13.13 Female Genital Mutilation
This procedure should be read in conjunction with HM Government ‘Multi-agency statutory guidance on female genital multilation’ published on 1st April 2016 . This multi-agency guidance on female genital mutilation (FGM) should be read and followed by all persons and bodies in England and Wales who are under statutory duties to safeguard and promote the welfare of children and vulnerable adults. It replaces ’Female Genital Mutilation: guidelines to protect children and women’ (2014)
This guidance should be considered together with other relevant safeguarding guidance, including (but not limited to):
- Working Together to Safeguard Children (2015) in England
- Keeping Children Safe in Education (2016)
- Safeguarding Children: Working Together under the Children Act 2004
It is not intended to replace wider safeguarding guidance, but to provide additional advice on FGM.
The information in this guidance may also be relevant to bodies working with women and girls at risk of FGM or dealing with its consequences.
See also the Gov.uk website for:
- FGM Risk and Safeguarding: Guidance for professionals
- Ending violence against women and girls in the UK
- Female Genital Mutilation Prevalence: Dataset Implementation Guidance
- Female genital mutilation and its management; Royal College of Obstetricians and Gynaecologists 2015
- Ending violence against women and girls: Strategy 2016-2020
Revised 'Keepng Children Safe in Education' (September 2016) link added.
A new Section 3, NHS Actions and number of new links were added in September 2014, as well as NHS data collection requirements.
Section A provides background information
Section B provides practice guidance
The aim of the protocol
The protocol covers female children under the age of 18. The primary purpose of this protocol is to provide professionals with an understanding of Female Genital Mutilation (FGM) and what action they should take to safeguard girls who they believe may be at risk, or have already been harmed through FGM. Note: Any information or concern that a female is at immediate risk of, or has undergone FGM should result in a safeguarding referral to Surrey Children’s Services and Surrey Police.
FGM is also an abuse of female adults usually categorized under honour based violence and domestic abuse definitions. Where a female adult is also defined under the Care Act 2014 definition of adult at risk, additional support mechanisms should be available through adult safeguarding processes. These women will have similar needs for support and protection but different legislation and routes to safety will apply. The definition of an adult at risk in the Care Act is an adult who has care and support needs and because of those needs is unable to protect themselves from abuse or neglect. Please refer to the multi-agency safeguarding adults procedures that are available from the Surrey Safeguarding Adults Board or the police.
This protocol should be read in conjunction with Multi-agency statutory guidance on female genital mutilation (HM Government 2016). Multi-agency statutory guidance on female genital mutilation should be read and followed by all persons and bodies in England and Wales who are under statutory duties to safeguard and promote the welfare of children and vulnerable adults. It replaces female genital mutilation: guidelines to protect children and women (2014).
Target audience: Relevant to all practitioners and professionals working in the Surrey area whose role brings them into contact with children and families
Review date: 27 February 2017 Reviewer: SSCB policy and procedures group
Section A – Background information
1.1What is FGM?
The World Health organisation defines female genital mutilation (FGM) 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’ (WHO Fact Sheet No. 241 February 2014).
FGM is a criminal offence – it is child abuse and a form of violence against women and girls, and therefore should be treated as such. Cases should be dealt with as part of existing structures, policies and procedures on child protection and adult safeguarding. There are, however, particular characteristics of FGM that front-line professionals should be aware of to ensure that they can provide appropriate protection and support to those affected.
The following principles should be adopted by all agencies in relation to identifying and responding to those at risk of, or who have undergone FGM, and their parent(s) or guardians:
- the safety and welfare of the child is paramount;
- all agencies should act in the interests of the rights of the child, as stated in the United Nations Convention on the Rights of the Child (1989);
- FGM is illegal in the UK
- FGM is an extremely harmful practice - responding to it cannot be left to personal choice;
- accessible, high quality and sensitive health, education, police, social care and voluntary sector services must underpin all interventions;
- as FGM is often an embedded social norm, engagement with families and communities plays an important role in contributing to ending it; and
- all decisions or plans should be based on high quality assessments (in accordance with Working Together to Safeguard Children 2015 statutory guidance in England, and the Framework for the Assessment of Children in Need and their Families in Wales 2001
1.2. FGM is classified into four major types:
- Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce.
- Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.
- 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.
- Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
FGM is included within the revised (2013) government definition of Domestic Violence and Abuse
1.3 International prevalence
FGM is practised around the world in various forms across all major faiths. The majority of FGM takes place in 28 African and Middle Eastern countries, and also includes other parts of the world; Middle East, Asia, and in industrialised nations through migration which includes; Europe, North America, Australia and New Zealand. Globally UNICEF estimates that over 200 million girls and women worldwide have undergone FGM. It is important to recognise that the migrant populations may not practice FGM to the same level as their country of origin; a migrant’s reason for being in the UK may well be avoidance of FGM and second and third generation migrant populations may have very different attitudes towards FGM than their parents. However that same second or third generation may often be the children at greatest risk of having the procedure carried out.
1.4.Communities at risk of FGM in the UK
UK communities that are most at risk of FGM include Kenyans, Somalis, Sudanese, Sierra Leoneans, Egyptians, Nigerians, Eritreans and Ethiopians. However women from non-African communities that are at risk of FGM include Yemeni, Kurdish (Iraqi, Iranian and Turkish country of origin), Indonesian, Malaysian, Pakistani women and Indian women (Muslim Bohra Community). It is estimated that approximately 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM; approximately 103,000 women aged 15-49 and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM. In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM.
1.5. Alternative terms used for the procedure
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 practising communities, largely because they are English terms. See Multi-agency statutory guidance on FGM for terms used for FGM in different languages and for advice about how to talk about FGM.
1.6. Health Impact
FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies; complications are common and can lead to death.
Many women appear to be unaware of the relationship between FGM and its health consequences; in particular the complications affecting sexual intercourse and childbirth which can occur many years after the mutilation has taken place.
1.7. Immediate Physical Problems
- Urinary retention due to pain and swelling
- Wound infection
- Injury to adjacent tissues
- Fracture or dislocation as a result of restraint
- Damage to other organs.
1.8. Long-term Health Implications
In the UK, girls and women affected by FGM will manifest some of these long term health complications.
They may range from mild to severe or chronic.
- Uterine, vaginal and pelvic infections;
- Cysts or abscesses;
- Complications with menstruation
- Keloid or Hypertrophic scarring (when a scar becomes raised and can be bigger than the original area of skin damage);
- Failure to heal
- Psychological damage; including a number of mental health and psychosexual problems, e.g. depression, anxiety, post-traumatic stress, fear of sex . Many children exhibit behavioural changes after FGM, but problems may not be evident until adulthood;
- Sexual dysfunction;
- Difficulty in passing urine;
- Increased risk of HIV transmission/Hepatitis B and/or C – using same instruments on several girls;
- Increased risk of maternal and child morbidity and mortality due to obstructed labour. Women who have undergone FGM are twice as likely to die during childbirth and are more likely to give birth to a stillborn child than other women. Obstructed labour can also cause brain damage to the infant and complications for the mother (including fistula formation, an abnormal opening between the vagina and the bladder or the vagina and the rectum, which can lead to incontinence).
2.1Risk Factors that Heighten the Girl’s Risk of Being Subjected to FGM
The most significant factor to consider when deciding whether a girl or woman may be at risk of FGM is whether her family has a history of practising FGM. In addition, it is important to consider whether FGM is known to be practised in her community or country of origin.
The age at which girls undergo FGM varies enormously according to the community. The procedure may be carried out when the girl is new-born, during childhood or adolescence, at marriage or during a first pregnancy.
Given the hidden nature of FGM, individuals from communities where it takes place may not be aware of the practice. Women and girls who have undergone FGM may not fully understand what FGM is, what the consequences are, or that they themselves have had FGM. Given this context, discussions about FGM should always be undertaken with appropriate care and sensitivity.
