16.25 Female Genital Mutilation

Female genital mutilation (FGM) is child abuse and a form of violence against women and girls, and therefore should be dealt with as part of existing child and adult safeguarding/protection structures, policies and procedures.

The practice is illegal in the UK and it is also illegal to take a British national or permanent or habitually resident abroad for the practice of FGM or to help someone trying to do this.

Female genital mutilation comprises 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.

FGM is known by a variety of names, including ‘female genital cutting’, ‘circumcision’ or ‘initiation’. The term ‘female circumcision’ is anatomically incorrect and misleading in terms of the harm FGM can cause. The terms ‘FGM’ or ‘cut’ are increasingly used at a community level, although they are not always understood by individuals in FGM affected communities, largely because they are English terms.

The World Health Organization (WHO) has classified FGM 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 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, or outer, labia, with or without removal of 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.

Female Genital Mutilation Act 2003: offence of female genital mutilation:

“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.”

It is an offence to:

• Undertake the operation (except in specific physical or mental health grounds);
• Assist a girl to mutilate her own genitalia;
• Assist a non-UK person to undertake female genital mutilation of a UK national outside the UK (except in specific physical or mental health grounds);
• Assist a UK national or permanent UK resident to undertake female genital mutilation of a UK national outside the UK (except in specific physical or mental health grounds).

A FGM protection order (FGMPO) is a civil order used to protect those who are vulnerable to FGM, and prevent it from taking place. It gives the courts flexibility in stipulating conditions around safeguarding the welfare of the protected person. This means a court can put provisions in place to facilitate the safe return of girls who have been taken outside the UK for the purpose of FGM.

A FGMPO can be obtained through three issuing family courts. Breaching a FGMPO can carry a penalty of up to five years in prison. Applications for FGMPOs can be made directly to the court by the person seeking protection, a relevant third party (such as local authority, teachers, health professionals, police, charity, and family members). The courts have the ability to grant an order without an application being made.

A person completing the application should read the FGM 700 guidance prior to completing.

Section 1(2) of Schedule 2 of the Female Genital Mutilation Act 2003 states:

“In deciding whether to exercise its powers under this paragraph and, if so, in what manner, the court must have regard to all the circumstances, including the need to secure the health, safety and well-being of the girl to be protected”.

The threshold is not equivalent to the threshold within care proceedings. The orders granted are distinct. An order should be applied for where there is concern that FGM could be performed upon a protected person in England and Wales and/or outside of the jurisdiction and this can be addressed within a witness statement.

Relevant evidence to support a case can include:

1) Medical reports confirming that the protected person has or has not been cut;

2) Minutes from children’s services’ meetings which explain why there is a fear that the protected person could be cut;

3) Where there has been involvement from a specific social worker, the social worker ought to strongly consider providing a witness statement outlining for example their involvement with the child and family, the risks present, and the steps taken to address such risks;

4) Witness statements from family members/friends/professionals, which identify the risk. For example, where threats have been made to remove the protected person from the jurisdiction and there are witnesses to confirm the same, such witnesses should be invited to file statements to support the application;

5) Flight tickets/information confirming a family intend to leave the jurisdiction;

6) Information from the protected person’s educational institution confirming any disclosures made or concerns raised by professionals about the child’s behaviour;

7) Where the protected child and/or her family’s immigration status is insecure, it might be helpful to provide the court with copies of documentation about the child’s immigration status to date and any on-going proceedings. This information could be relevant where there is risk of imminent deportation.

*The list above is not intended to be exhaustive.*

FGM Protection Orders can extend to prohibiting conduct inside and outside England and Wales (section 1(4) of Schedule 2 of the Female Genital Mutilation Act 2003).

The FGM mandatory reporting duty is a legal duty provided for in the FGM Act 2003 as amended by the Serious Crime Act 2015 under section 5B.

