4.2 Female Genital Mutilation: Procedure and Guidance
- Key Principles
- Legal Status
- Definition of types of female genital mutilation
- Cultural Context
- Signs and Indicators
- Health implications of FGM
- Procedure for responding to FGM
- School context of FGM
- Health Professionals
- Information Sharing
- Mandatory Reporting
- The FGM Enhanced Dataset
- Talking to women and children
- Requests for re-infibulation
- Interpreters and Independent Mental Capacity Advocates
- Related Policies, Procedures, and Guidance
Female Genital Mutilation (FGM) is considered child abuse in the UK and 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 underestimation.
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:
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:
a) to excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia
b) to aid, abet, counsel or procure the performance by another person of any of those acts on that
On conviction or indictment: a fine or imprisonment for a term not exceeding 14 years or both.
Definition of types of female genital mutilation
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:
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.
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
[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:
[i] Equality Now and City University
The Local Picture
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:
Religion and FGM
Signs and Indicators
Specific factors that may heighten a child’s risk of being subjected to FGM include:
Indications that FGM may be about to take place include:
Indications that FGM may have already taken place include:
Health implications of FGM
Short term consequences of FGM may include:[i]
Long term consequences may include:
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]
Procedure for responding to FGM
The following circumstances relating to FGM require identification and intervention:
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.
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.
School context of FGM
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.
The FGM Enhanced Dataset
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 1st July 2015 and all mental health trusts and GPs from 1st 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.
Talking to women and children
Professionals discussing FGM with a child or woman suspected to be abused through FGM should tailor their response appropriately, including:
Professionals can refer to ‘Key questions for interviewing women with FGM’ (Appendix B) to start a conversation on FGM. The following leaflets may also be useful for practitioners who are discussing FGM with women and children:
Requests for re-infibulation
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.
Interpreters and Independent Mental Capacity Advocates
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:
NB, all of these assessments tools can also be used for adults with care and support needs.