4.2 Female Genital Mutilation: Procedure and Guidance

Female Genital Mutilation (FGM) is considered to be a form of gender based violence and child abuse in the UK, it is a grave violation of the human rights of girls and women. It has intolerable long-term physical and emotional consequences for the survivors and has been illegal in the UK for over 30 years. It is estimated that 137,000 girls and women in the UK are affected by this practice, but this is likely to be an underesimation.

This multi-agency FGM guidance and procedure is relevant for agencies working with both children and adults. It has been produced to support agencies in Buckinghamshire to work effectively together to tackle FGM. Agencies should continue to refer to relevant specialist professional guidance alongside this document.

This document should also be read in conjunction with:

•  Multi-Agency Statutory Guidance on Female Genital Mutilation. This should be read and followed by all professionals who are working to safeguard and promote the welfare of children and vulnerable adults.
• BSCP Continuum of Need Incorporating Threshold Guidance for what to do if you are concerned about a child in Bucks
• The government’s procedural information for professionals subject to the FGM mandatory reporting duty

All agencies/services should be alert to the possibility of FGM, and their approach should include a preventative strategy that focuses upon education, as well as the protection of girls/women at risk of significant harm.

The following principles should be adhered to:

• The safety and welfare of the girl/woman is paramount.
• All agencies/services and staff, including volunteers, should act in the interest of the rights of the girl/woman, as stated in the UN Convention on the Rights of the Child (1989).
• All decisions or plans for the girl/woman should be based on thorough assessments which have a sensitive approach to the issues of age, race, culture, gender, religion. Stigmatisation of the girl/woman or their specific community should be avoided.
• Buckinghamshire’s agencies/services should work in partnership with members of affected local communities, to develop support networks and appropriate education programme.

1. The momentum to end FGM has grown significantly in the last four years due to various campaigners raising awareness of the issue and the government strengthening its stance on FGM. The UK government is committed to eradicating this harmful practice within a generation and has strengthened the legal framework to help achieve this.
2. Mandatory Reporting Duty (October 2015): Introduced under Section 5B of the 2003 Female Genital Mutilation Act, the duty requires regulated health and social care professionals and teachers in England and Wales to report ‘known’ cases of FGM in under 18s to the police which they identify in the course of their professional work. See Section 12 of this guidance for further details
3. Serious Crime Act (2015): This strengthened the 2003 Female Genital Mutilation Act with the following measures:

   1) Created a new offence of failing to protect a girl from FGM. Anyone with parental responsibility for a girl under 16 who was mutilated will be potentially liable if they did not take steps to prevent it.

   2) Granted life-long anonymity for persons against whom a female genital mutilation offence is alleged to have been committed.

   3) Enabled a court to grant an “FGM protection order” for the purposes of:

   a) protecting a girl against the infliction of a genital mutilation offence, or                                              
   b) protecting a girl against whom any such offence has been committed.

4. Female Genital Mutilation Act (2003): This replaced the 1985 Act in England, Wales and Northern Ireland.[1]

   Made the following an offence:

   1) To aid, abet, counsel or procure a person who is not a UK national or permanent UK resident to undertake a relevant act of FGM outside the UK.

   2) To aid, abet, counsel or procure a girl to excise, infibulate or otherwise mutilate the whole or any part of her own labia majora, labia minora or clitoris.

   On conviction of indictment: a fine, or imprisonment for a term not exceeding 14 years, or both.

5. Prohibition of Female Circumcision Act (1985): It became an offence for any person:

          a) to excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia
              minora or clitoris of another person

          b) to aid, abet, counsel or procure the performance by another person of any of those acts on that
              other person's own body

      On conviction or indictment: a fine or imprisonment for a term not exceeding 14 years or both.

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

FGM has been classified by the WHO into four types: 

• Type 1 - Clitoridectomy: Partial or total removal of the clitoris and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.
• Type 2 - Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are ‘the lips’ that surround the vagina).
• Type 3 - Infibulation: Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner and sometimes outer labia, with or without removal of the clitoris. This is the most extreme form of FGM.
• Type 4 - Other: All other harmful procedures to the female genitalia for non-medical purposes for example, pricking, piercing, tattooing, incising, scraping and cauterising the genital area. Type 4 is noted by professionals to be common among practising communities. However, it is also the type that often goes unnoticed and therefore not recorded.