The legislation requires regulated Health and Social Care Professionals and Teachers in England and Wales to make a report to the Police on the single non-emergency number 101 when in the course of their duties, they either:

• Are informed by a girl under 18 that an act of FGM has been carried out on her; or

• Observe physical signs which appear to show that an act of FGM has been carried out on a girl under 18 and they have no reason to believe that the act was necessary for the girl’s physical or mental health or for purposes connected with labour or birth.

Best practice is to submit a report as soon as possible after a case is discovered and for reports to be made no later than by the close of the next working day. Legislation states that a report MUST be made before the end of one month. This provision was made in order to allow for exceptional cases, from when the discovery is made to submitting a report. However, the expectation is that reports will be made much sooner than this.

For the purposes of the duty, the relevant age is the girl’s age at the time of disclosure/identification (i.e. it does not apply where a woman aged 18 or over discloses she had FGM when she was under 18).

The duty does not apply if a relative/carer divulges that a child has undergone FGM however safeguarding guidance should be followed. See also  Recognition and Referral of Abuse and Neglect 

The duty is a personal duty which cannot be delegated, and it does not breach any confidentiality requirement.

The duty applies to cases you discover in the course of your professional work, if you do not currently undertake genital examinations in the course of delivering your job, then the duty does not change this. Most professionals will only visually identify FGM as a secondary result of undertaking another action. For example- a teacher who is assisting a child with toileting requirements.

The duty applies to all regulated health, teaching and social work professionals. For teachers this includes persons employed to carry out teaching work in schools and other institutions.

All other practitioners who are not covered by the mandatory reporting duty described at 8.25.10 under their safeguarding children responsibilities must take appropriate safeguarding action in relation to any identified or suspected case of FGM.

The safety of the child is the priority, reports under the duty should be made as soon as possible and best practice is before close of the next working day. The Police and Local Authority should be the area in which the child resides, ring 101 and explain that you are making a report under the FGM mandatory reporting duty. You will be given a reference number for the call, ensure that you document this in your records.

In addition, if you have concerns that the child may be leaving the UK imminently professionals should also inform Border Force South on Tel: 01293 507075/502019

Where there is a risk to life or of serious immediate harm professionals should report the case immediately to Police, dialling 999 if appropriate.

Professionals working in maternity services are uniquely placed to identify and prevent FGM as most survivors of FGM are identified when they are pregnant. All pregnant women are routinely asked whether they have been cut, regardless of their background or where they were born. The intimate nature of maternity care also aids identification through observation during clinical examination and care. This affords maternity professionals an opportunity, at a time when parents are receptive to public health messaging and behaviour change interventions, to undertake early preventative work with parents. As a minimum, this will include:

• a sensitive, supportive and honest conversation with women who are survivors of FGM and their family about the law in the UK and the physical and psychological health consequences of practising FGM.
• information sharing with other healthcare professionals i.e. health visitor and GP who are in a position to reinforce preventative messages with parents.

Please also see sections 8.25. 19 -23 below (Recognition) and 8.25.26-7 (Response) where support for survivors and safeguarding risk assessment is covered.

The FGM Enhanced Dataset is a national resource collected from NHS acute trusts, mental health trusts and GP practices. Reports are published as an official statistic every quarter. Clinicians are required to record into clinical notes when FGM is identified, and also what type it is.

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 and plan the local NHS services needed both now and in the future
• help other agencies and organisations to develop plans to stop FGM happening in local communities.

Female Genital Mutilation – Information Sharing (FGM-IS) is a national IT system that supports the prevention, early intervention and ongoing safeguarding of girls, under the age of 18, who are potentially at risk of FGM. This system allows information to be shared about an immediate family history of FGM with healthcare professionals providing care for a girl.

An FGM indicator is recorded on a girl’s record (usually at birth by the Maternity Unit) on the FGM-IS system (part of the National NHS Spine) and can be viewed by authorised health professionals throughout England.

