinely in health visiting records.  FGM guidance should always be provided by Health Visitors and recorded within the notes, and Health Visitors should also consider informing the child’s GP.

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 FGM Information Sharing (FGM-IS) System in the NHS in England

The Female Genital Mutilation Information Sharing (FGM-IS), is a national IT system for health that allows clinicians across England to note on a girl's record within the NHS Summary Care Record application (an existing part of a child’s electronic record) that they are potentially at risk of FGM.

The FGM-IS allows the potential risk of FGM to be shared confidentially with health professionals across all care settings until a girl is 18 years old. The FGM-IS can be used at any appropriate time during the delivery of care to check whether the girl has been assessed as being potentially at risk of FGM.

If a girl is identified as being at potential risk of FGM, the FGM risk indicator should be added to the system following completion of an FGM risk assessment, as detailed in the Department of Health's guidance titled ‘Female Genital Mutilation Risk and Safeguarding Guidance for professionals’ (2017)

The police

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

All Police child abuse investigation teams 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, the Police will take a lead role in the investigation. 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.

Where there are concerns that a child is at risk of FGM and despite work with the parents those concerns remain that the family intend to subject the child to FGM, Police should consider their use of powers under Section 46 Children Act 1989 to protect that child from harm.

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.

 

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 Children’s 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.

 

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 2018 “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.”

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. (Dependent 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 between professionals on the appropriate response, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child’s safety.  If it is not possible to resolve professional differences of opinion in a timely way consideration should be given to implementing the local Escalation Policy for resolving professional differences of opinion.

One outcome of a strategy meeting/discussion could be the decision to apply for an FGM Protection Order. 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.

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. (Dependent 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.

As set out in Working Together to Safeguard Children (2018), it is the role of the three safeguarding partners to agree on ways to co-ordinate their safeguarding services; act as a strategic leadership group in supporting and engaging others; and implement local and national learning including from serious child safeguarding incidents.

In discharging this function, it is important that the safeguarding partners, working with relevant agencies, consider how they support and enable local organisations and agencies to work together in a system where:

  • children are safeguarded and their welfare promoted
  • partner organisations and agencies collaborate, share and co-own the vision for how to achieve improved outcomes for vulnerable children
  • organisations and agencies challenge appropriately and hold one another to account effectively
  • there is early identification and analysis of new safeguarding issues and emerging threats
  • learning is promoted and embedded in a way that local services for children and families can become more reflective and implement changes to practice
  • information is shared effectively to facilitate more accurate and timely decision making for children and families

Safeguarding partners should therefore have due regard for the need to ensure that safeguarding children and young people from FGM, promoting the awareness and confidence of professionals to respond appropriately to concerns about FGM, and ensuring the appropriate pathways are in place to respond to these concerns within their area.

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. Also, see Female Genital Mutilation Protection Orders (FGMPO) above.

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). 

  • NSPCC 24 hour Female Genital Mutilation Helpline - 0800 028 3550;  or email: fgmhelp@nspcc.org.uk. Female Genital Mutilation - Prevent & Protect | NSPCC
  • 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.

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 Thursday 21st of November 2024 09:41:35 AM please refer back to this website (http://westmidlands.procedures.org.uk) for updates.