See Multi-agency statutory guidance on female genital mutilation Annex C – Talking about FGM).
See Appendix 1 guidance for interviewing parents/carers/vulnerable adults
It is believed that FGM may happen to girls in the UK as well as overseas. Girls of school age who are subjected to FGM overseas are likely to be taken abroad (often to the family’s country of origin) at the start of the school holidays, particularly in the summer, in order for there to be sufficient time for her to recover before returning to school.
There are a number of factors in addition to a girl’s or woman’s community, country of origin and family history that could indicate she is at risk of being subjected to FGM. Potential risk factors may include:
- Any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family;
- Any female who has a relative who has already undergone FGM must be considered to be at risk;
- The socio-economic position of the family and the level of integration within UK society can increase risk;
- Parents state that they or a relative will take the child out of the country for a prolonged period;
- Parents have poor access to information about FGM and do not know about harmful impact;
- Girl has attended travel clinic for vaccinations;
- Family not engaging with professionals i.e.: health or school;
- A child may talk about a long holiday (usually over the school summer holiday) to her country of origin or another country where the practice is prevalent;
- A child may confide to a professional that she is to have a ‘special procedure’ or to attend a special occasion;
- A professional hears reference to FGM in conversation, for example a child may tell other children about it.
Remember: this is not an exhaustive list of risk factors. There may be additional risk factors specific to particular communities. For example, in certain communities FGM is closely associated to when a girl reaches a particular age.
If any of these risk factors are identified professionals will need to consider what action to take. If unsure whether the level of risk requires referral at this point, professionals should discuss with their named/designated safeguarding lead (HM Government 2016).
2.2. Significant/Immediate Risk Factors
If a child/young person under age of 18 identifies one or more serious or immediate risks from the list below, or other risks that in your judgment appear to be serious, then refer to Surrey Children’s Services;
- A child or sibling asks for help;
- A parent or family member expresses concern that FGM may be carried out on the child;
- Girl has confided that she is to have a `special procedure; or to attend a ` special occasion’. Girl has talked about going away to ‘become a woman’ or to ‘become like my mum and sister’;
- Girl has a sister or other female child relative who has already undergone FGM;
- Family/child is already known to Children’s Services- if known and have identified FGM within a family you must share this information with Children Services
2.3 Signs that FGM has taken place:
- Prolonged absence from school with noticeable behaviour changes on the girl's return;
- Longer/frequent visits to the toilet particularly after a holiday abroad, or at any time;
- Some girls may find it difficult to sit still and appear uncomfortable or may complain of pain between their legs;
- Some girls may speak about ‘something somebody did to them, that they are not allowed to talk about';
- A professional overhears a conversation amongst children about a `special procedure’ that took place when on holiday;
- Young girls refusing to participate in P.E regularly without a medical note;
- Recurrent Urinary Tract Infections (UTI) or complaints of abdominal pain.
Any information or concern that a female is at immediate risk of FGM, should result in a safeguarding referral to Surrey Children’s Services.
A disclosure from the girl or professional observing a physical sign that an FGM procedure has taken place should be reported to the police via mandatory reporting pathway.
Information should be shared with the child’s GP and school nurse / health visitor
Cultural Underpinnings and Motives of FGM
FGM is a complex issue, and individuals and families who support it give a variety of justifications and motivations for this. However, FGM is a crime and child abuse, and no explanation or motive can justify it. The justifications given may be based on a belief that, for example, it:
- brings status and respect to the girl;
- preserves a girl’s virginity/chastity;
- is part of being a woman;
- is a rite of passage;
- gives a girl social acceptance, especially for marriage;
- upholds the family “honour”;
- cleanses and purifies the girl;
- gives the girl and her family a sense of belonging to the community;
- fulfils a religious requirement believed to exist;
- perpetuates a custom/tradition;
- helps girls and women to be clean and hygienic;
- is aesthetically desirable;
- makes childbirth safer for the infant; and
- rids the family of bad luck or evil spirits.