FGM is known by a number of names, including female genital cutting or circumcision. The names ‘FGM’ or ‘cut’ are increasingly used at the community level, although they are still not always understood by individuals in practicing communities, largely because they are English terms. Appendices B and C provide further information to help professionals talk about FGM with different communities, including the various names that may be used for FGM across different communities.

Those who are affected by FGM may be born to parents from FGM practising communities or women resident in the UK who were born in countries that practice FGM. These may include (but are not limited to) immigrants, refugees, asylum seekers, overseas students or the wives of overseas students.

The age at which girls undergo FGM varies enormously according to the community. The procedure may be carried out at any time, including when the girl is newborn, during childhood, adolescence, at marriage or during the first pregnancy. However, in the majority of cases FGM takes place between the ages of 5-8 and therefore girls within that age bracket are at a higher risk.

Not all mutilation is vaginal. Breast ironing/stretching/flattening is the process during which young pubescent girls’ breasts are ironed, massaged, flattened and/or pounded down over a period of time (sometimes years) in order for the breasts to disappear or delay the development of the breasts entirely.

Breast ironing is now classed as a crime and can be prosecuted as a form of child abuse. 

Find out more from the National FGM centre.

The Buckinghamshire Strategy for Tackling FGM contains more detailed information on the prevalence of FGM at an international, national and local level. A summary of key points is listed below.

The International Picture

• Globally 100 – 140 million women and girls have undergone FGM and a further 3 million girls undergo FGM every year in Africa.[i]
• Most of the females affected live in 28 African countries, with some also from parts of the Middle East and Asia. In Somalia, Sudan, Djibouti, Egypt, Guinea and Sierra Leone, FGM prevalence rates are over 90%.

[i] United Nations Children’s Fund (2013). Female Genital Mutilation / Cutting: A Statistical overview and exploration of the dynamics of change. UNICEF, New York.

The National Picture

The prevalence of FGM in the UK is difficult to estimate because of its hidden nature. However, a report published in July 2014[i] estimated that as of 2011:

• Approximately 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM.
• 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.
• Combining the figures for the three age groups, an estimated 137,000 women and girls with FGM, born in countries where FGM is practised, were permanently resident in England and Wales in 2011.

[i] Equality Now and City University

The Local Picture

1. There is an uneven distribution of cases of FGM around the country, with more occurring in those areas of the UK with larger communities from the practising countries. Whilst this would not make Buckinghamshire an area of high FGM prevalence, there are some areas close by that are likely to have far more cases such as Oxford, Reading, Slough and Milton Keynes.
   
   
2. the Buckinghamshire Joint Strategic Needs Assessment (JNSA) has used 2011 census data to estimate the number of women aged 15-49 years in Buckinghamshire and within each of the four Districts who may have undergone FGM:[i]

• approximately 792 (0.16% of the total population) Buckinghamshire resident women aged 15-49 years may have undergone FGM. In addition there will also be women aged 50 and over who have undergone FGM who are not included in these estimates.
• the highest number of women aged 15-49 estimated to have undergone FGM live in Wycombe District, although the proportion of the total population is slightly higher in South Bucks than in other Districts.
• in Wycombe District there are estimated to be 257 women (0.15% of total residents) who have had FGM, 238 (0.14% of total residents) in Aylesbury, 161 (0.24% of total residents) in South Bucks District, and 136 (0.15% of total residents) in Chiltern District.
• since the mandatory reporting duty was implemented in October 2015, no cases of FGM in Buckinghamshire have been reported to Thames Valley Police that could be recorded as a crime under Home Office Counting Rules
• data on FGM prevalence can also be derived from The Female Genital Mutilation (FGM) Enhanced Dataset. This is a repository for individual level data collected by healthcare providers in England. As of September 2016, all statistical releases relating to Buckinghamshire have data suppressed for statistical reasons, indicating between 0 and 4 reported cases for each reporting period. 

It is important that professionals understand how to follow relevant reporting procedures so that we have an accurate picture of the prevalence of FGM in Buckinghamshire. Professionals should also be aware that as the demographics of our community shift over time, it is possible that we will see an increase in residents from those countries where FGM is prevalent.

The procedure is often carried out by an older woman in the community, who may see conducting FGM as a prestigious act.