A positive FGM indicator should prompt the professional to consider if they need to take any preventative or safeguarding actions. The FGM-IS system should reduce the chance that health services might overlook that a girl has a family history of FGM when providing treatment.

https://digital.nhs.uk/services/female-genital-mutilation-information-sharing

Many girls may not be aware that they may be at risk of undergoing FGM, but concerns may arise in various ways that a child is being prepared for FGM to take place abroad. These include knowing that the family belongs to an FGM affected community and is preparing for the child to take a holiday, arranging vaccinations or planning absence from school. The child may also talk about a 'special procedure/ceremony' that is going to take place.

Girls are at particular risk of FGM during school holidays and prolonged absences from school as these are the times when families may take their children abroad for the procedure.

Any medical provision for a pregnant woman and also non-pregnant women with children who have been the subject of female genital mutilation provides an opportunity for recognition of risk and preventative work with parents. The role of men/fathers from FGM affected communities should also be considered within this context.

A child may be at risk if it is known that other family members have been subjected to the procedure and it should not be automatically assumed this is the case. The age at which girls undergo FGM varies enormously according to their community practice. The procedure may be carried out when the girl is new-born, during childhood or adolescence, just before marriage or during the first pregnancy. However, the majority of cases of FGM are thought to take place between the ages of five and eight (source: Serious Crime Act 2015: FGM Factsheet).

Possible indicators are similar to other forms of abuse, especially Sexual Abuse - a girl may not know that she has been cut or that the health issues being experienced are linked to being cut - including:

Physical Symptoms:

• Genital bleeding and genital discharge;
• Recurrent urinary problems, including urinary infections;
• Girl has difficulty walking, sitting or standing or looks uncomfortable;
• Girl finds it hard to sit still for long periods of time, which was not a problem previously;
• Girl presents to GP or A&E with frequent urine, menstrual or stomach problems.

Verbal indicators:

• Girl mentions something somebody did to them, that they are not allowed to talk about;
• FGM is referred to in conversation by the girl, family or close friends of the child;
• Girl has spoken about a long holiday to her country of origin/another country where the practice is prevalent;
• Parents/child/family member say that 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 more likely lead to a concern;
• Girl talks about pain or discomfort between her legs.

Behavioural and non-verbal responses:

• Reluctance to receive medical attention or to participate in sporting activities; may avoid physical exercise or requiring to be excused from PE lessons without a GP’s letter;
• Prolonged absence from school, with noticeable behaviour change on return and long periods away from classes or other normal activities;
• Girl is reluctant to undergo any medical examination;
• Increased emotional and psychological needs e.g. withdrawal, depression, or significant change in behaviour;
• Girl spends a long time in the bathroom/toilet/long periods of time away from the classroom; or girl avoids going to the toilet;
• Some girls look/appear to be uncomfortable/experiencing discomfort.

Potentially related activity instigated by parent/care giver:

• Girl has attended a travel clinic or equivalent for vaccinations/anti-malarial medication;
• Sections missing from the child’s personal health record (red book).

Any suspicion of intended or actual female genital mutilation must be referred to Children's Social Care, in accordance with the Making a Referral Procedure. The National FGM Centre resources include an FGM Referral Guide . It is important to note however that a multi-agency response is the best approach to safeguarding girls who are at risk of FGM. Normally the first response to a referral makes a big difference with how families engage, so good quality information in the referral helps to achieve a good outcome. Where professionals making the referral have undertaken a risk assessment this should be accompanied with the referral. For example, health professionals should attach the Department of Health FGM Risk Assessment completed with the referral.

Children's Social Care (CSC) MUST inform Sussex Police and the Children’s Sexual Assault Referral Centre (CSARC); and a Border Force South safeguarding lead when appropriate (if the child is resident in Sussex) for advice at the earliest opportunity.  CSC must convene a Strategy Discussion within two working days if:

• There is concern that a girl or young woman, under the age of eighteen, is at risk of undergoing this procedure within the UK;
• It is believed that a girl or young woman is sent or taken abroad or is at risk of being sent abroad for that purpose; or
• There are indications that a girl or young woman has suffered FGM.