FGM is a traditional practice often carried out by a family who believe it is beneficial and is in a girl or woman’s best interests. This may limit a girl’s motivation to come forward to raise concerns or talk openly about FGM – reinforcing the need for all professionals to be aware of the issues and risks of FGM.
Infibulation (Type 3) is strongly linked to virginity and chastity, and used to ‘protect’ girls from sex outside marriage and from having sexual feelings. In some cultures, it is considered necessary at marriage for the husband and his family to see her ‘closed’ and, in some instances, both mothers will take the girl to be cut open enough to be able to have sex.
Although FGM is practised by secular communities, it is most often claimed to be carried out in accordance with religious beliefs. However, FGM predates Christianity, Islam and Judaism, and the Bible, Koran, Torah and other religious texts do not advocate or justify FGM (HM Government 2016).
4.1 FGM has been a criminal offence in the UK since The Prohibition of Female Circumcision Act 1985. The Act was repealed by The Female Genital Mutilation Act 2003 and terminated a legal loophole which enabled victims to be taken outside of the jurisdiction for the purposes of FGM, without sanction. The Female Genital Mutilation Act 2003 made it unlawful for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where FGM is legal. This legislation was designed to prevent families and carers from taking girls abroad to undergo the procedure. The Act increased the maximum penalty for being found guilty of FGM from 5 to 14 years imprisonment. The Female Genital Mutilation Act 2003 also made it a criminal offence to re-infibulate following an FGM procedure.
With effect from 3 May 2015, the Female Genital Mutilation Act 2003 was amended by the Serious Crime Act 2015. The law is extended so that:
- A non-UK national who is ‘habitually resident’ in the UK and commits such an offence abroad can now face a maximum penalty of 14 years imprisonment. It is also an offence to assist a non-UK resident to carry out FGM overseas on a girl who is habitually, rather than only permanently, resident in the UK. This follows a number of cases where victims were unable to get justice as FGM was committed by those not permanently residing in the UK;
- A new offence is created of failing to protect a girl from the risk of FGM. Anyone convicted can face imprisonment for up to seven years and/or an unlimited fine;
- Anonymity for victims of FGM. Anyone identifying a victim can be subject to an unlimited fine.
4.2 Female Genital Mutilation Protection Orders
FGM Protection Orders came into force in July 2015; it is a civil measure that can be applied through the family court. The Protection Order offers the means of protecting actual or potential victims from FGM under civil law.
Breach of an FGM Protection Order is a criminal offence carrying a sentence of up to five years in prison. As an alternative to criminal prosecution, a breach could be dealt with in the family court as a contempt of court, carrying a maximum of two years’ imprisonment.
Who can apply for an order?
- The person who is to be protected by the order
- a relevant third party (such as the local authority); or
- any other person with the permission of the court (for example, teachers, health care professionals, police, family member).
FGM Protection Orders are unique to each case and contain legally binding conditions, prohibitions and restrictions to protect the person at risk of FGM. The court can make an order in an emergency so that protection is in place straightaway.
FGM is considered to be a form of child abuse (it is categorised under the headings of both physical abuse and emotional abuse. A local authority may exercise its powers under section 47 of the Children Act 1989 if it has reason to believe that a child is likely to suffer or has suffered FGM. Under the Children Act 1989, local authorities can apply to the Courts for various Orders to prevent a child being taken abroad for mutilation.
Private law remedies can be used as a form of legal protection. For example a prohibited steps order under Section 8 Children Act 1989 can be used to prevent a child being taken abroad or from having the procedure. A Non Molestation Order under Part IV of the Family Law Act 1996 may also be used as protection for the child or adult. The Domestic Violence Crime and Victims Act 2004 make the breach of a Non Molestation Order a criminal offence.
It may be possible for victims of FGM to claim compensation from the criminal injuries compensation authority. The injuries must be reported to the police.
