17.4 Female Genital Mutilation (or Cutting)

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.

The practice is illegal in the UK, and it is also illegal to take a British national or permanent or habitually resident girl abroad for the practice of FGM or to help someone trying to do this, under the FGM Act 2003.

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.

FGM is known by a variety of names, including ‘female genital cutting’, ‘circumcision’. The terms ‘FGM’ or ‘cut’ are increasingly used at a community level in the UK, although they are not always understood by individuals in FGM affected communities, largely because they are English terms. So care needs to be taken, in developing a cultural understanding of the terms used by communities to describe FGM. (See ‘National FGM Centre Traditional terms used for FGM, Appendix 3, in Paragraph, 17.4.34)

Important to note – Transgender Men.

Individuals who may have been cut as a child and have transitioned from female to male, are also survivors of genital mutilation/cutting. Transgender men may also experience the same challenges as regards trauma, health and sexual relationship challenges. Thus, services need to also how they can be more inclusive or adaptive of their services, which can predominantly support cisgendered women, impacted by FGM. Once such inclusive service providing support for Femmes in Sussex in ‘HERSANA’

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 and labia elongation. 

Labia minora elongation is a form of FGM, that is often undertaken over a prolonged period of time. If a child is undergoing this practice, it is child abuse and should be treated as such.  Labia minora elongation (LME) is a form of female genital mutilation (FGM) that involves the elongation of the inner lips of the female external genitalia or labia minora with the use of herbs. Unlike other types of FGM, LME is a prolonged process that takes months to years of physical and mental suffering. However, less emphasis has been given to the suffering related to this practice than other forms of FGM. (See the Lancet article below for more information). Labia minora elongation: a neglected form of genital mutilation with mental and sexual health concerns - eClinicalMedicine (thelancet.com)

Also see - Type 4 FGM - mixed messages - Safeguarding Hub

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).

The Serious Crime Act 2015, amended the FGM Act 2003, by bringing in:

• Mandatory reporting
• Need to notify the police
• FGM Protection orders
• Failure to protect a girl at risk of FGM

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 

It is also important to note however, that if a relative or carer informs a practitioner that a child under the age of 18 has undergone FGM, there may also be a risk to other girls/Transgender (female to male) siblings/children under 18 within the home or family network, who may also need to be safeguarded. Children’s Services are best placed, to assess any ongoing risk of FGM following a referral.

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

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 (e.g. report to your safeguarding lead)

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. If a medical examination is required, ensure that this is undertaken via a trained SARC’S service or FGM trained paediatrician. 

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.

A FGM protection order (FGMPO) is a civil order used to protect those who are vulnerable to FGM, to prevent it from taking place, in addition to protecting survivors under the age of 18. It gives the courts flexibility in stipulating conditions around safeguarding the welfare of the protected person. (e.g., preventing parents from taking children at risk out of the UK or minimise/prevent contact with a family member deemed to be a risk, in the UK or abroad) This means a court can also put provisions in place to facilitate the safe return of girls who have been taken outside the UK for the purpose of FGM.

It is important to note that FGM can also take place within the UK, and known or suspected cutters can also be of concern. It can be medicalised, where cutting can take place in a hospital/medical setting.

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. As well as speak to your legal department, particularly if you are working with a child/family subject to immigration control (asylum seeker).

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; (Sec 47,CA 89, strategy discussion/enquiry)

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; bearing in mind cultural and linguistic family needs and highlighting any educative work undertaken toward change in views and risk. (A community resource may also prove helpful)

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. (Note that a risk of FGM, should a child be returned or deported to a home country, could be enough to warrant a FGMPO application to the court. Parents/relatives can also apply to the court directly and may be able to receive pro-bono legal assistance)

8) be mindful of the fact that FGM does not just impact girls from Practicing FGM countries, so there is also a need to consider families in mixed relationships, with dual heritage children. As well as white females for example, under 18, who may have genital piercing, which is classified as type 4 FGM.

*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).

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, culturally competent and honest conversation with women who are survivors of FGM and their family about the law in the UK and the physical and psychological short- and long-term 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. As well as culturally competent FGM community groups and women’s grou
  • Please also Recognition and Response (below) 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 prevent 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 or in the UK. These include knowing that the family belongs to an FGM affected community and is preparing for the child to be taken on holiday, arranging vaccinations or planning absence from school. The child may also talk about a 'special procedure/Party/ceremony' that is going to take place.

It will always be important however, to ensure you are talking to families about their planned trips abroad, in terms of information gathering and risk assessments, so as not to unwittingly racially profile specific groups of people, due to their ethnicity and country of origin. As they may be going on holiday and may be having a cultural celebration, that may not be FGM.

Girls are at particular risk of FGM at any time, but particularly during school holidays and prolonged absences from school, as these are the times when families may take their children abroad for the procedure or arrange for cutters to come to the UK.