The Children's Social Care manager should have relevant knowledge and experience of female genital mutilation or consider inviting someone with appropriate knowledge e.g. a child protection adviser / senior manager to chair the Strategy Discussion. Health Professionals working with the family such as the Health Visitor, School Nurse, GP and Health Specialists at CSARC, community and voluntary organisations with specific expertise and Sussex Police should be invited. Consideration must be given to inviting a legal adviser and a Border Force South safeguarding lead where appropriate.

To make appropriate and informed professional judgements about the child's needs, it is important that professionals are sensitive to differing family patterns and lifestyles and to child-rearing patterns that vary across different racial, ethnic and cultural groups. At the same time, they must be clear that child abuse cannot be condoned for cultural reasons. Siblings should be included in the assessment and any subsequent child protection planning. The National FGM Centre’s assessment tool and accompanying guidance should be used by Social Workers when undertaking the assessment. The assessment must also include family history of FGM practice as this helps to identify those who may present a risk and who could be a protective factor.

FGM could sometimes be a precursor for other forms of harmful practices such as a forced marriage and there could be other safeguarding concerns e.g. domestic abuse and parental mental health, so these issues must be explored as part of the assessment.

Since there is a risk of the girl being taken overseas the assessment must include risk of flight, and if the girl is taken overseas the level of risk presented to her and the actions required to ensure she’s safeguarded or repatriated. The Forced Marriage Unit remit also includes FGM, so steps should be taken to contact them or Children and Families Across Borders Charity. Please see advice and information section below for contact details.

In planning any intervention, it is important to think about how to frame a conversation with the child and her family. Female genital mutilation is generally performed because of the significance it has in terms of cultural identity. It is important to use FGM terminology that is understood by the family. Community terms include cutting, circumcision^[1], sunna, gudniin, halalays, tahur, megrez and khitan. The National FGM centre’s Traditional terms for FGM resource provides detail at individual country level. Any intervention is more likely to be successful if it involves workers from, or with a detailed knowledge of, the community concerned. The National FGM Centre provides tips for direct work with children and families. Tips to help professionals hold a conversation about FGM with a child and female members of their family can be found as an addendum at the end of this FGM procedure.

^[1] The term ‘female circumcision’ is anatomically incorrect and misleading in terms of the harm FGM can cause.

If necessary, legal advice must be taken on the options which could be considered to protect a child. Under the Children Act 1989, possible legal proceedings could include a Prohibited Steps Order with or without a Supervision Order. Removal from home should be considered only as a last resort. Please also see para 8.25.6 FGM protection orders (FGMPOs).

If the child has already suffered female genital mutilation, the Strategy Discussion must look at the child’s family composition when considering whether to continue enquiries and whilst assessing the need for support services. FGM isn't always a one-off act, so professionals are encouraged to explore the possibility of the girl being cut again in the future.

Strategy discussions should evaluate the information collected via agency enquiries. Consideration should be given as to whether a second Strategy Discussionshould take place.

When a medical examination is needed for evidential purposes professionals should consider therapeutic support needs at this juncture. It is important that therapeutic support needs are considered at regular intervals and in particular when events which might trigger a traumatic response occur, such as a medical intervention and/or a medical procedure.

The main emphasis of work in cases of actual or threatened female genital mutilation should be through education, support, advice and engagement, linking children and families to advice and support networks. This approach should also be reflected in Child Protection Planning. Agencies and organisations should also ensure that action taken is line with their local FGM guidance and processes.