The procedure can involve the girl / woman being held down on the floor by several women. It is often carried out without medical expertise, attention to hygiene or an anaesthetic. Instruments used have been known to include un-sterilised household knives, razor blades, broken glass and stones. The girl / woman may undergo the procedure unexpectedly, or it may be planned in advance.

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. Increasingly, however, FGM is being performed by health care providers.

The WHO cites a number of reasons for the continuation of FGM, such as:

• Custom and tradition
• A mistaken belief that FGM is a religious requirement
• Preservation of virginity/chastity
• Social acceptance, especially for marriage
• A belief that it will increase marriageability
• Hygiene and cleanliness
• Increasing sexual pleasure for the male
• Family honour
• A sense of belonging to the group and conversely the fear of social exclusion
• Enhancing fertility

Religion and FGM

1. Muslim scholars and faith leaders, including the Muslim Council of Britain, have condemned the practice and are clear that FGM is an act of violence against women. Further, scholars and clerics have stressed that Islam forbids people from inflicting harm on others and therefore the practice of FGM is counter to the teachings of Islam. 
2. The Bible does not support this practice nor is there any suggestion that FGM is a requirement or condoned by Christian teaching and beliefs.

Specific factors that may heighten a child’s risk of being subjected to FGM include:

• girl’s mother has undergone FGM
• other family members have undergone FGM
• father comes from a community known to practice FGM
• mother / family have limited contact with people outside of her family
• parents have poor access to information about FGM and do not know about the harmful effects of FGM or UK law
• girl/family has limited level of integration within UK community
• girl/women repeatedly fail to attend or engage with health and welfare services
• a family elder such a grandmother is very influential within the family and is / will be involved in the care of the girl.

Indications that FGM may be about to take place include:

• parents say they or a relative will be taking the girl abroad for a prolonged period – this may not only be to a country with high prevalence, but this would be more likely to lead to a concern
• girl has spoken about a long holiday to her country of origin / another country where the practice is prevalent
• girl has attended a travel clinic or equivalent for vaccinations / anti-malarials
• FGM is referred to in conversation by the child, family or close friends of the family (see Appendix C for traditional and local terms) – the context of the discussion will be important
• girl withdrawn from PHSE lessons or from learning about FGM at school
• girl has confided in another that she is to have a ‘special procedure’ or to attend a ‘special occasion’.
• girl has talked about going away ‘to become a woman’ or to ‘become like my mum and sister’
• the girl or a sibling may ask for help
• a parent or family member expresses concern that FGM may be carried out on a child.

Indications that FGM may have already taken place include:

• girl is reluctant to undergo any medical examination
• girl spends long periods of time in the bathroom / toilet / away from the classroom
• girl has spoken about having been on a long holiday to her country of origin / another country where the practice is prevalent
• increased emotional and psychological needs such as withdrawal, depression or significant changes in behaviour
• girl presents to GP or A&E with frequent urine, menstrual or stomach problems
• girl talks about pain or discomfort between her legs
• girl has difficulty walking, sitting or standing and looks uncomfortable
• girl finds it hard to sit still for long periods of time, which was not a problem previously
• girl is avoiding physical exercise or requiring to be excused from PE lessons without a GP letter
• a child may ask for help or confides in a professional that FGM has taken place
• mother of family member discloses that FGM has taken place

Short term consequences of FGM may include:[i]

• severe pain during the procedure and healing
• shock, which may be caused by pain and / or haemorrhage
• excessive bleeding
• difficulty in passing urine and faeces due to swelling and pain
• infections or septic shock are common, particularly as the procedure can be carried out in unhygienic conditions and/or with instruments that are not sterilised.
• psychological consequences due to the pain, shock and use of physical force by those performing the procedure
• death can be caused by haemorrhage or infections
• blood born viruses (for example Hepatitis B and C and HIV) and Tetanus are also a potential risk due to non-sterile equipment being used.

Long term consequences may include:

• chronic pain
• infections, particularly of the reproductive and urinary tracts
• abscesses, painful cysts or keloids (excessive scar tissue formed at the site of the cutting)
• menstrual problems
• birth complications such as prolonged labour, recourse to caesarean section, postpartum haemorrhage and tearing
• danger to the new-born, with high death rates and reduced Apgar scores
• increased risk of HIV infection and transmission in adulthood due to an increased risk of bleeding during intercourse
• psychological consequences such as fear of sexual intercourse, post-traumatic stress disorder, anxiety, depression and memory loss
• loss of pleasure in sex and / or loss of ability to experience orgasm.