 Signs that a girl could be at risk of FGM

• One or both of a girl’s parents come from a community affected by FGM
• A girl is born to a woman who has undergone FGM
• Mother has requested re-infibulation following childbirth
• A girl has an older sibling or cousin who has undergone FGM
• One or both parents or elder family members consider FGM integral to their cultural or religious identity
• The family indicate that there are strong levels of influence held by elders and/ or elders who are involved in bringing up female children
• A girl/family has limited level of integration within UK community
• A girl from a practising community is withdrawn from PSHE and/or Sex and Relationship Education or its equivalent may be at risk as a result of her parents wishing to keep her uninformed about her body, FGM and her rights

Signs that a girl could be at immediate risk of FGM

• 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
• If there are references to FGM in conversation, for example a girl may tell other children about it
• A girl may confide that she is to have a ‘special procedure’ or to attend a special occasion to ‘become a woman’
• A girl may request help from a teacher or another adult if she is aware or suspects that she is at immediate risk
• Parents state that they or a relative will take the child out of the country for a prolonged period
• A girl may talk about a long holiday to her country of origin or another country where the practice is prevalent
• A girl is taken abroad to a country with high prevalence of FGM, especially during the summer holidays which is known as the ‘cutting season’

Signs that FGM has occurred.

• prolonged absence from schools
• frequent need to go to the toilet
• long break to urinate
• urinary tract infections.

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 open discussions recognition of risk, or minimised risk if this is not a woman’s first female child and preventative work with parents. The role of men/fathers from FGM affected communities should also be considered within this context. With the support of community and religious groups and community champions. The provision of face-to-face interpreters for this work must be a priority where needed, language line if not possible. Do not use family members as interpreters.

Bear in mind that concerns around FGM may not always be from the parents, but from extended family members in the UK or in families’ countries of origin. Children’s Social care Genogram tools will be good to look at wider risk factors within families.

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 infancy and fifteen years old  (https://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions#age_performed) 

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.
• Consider the need for a SARC medical examination if there has been verbal disclosure that FGM has taken place.

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 such as HERSANA or FORWARD 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 cultural traditions, customs, religious beliefs, lifestyles, linguistic needs and to child-rearing practices, that may differ from your own and that vary across different racial, ethnic and cultural groups.

At the same time, we must make explicit our safeguarding concerns at all times and ensure families have a clear understanding of what constitutes child abuse and that families cultures will be respected, but not when harmful practices, in the name of culture, pose a risk or harm children.

Siblings should be included in the assessment and any subsequent child protection planning.

The National FGM Centre’s assessment tool and accompanying ‘FGM best practice guidance for social workers,’ will be helpful to use in assessing risk, to support engagement with a child and family member, with a good guide in Appendix 5, on how to ask culturally competent questions, as well as how to use Genograms, to assess the risk in a wider family context. http://nationalfgmcentre.org.uk/wp-content/uploads/2018/03/FGM-Best-Practice-Guidance-for-Social-Workers-1.pdf

FGM could sometimes be a precursor for other forms of harmful practices such as:

•  Forced Marriage of a child
•  Abuse Linked to Spiritual and Religious Beliefs/Ritual Abuse 
• Breast Ironing

Also consider other safeguarding concerns such as the following as part of a hollistic assessment: 

• Safeguarding Children impacted by Domestic Abuse
•  Parenting Capacity and Mental Health Difficulties 

If there is a risk of the girl being taken overseas the assessment must include risk of flight, and the need for an FGMPO, which could prevent a girl from being taken overseas or repatriated if risks to her safety is high. Should a girl be taken out of the country you can also seek advice and support via the The Forced Marriage Unit. Who also provide advice on FGM, speaking to consulates and Embassy’s, as well as 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. In addition, it is important to ask families about terms used within their culture, as there may be slight variations in what you may read about people and their countries of origin. Some 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 Black and global majority communities, or with a detailed knowledge of, the community concerned, who can also  remain open and curious about how they can affect change. 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 family members can be found in Appendix 5, of the National FGM Centre best practice guide for social workers, which can be found above in paragraph (17.4.31).

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 FGM protection orders (FGMPOs) above.

Educative and preventative work should be undertaken with the family in the first instance, supported by community groups, in partnership with Children's Services and multi-agency partners, to affect change. Particularly as in many instances, FGM may be the only safeguarding concern.

If the child has already suffered female genital mutilation, the Strategy Discussion must look at the need for the child to have an urgent medical examination and CSC, will need to undertake assessments of further risk within the family, using the Genogram tool and guidance outlined above. To enable decision to be made about continuing enquiries and sec 47 investigations, in conjunction with providing support services. Strategy discussions should evaluate the information collected via agency enquiries.

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. Specialist Support/examinations for children can be accessed via University College London Hospital (UCLH) supported by LA SARCS services.

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. Support and counselling services can be accessed via HERSANA. Details of their service provision is in the link on the resources section.

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 a face to face (where possible) 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. Children and professionals concerned about FGM can  call the NSPCC - FGM Helpline on: 0800-028-3550

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. To aide conversations with children, also see the NSPCC PANTS Rule - https://www.nspcc.org.uk/keeping-children-safe/support-for-parents/pants-underwear-rule/  

Useful contacts are:

• https://niwbh.org/ - Network of International women – Brighton and Hove
• https://www.hersana.org/ HERSANA
• https://www.fgmcri.org/research-resources/ - 28 Too Many – FGM resources
• 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) is 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.