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4.8 Female Genital Mutilation

AMENDMENT

In March 2018 the link was updated in the further information section to the DHSC page on 'Safeguarding Women and Girls at Risk of FGM', which now includes the guidance plus additional resources including a safeguarding pathway and risk assessment tools.


Contents

  1. Definition
  2. Indicators
  3. NHS Actions
  4. Mandatory Reporting of FGM
  5. Protection and Action to be Taken
  6. Issues
  7. Law
  8. Further Information


1. Definition

Female genital mutilation (FGM) is a collective term for procedures which include the removal of part or all of the external female genitalia for cultural or other non-therapeutic reasons. The practice may be performed without anaesthetic, with non-sterile equipment and has no medical benefit whatsoever. It is, often extremely painful and can have serious health consequences, both at the time when the mutilation is carried out and in later life. The procedure can be performed on girls aged between 4 and 13 in some communities, but is very individual as other communities may perform it on new-born infants or on young women before marriage or pregnancy.

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

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

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

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

For more detail, please refer to the Multi-agency statutory guidance on female genital mutilation April 2016.

Click here to access the Gov.uk website for Female Genital Mutilation.


2. Indicators

These indicators are not exhaustive and whilst the factors detailed below may be an indication that a child is at risk of FGM, it should not be assumed that this is the case simply on the basis of someone presenting with one or more of these warning signs. These warning signs may indicate other types of abuse such as forced marriage or sexual abuse that will also require a multi-agency response. See also statutory guidance Annex B: Risk, for details.

FGM itself is regarded as a form of physical, rather than sexual, abuse.

The following are some signs that the child may be at risk of FGM:

  • The girl asks an adult for help;
  • A female child is born to a woman who has undergone FGM or whose older sibling or cousin has undergone FGM;
  • The family belongs to a community in which FGM is practised; or have limited level of integration within UK community, however this in itself is not the sole reason for a referral to children’s social care;
  • The family makes preparations for the child to take a holiday to their country of origin or another country where the practice is prevalent, e.g. arranging vaccinations, planning an absence from school. Again this does not necessarily mean FGM will take place - more information needs to be gained;
  • The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
  • If a female family elder is present, particularly when she is visiting from a country of origin, and taking a more active / influential role in the family;
  • The child talks about a ‘special procedure/ceremony’ that is going to take place;
  • An awareness by a midwife or obstetrician that the procedure has already been carried out on a mother, or on other women or older girls in the family prompting concern for any daughters, girls or young women in the family. Again work with family is needed to gain more information;
  • Repeated failure to attend or engage with health and welfare services or the mother of a girl is very reluctant to undergo genital examination; including cervical smears;
  • Where a girl from a practising community is withdrawn from Sex and Relationship Education they may be at risk from their parents wishing to keep them uninformed about their body and rights.

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

  1. The child has changed in behaviour after a prolonged absence from school;
  2. The child has health problems, particularly bladder or menstrual problems;
  3. The child has difficulty walking, sitting or standing and may appear to be uncomfortable.

Where it is believed that FGM has already taken place children’s social care will liaise with the Paediatric services to ensure that a Medical Assessment takes place.

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

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

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

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

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


3. NHS Actions

Health professionals such as midwives, obstetricians, gynaecologists, general practitioners and paediatricians are the most likely to encounter a girl or woman who has been subjected to female genital mutilation. They should be aware of the risk in relation to:

  • Any younger sisters;
  • Daughters she has or daughters she may have in the future; and
  • Any female members in her extended family.

Since 2014 all acute Hospital Trusts have been required to record:

  • If a patient has had Female Genital Mutilation;
  • If there is a family history of Female Genital Mutilation;
  • If a Female Genital Mutilation-related procedure has been carried out on a patient;
  • Type Of FGM;
  • If the patient has been re-sutured.

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

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

For further information, see Female Genital Mutilation Datasets (NHS Digital website).


4. Mandatory Reporting of FGM

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

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

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

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 the potential risk and the actions which are to be taken. Next steps should be discussed with the safeguarding lead and if necessary a social care referral made.


5. Protection and Action to be Taken

Where concerns about the welfare and safety of a child or young person have come to light in relation to FGM a referral to Children’s social care should be made in accordance with the Making Referrals to Children's Social Care Procedure.

A strategy meeting should be convened within two working days (but in some cases will need to take place immediately). This will involve children’s social care, the police and other relevant services such as health and education professionals and voluntary organisations. Where possible it will be chaired by a Principal Officer/Child Protection.

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;
  • Whether the child’s parents are well informed about the harmful consequences of female genital mutilation and the law in the UK;
  • Whether a medical examination is required and if so for what purpose; and
  • What action may be necessary in response to an attempt to remove the child from the UK.

Every attempt should be made to work with parents on a voluntary basis to prevent the abuse, including the involvement of community organisations and/or community leaders. However, if no agreement can be reached, the first priority is protection of the child.