Steps to take when it is suspected that a child suspected of either having undergone or is deemed to be at risk of undergoing FGM should include:

• Arranging for an interpreter if required; good practice would be to offer to use a female interpreter;
• Creating an opportunity for the child to divulge, seeing the child on their own;
• Using simple language and asking straightforward questions;
• Using terminology that is non-blaming and that the child will understand, e.g. using an approach that does not retraumatise the girl so that she is unlikely to view the procedure as abusive;
• Being sensitive to the fact that the girl will be loyal to their parents;
• Giving the girl time to talk;
• Getting accurate information about the urgency of the situation, if the girl is at risk of being subjected to FGM;
• Giving the message that the girl can come back to you again and signposting the child to additional sources of support and advice where appropriate.

Further tips to help plan a conversation are appended to this guidance. Safety planning must then be considered, this may involve a conversation with the child so that she is clear about how to keep safe in the immediate and near future.

Useful contacts are:

• Foundation for Women's Health, Research and Development, (FORWARD)
• National FGM Specialist Network

Tel: 020 8960 4000;

• The African Well Woman Clinic at Central Middlesex Hospital, Acton Lane, Park Royal, NW10 7NS.
• National Centre for FGM
• Border Force South Tel: 01293 507075/502019
• Daughters of Eve - A charity supporting girls and young women at risk of FGM.
• Forced Marriage Unit

Telephone: +44 (0) 20 7008 0151

email: fmu@fcdo.gov.uk

email for outreach work: fmuoutreach@fcdo.gov.uk

• Children and Families Across Borders

Telephone: 0207 735 8941

Email: info@cfab.org.uk

• Flowchart: Child/Young Adult (under 18rs) at risk of FGM
• Flowchart: Pregnant Women

• Flowchart: Non Pregnant Adult Women (over 18yrs) - routine enquiry or unplanned disclosure of FGM or potential FGM risk to self or others
• National FGM Centre Assessment Tool

GOV.UK Multi_Agency_Statutory_Guidance_on_FGM

GOV.UK FGM_Mandatory_Reporting

GOV.UK FGM_mandatory_reporting_Factsheet

e-Learning For Healthcare - Female Genital Mutilation programme

Public information leaflets:

The Department of Health published leaflets for people who want to know more about FGM. These are available in multiple languages.

Addendum to para 8.25.35: Tips to help professionals hold a conversation about FGM with a child and female members of their family

• Ensure that the conversation is opened sensitively
• Be aware of the specific circumstances of the individual when a discussion about FGM needs to take place
• Be non-judgmental
• Allow the girl to speak - actively listening, gently encouraging, and seeking the girl or woman’s permission to discuss sensitive areas
• Not being afraid to ask about FGM, using appropriate and sensitive language
• It is not unusual for women and girls to report that professionals have avoided asking questions about FGM, and this can lead to a breakdown in trust
• If a professional does not give a girl the opportunity to talk about FGM , it can be very difficult for a girl to bring this up herself
• Asking one question at a time – it can be difficult to think through the answers to several questions at the same time
• Making sure there is appropriate time to listen; a girl may relate information she has not disclosed previously
• Avoid interrupting her story part way through
• Make time to have the conversation
• Preparing by understanding what written materials are available to support conversations
• Find out more about the child’s Country of Origin and cultural practice
• Consider what other community and voluntary organisations are able to offer support and additional information within the area.

Professionals should:

•  Use culturally sensitive language
• Be aware that different communities have different terms for FGM
• Remember that women or girls may not be aware that they have had FGM.

Professionals should also think about how they frame their questions to the child and family members – the examples below could be used when talking to female adult family members

• “I can see in your notes from the obstetrician or midwife that you have been cut. Could you tell me a bit more about this?”
• “I know that (some) women in your country have been cut. How do you feel about this? Could you tell me a bit more?”
• “You have talked about your cutting and the traditions in your country. Is there anything else you want to tell me about this?”
• “How do you, and how does your partner, feel about female genital cutting? How do the people around you feel about this? Are you still in touch with relatives in your country? How do they feel about it? At what age is it usually performed?”
• “Are you closed or open?”