Results from research in practicing 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. Research also indicates that the majority of the women (80%) suffer from affective (mood) or anxiety disorders.[i]

The following circumstances relating to FGM require identification and intervention:

• It is known that an adult woman has undergone FGM and there are no children or pregnant women in the household.
• It is known that an adult woman has undergone FGM and there is an unborn child / female child(ren) in the family or household. However, FGM has not been identified in them and there are no signs that FGM is imminent.
• It is known that an adult woman has undergone FGM, there is a female child / children in the family or household and there is suspicion FGM has occurred or may be imminent.
• A female child / children have been subjected to FGM and this is confirmed by a disclosure or evident on examination.

Please refer to the Multi-Agency FGM Pathway to guide you through the procedure in Buckinghamshire for each of these circumstances.

All professionals are encouraged to complete a risk screening tool for any case of FGM, whether it is known or suspected. This will help with the assessment of the situation, decision making and record keeping. A screening tool is provided at Appendix A.

In all cases, professionals should consider dialling 999 if immediate Police action is needed.

In cases where it is known that a child has undergone FGM (if a professional has seen evidence of it or heard about it directly from the child) professionals must make a referral to Children’s Social Care using the Multi Agency Referral Form (MARF). Regulated professionals working within health or social care, and teacher, must also act in accordance with the FGM Mandatory Reporting Duty by reporting the case without delay to the police on 101.

If there are reasons to suspect that a child has been abused through FGM, (for example, see signs and symptoms), the professional or the Safeguarding Lead from the organisation should make a referral to Children’s Social Care using the MARF.

In cases where it is known or suspected that a vulnerable adult has undergone FGM, the professional should consider making a referral to Adult Social Care. Consideration should be given to how recently the FGM was undertaken and the impact on the individual. If there are any doubts about whether a referral should be made, the professional can ring the Multi-Agency Safeguarding Hub (MASH) for advice on 0800 137 915.

If there is a perception that a child may be at risk of FGM in the future it is important to determine whether this risk is high and immediate, or low and future. All professionals should complete an FGM risk screening tool (see Appendix A) to help with the assessment of the situation, decision making and record keeping.

If there is concern that a vulnerable adult may be at risk of FGM in the future it is important to determine whether this risk is high and immediate, or low and future. All professionals should complete an FGM risk screening tool (see Appendix A) to help with the assessment of the situation, decision making and record keeping.

* In this content, a vulnerable adult is defined as someone who has care and support needs.[1]

An example of a high/immediate level of risk is if a girl is talking about a ‘special’ ceremony, going on a long holiday, or if a woman who has had FGM and gave birth to a girl admits to be supporting the practice.

An example of a low/future level of risk is when a woman who has had FGM and gave birth to a girl speaks against cutting her daughter.

Professionals should seek to undertake a holistic assessment of the family given the pressure to undertake FGM can come from other members of the family such as female family elders.

In all cases the risk to other female children in the family and extended family must be considered, and all parents/carers should be given information on FGM explaining that it is illegal to carry it out in the UK or to take their child abroad and they have a statutory responsibility to protect their child from this practice.

If it has been determined that the risk is high/immediate it is important to act quickly – before the child is abused by being subjected to FGM in the UK, or taken abroad to undergo the procedure.

Every attempt should be made to work with parents to prevent abuse of FGM occurring. All professionals should ensure that parental co-operation is achieved wherever possible, including the use of community organisations and / or community leaders to facilitate the work with parents/family.

However, if it is not possible to reach an agreement and if the parents cannot guarantee that they will not proceed with the mutilation, the first priority is protection of the girl / woman and appropriate measures should be taken such as an Emergency Protection Order, Police Protection or an FGM Prevention Order should be sought.

There may be cases where the risk is determined as low at the time of the assessment, for example if a mother who has had FGM speaks against mutilating her daughter. However, as the child is growing up the risk might change from low to high and it is important that all agencies follow their internal procedures, and complete and attach an appropriate risk screening tool to the child’s health records for future reference.

Regardless of the age of the girl or woman, or when the procedure took place, all professionals should make appropriate referrals to support those suffering from the physical or emotional consequences of FGM.