Where a child has been identified as having suffered, or being likely to suffer, significant harm, it may not always be appropriate to remove the child from an otherwise loving family environment. Parents and carers may genuinely believe that it is in the girl’s best interest to conform to their prevailing custom. Professionals should work in a sensitive manner with families to explain the legal position around FGM in the UK. The families will need to understand that FGM and re-infibulation (the process of resealing the vagina after childbirth) is illegal in the UK and that if they are insistent upon carrying out the practice, the health visitor and children’s social care must be informed that a female child may be at risk of significant harm.

Interpretation services should be used if English is not spoken or well understood and the interpreter should not be an individual who is known to the family. Caution is needed in selecting an interpreter: she may have difficulty in discussing the subject, and if she is from an affected community she may support the practice and view it as valuable.

No evidence of risk

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

  • Consult the child's GP about this conclusion and invite her/him to notify children’s social care if any further information challenges it;
  • Notify appropriate professionals involved with the family of the reasons why the enquiry was concluded;
  • Inform the family and the referrer that the enquiry has been concluded; and
  • Offer the family any appropriate support services.

Child at risk of genital mutilation

If it appears that a child is at risk of genital mutilation, the social worker will:

  • Notify the parents that this is a criminal act in the UK;
  • Arrange a child protection conference to discuss the issues;
  • Consider whether to apply for a Prohibited Steps Order to prevent the parents removing the child from the country; and
  • Consider whether there is a need for an Emergency Protection Order to protect the child before the conference.

If a child protection conference concludes that the child needs to be the subject of a child protection plan, female genital mutilation is normally regarded as a form of physical, rather than sexual, abuse.

If the child has already undergone genital mutilation

If the operation has already taken place practitioners should focus on:

  • The position of any younger girls in the family (including the extended family);
  • The family's willingness to co-operate with the agencies concerned;
  • Health, education and other work with the family to reduce the risk to other members of the family;
  • Help the affected girl may need to deal with the consequences of the genital mutilation; and
  • Support the family may need in the face of community pressure.

The strategy meeting should be reconvened within 10 working days of the initial referral to consider:

  • Any available information about how, when and where the procedure was performed;
  • Any action that could be taken to prosecute the perpetrator;
  • How to address any concerns for the welfare of the child who has undergone the procedure, including, but not limited to, any health implications;
  • The implications for any other children in the family, including the extended family;
  • The family’s need for support services; and
  • Whether a child protection conference should be convened to make decisions about any continuing risk of significant harm to any child.

Children’s social care will notify the child's GP and midwifery service and invite them to report any changes in the situation that give rise to further concerns, for example the mother giving birth to further girls.


6. Issues

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

The early part of the school summer holiday is the time when girls are most at risk of having the procedure carried out in the UK or being sent abroad to have it carried out, as this allows for the recovery period over the school break. Consequently a change in a child's behaviour in the lead up to school holidays or on return to school may be significant.

After childbirth, a woman who has been de-infibulated may request re-infibulation. Health professionals must state clearly that re-infibulation is against the law and will not be done under any circumstances. If the mother appears reluctant to comply with UK law and to consider that the process is harmful, this raises concerns in relation to any daughters she may already have, or may have in the future. It should be treated as a child protection concern.

Where is FGM Practised?

There are 28 practising countries across Africa itself and also including Middle Eastern Countries. For a full list of practising countries please visit FORWARD (Foundation for Women's Health Research and Development) website.

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

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

Consequences of FGM

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

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

Long-term implications can entail:

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

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

Justifications of FGM

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

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

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

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


7. Law

In England and Wales, criminal and civil legislation on FGM is contained in the Female Genital Mutilation Act 200319 (‘“the 2003 Act’”):

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

As amended by the Serious Crime Act 2015, the Female Genital Mutilation Act 2003 now includes:

  1. Creating a new offence of failing to protect a girl from FGM  with a penalty of up to 7 years in prison or a fine or both.  A person is liable if they are “responsible” for a girl at the time when an offence is committed. This will cover someone who has “parental responsibility” for the girl and has “frequent contact” with her and any adult who has assumed responsibility for caring for the girl in the manner of a parent. This could be for example family members, with whom she was staying during the school holidays;
  2. Introduced Female Genital Mutilation Protection Orders (“FGMPO”) - breaching an order carries a penalty of up to five years in prison. The terms of the order can be flexible and the court can include whatever terms it considers necessary and appropriate to protect the girl or woman;
  3. Allowing for the lifelong anonymity of victims of FGM – prohibiting the publication of any information that could lead to the identification of the victim. Publication covers all aspects of media including social media;
  4. Extended the extra-territorial reach of Female Genital Mutilation (FGM) offences to include “habitual residents” of the UK;
  5. Created a new duty of Mandatory Reporting of Female Genital Mutilation for regulated professionals in health and social care professionals and teachers in England and Wales which came into force on the 31st October 2015.


8. Further Information

AFRUCA (Child Protection of African Children)

Forward (Foundation for Women's Health Research and Development)

Multi-agency Statutory Guidance on Female Genital Mutilation April 2016

FGM Protection Orders: Factsheet - Information about FGM protection orders and how to apply for an order

Female genital Mutilation: Resource Pack

Female Genital Mutilation and its Management: Royal College of Obstetricians and Gynaecologists 2015

Mandatory Reporting of Female Genital Mutilation – procedural information

Safeguarding women and girls at risk of FGM (DHSC)

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