There is no requirement for automatic referral of other adult women with FGM to adult social services or the police. Healthcare professionals should be aware that any disclosure may be the first time that a woman has ever discussed her FGM with anyone. Referral to the police must not be introduced as an automatic response when identifying adult women with FGM, and each case must continue to be individually assessed. Healthcare professionals should seek to support women by offering referral to specialist organisations that can provide support, and for possible clinical intervention or other services as appropriate. The wishes of the woman must be respected at all times.

Schools and educational professionals are ideally suited to not only raise awareness of the practice, but also to safeguard and support girls and young women.

Governing bodies have a statutory duty to have a named governor responsible for Safeguarding. This person needs to be kept informed of work around FGM safeguarding and education in the school; they should ensure that the full governing body is aware of how the school is working to address the issue of FGM.

For more information, see: Female Genital Mutilation: Guidance for Schools.

Health professionals in GP surgeries, sexual health clinics and maternity services are the most likely to encounter a girl or woman who has been subjected to FGM. A question about FGM should be incorporated when the routine patient history is being taken and professionals should consider the advice provided about talking to a child or woman about FGM.

As with any form of child abuse, when FGM/risk of FGM is identified it is important that information is shared appropriately with relevant professionals. This will help ensure the right measures are put in place to safeguard against the risk of FGM or to meet the physical and psychological needs of those who have undergone FGM.

You should discuss openly with the girl/woman and, where possible, with the parents of a girl, how, why and with whom information will be shared and seek their consent. However, be aware that by alerting a girl’s family, you may place her at increased risk of harm. Professionals should take this into account and remember that consent for information sharing is not required where there is evidence the child is suffering or at risk of suffering significant harm, or in order to prevent a criminal offence from taking place.

The risk of FGM can change over time and if information has been shared then professionals who are in contact with a child in the future may be in a good position to spot signs of imminent or actual FGM. For example, if a midwife has shared information with a GP that a mother has had FGM, when her daughter attends the GP Practice with urine and stomach problems this may prompt early questioning about possible FGM.

Information should always be shared in line with the BSCP Information Sharing Code of Practice and the Government’s information sharing advice for safeguarding practitioners.

The multi-agency pathway diagram provides further guidance on information sharing in relation to FGM. However, if you are unsure whether you can share information, then please refer to the BSCP Information Sharing Code of Practice and the government guidance. If you are in doubt, speak to your designated safeguarding lead as soon as possible.

For known cases of FGM, those agencies subject to the Mandatory Reporting Duty must share information in order to make a report (see below). Whilst it is good practice to discuss that you will need to share information to make a report, consent is not required. In cases where mandatory reporting has taken place, this does not negate the need to share information with other relevant professionals.

On the 31 October 2015 a new duty was introduced that requires all regulated professionals working within health or social care, and teachers, to report ‘known’ cases of FGM in girls aged under 18 to the police. This is an individual rather than a corporate duty.

‘Known’ cases are those where either a girl discloses that FGM has been carried out on her, or where a professional observes physical signs on a girl appearing to show that FGM has been carried out. For example, if a doctor sees that a girl aged under 18 has had FGM they will need to make a report to the police. Similarly if a girl tells her teacher that she has had FGM, the teacher will need to report this to the police.

To make a report you should call the Police on 101 and state you wish to make a report under the FGM mandatory reporting duty. Reports should be made as soon as possible after the FGM is discovered, and best practice is to complete the report by the close of the next working day.

All agencies should ensure relevant frontline staff understand this duty and how to make a report. The professional consequences for failing to report a known case of FGM in a child are very serious.

Professionals subject to the duty and their employers should refer to the government guidance on mandatory reporting. This includes a list of those professionals covered by the report and more detail on how to make a report.

The government has also published additional information on the mandatory duty for health care professionals in England.

Some agencies will also need to submit data on FGM to the FGM Enhanced Dataset.

This dataset was set up to collect information on the prevalence of FGM from across the NHS in order to support a response to FGM that is based on an understanding of need. The Information Standard (SCC 12026 FGM Enhanced Dataset) requires clinicians across all NHS healthcare settings to record in clinical notes when patients with FGM are identified, and what type it is.

It became mandatory for all acute trusts to collect and submit the FGM Enhanced Dataset from 1^st July 2015 and all mental health trusts and GPs from 1^st October 2015. Community services within mental health trusts can participate. Sexual Health and GUM clinics do not need to submit FGM information but the legal obligation to appropriately share information for safeguarding purposes still applies.

All relevant agencies should ensure their staff are familiar with these requirements. Further information on the dataset is available.

Professionals discussing FGM with a child or woman suspected to be abused through FGM should tailor their response appropriately, including:

• Arranging for an interpreter if this is necessary and appropriate (avoid using a family member as an interpreter)
• Creating an opportunity for the child/woman to disclose, seeing the child/woman on their own
• Using simple language and asking straightforward questions
• Giving the opportunity to be accompanied by someone they know and trust
• Using terminology that the child/woman will understand, e.g. the child/woman may not view the procedure as abusive
• Being sensitive to the fact that the child / woman will be loyal to their parents
• Being willing to listen and giving the child/woman time to talk
• Getting accurate information about the urgency of the situation, if the child is at risk of being subjected to the procedure
• Giving the message that the child/woman can come back to you again
• Being sensitive to the intimate nature of the subject
• Making no assumptions
• Being non-judgemental (condemning the practice, but not blaming the girl/woman)
• Understanding how she may feel in terms of language barriers, culture shock, that she, her partner, her family are being judged
• ‘Circumcised’ is not medically correct and although ‘mutilation’ is the most appropriate term, it might not be understood or it may be offensive to a woman from a practising community who does not view FGM in that way. Different terminology will be appropriate to the different cultures (see Appendix C)
• Giving a clear explanation that FGM is illegal and that the law can be used to help the family avoid FGM if/when they have daughters
• Carrying out Mental Capacity Assessment as necessary

Professionals can refer to ‘Key questions for interviewing women with FGM’ (Appendix B) to start a conversation on FGM. The following leaflets and websites may also be useful for practitioners who are discussing FGM with women and children:

• FGM: The Facts (Home Office)
• More about FGM (Department of Health) – available in several different languages
• Various Publications on FGM for young people (Forward UK)
• Karma Nirvana

After childbirth, a girl / woman who has been deinfibulated (a surgical procedure to open up the scar tissue to restore the normal vaginal opening, commonly called a ‘reversal’) may request re-infibulation. All girls / women who have undergone FGM (and their partners or husbands) must be told that re-infibulation is against the law and will not be done under any circumstances. Each woman should be offered counselling to address how things will be different for her afterwards.

If a woman continues to request re-infibulation this should be treated as a potential child protection concern, as the girl / woman’s apparent reluctance to comply with UK law, may have implications for her own children if they are female. Professionals should consult with their agency’s designated safeguarding lead and make a referral to Children’s Social Care using the MARF.

Wherever possible, a professional female interpreter should be used for a girl/woman known to have limited English. This will reduce misunderstanding, increase the likelihood of identification of FGM and any additional physical, psychological and social concerns. Use of family members is not advised as they may influence decisions and inhibit true expression of the woman’s feelings.

Always brief / debrief the interpreter, explain the purpose of the meeting, ensure they understand the issue and are happy to talk about FGM. We must remain aware that the interpreter may have experienced FGM, hence may have difficulty discussing it. Alternatively, they may view FGM as a valuable practice, hindering the interpretation process.

Always check that the girl/woman is happy to continue with the chosen interpreter, as communities affected by FGM are often small and therefore interpreters may be known socially by the girl/woman. The importance of confidentiality should be stressed to all parties involved.

In the case of an adult with care and support needs, it may be necessary to appoint an Independent Mental Capacity Advocate (IMCA) to support them with decision making. Further information, including how to book an IMCA is available.

Appendix A: FGM Screening Tool / Risk Assessment

This section provides 4 short risk assessments that can be used by relevant professionals in the following scenarios:

1. Child under 18 years old: Use when considering whether a child has had FGM

2. Child under 18 years old: Use when considering whether a child may be at risk of FGM or whether there are other children in the family for whom a risk assessment may be required.

3. Non-Pregnant woman over 18 years old: Use when considering whether any female children are at risk of FGM, whether there are any other children in the family for whom a risk assessment may be required, or whether the woman herself is at risk of further harm in relation to FGM.

4. Pregnant woman: Use when considering whether the unborn child, or other female children in the family are at risk of FGM or whether the woman herself is at risk of further harm in relation to FGM.

NB, all of these assessments tools can also be used for adults with care and support needs.

FGM Professional Guidance Forms (publishing.service.gov.uk)

Appendix B: 3 Key Questions for discussing FGM with women

Appendix C: Terms for FGM in different languages

Appendix D: FGM Pathway