4.3 The Police have police protection powers where there is reasonable cause to believe that a child or young person, under the age of 18 years, is at risk of significant harm. A police officer may (with or without the cooperation of social care) remove the child from the parent and use the powers for ‘police protection’ (section 46 of the Children Act 1989) for up to 72 hours.
4.4 The Local Authority has further powers under Section 44 of the Children Act 1989. Under this section, the Local Authority may apply for an emergency protection order (EPO). The Order authorizes the applicant to remove the girl and keep her in safe accommodation for up to 8 days. This Order is often sought to ensure the short term safety of the child.
An EPO can be followed by an application from the Local Authority for an interim care order, care order, or supervision order (sections 31 and 38 of the Children Act 1989). Without such an application, the EPO will lapse and the local authority will no longer have parental responsibility for the child.
4.5 Once a young person has left or been removed from the jurisdiction, the options available to police, Local Authority and other services become more limited. In such situations an application may be made to the High Court to make the young person a Ward of Court and have them returned to the UK.
When a British national seeks assistance at a British Embassy or High Commission overseas and wishes to return to the UK, the Foreign and Commonwealth Office (FCO) will do what it can to assist or repatriate the individual.
4.6 FGM Mandatory Reporting Duty
Home office: Mandatory Reporting of FGM – procedural information
From 31 October 2015, regulated health and social care professionals and teachers in England and Wales must report ‘known’ cases of FGM in under 18’s which they identify in the course of their professional work to the police; (either if they have visually confirmed it or it has been verbally disclosed by an affected girl). The only exception to the duty is if the professional knows that another individual from their profession has already made a report - there is no requirement to make a second.
The Home Office procedure provides information on the duty to help health and social care professionals; teachers and the police understand the legal requirements placed upon them, a suggested process to follow, and an overview of the action which may be taken if they fail to comply with the duty. It also aims to give the police an understanding of the duty and the next steps upon receiving a report.
The Home Office procedure provides that social workers should not under any circumstances examine a girl for signs of FGM.
For the purposes of the duty, the relevant age is the girl’s age at the time of the disclosure or identification of FGM – 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 where there is merely a suspicion that a girl is at risk of undergoing FGM.
The duty only applies to cases directly disclosed by the victim: it does not apply where a disclosure is made by a third party such as a parent, guardian or sibling.
The Home Office procedure states that complying with the duty “does not breach any confidentiality requirement or other restriction on disclosure which might otherwise apply.”
A failure to report the discovery in the course of their work could result in a referral to the relevant professional body.
Professionals Not Subject to the Mandatory Reporting Duty
While the duty is limited to the specified professionals described above, non-regulated practitioners still have a general responsibility to report cases of FGM, in line with wider local safeguarding policies and procedures. If a non-regulated professional becomes aware that FGM has been carried out on a girl under 18, they should still share this information with their named/designated safeguarding lead and follow their organisation’s safeguarding procedures (HM Government 2016).
Section B - Practice Guidance - Actions to be taken by Single and Multi-Agency Workforce
There are three circumstances relating to FGM which require identification and intervention:
- Where a child is at risk of FGM;
- Where a child has undergone FGM;
- Where a prospective mother has undergone FGM and the implications for the unborn child.
See Appendix 2 multi-agency risk assessment tool
The risk assessment tool in Appendix 2 should be used by professionals in all agencies to identify and consider risks relating to FGM, and to support the discussion with females and family members.
It should be used to help assess whether the female is either at risk of harm in relation to FGM or has had FGM, and whether she has children who are potentially at risk of FGM, or if there are other children in the family/close friends who might be at risk.
Additionally, the following agency specific guidance may help support the professional.
- Procedure within Surrey Children’s Service for Safeguarding Children at Risk of or who have Undergone FGM
2.1 When information is received by Surrey Children’s Service, it will be responded to in line with the Surrey multiagency levels of need document. In all cases, professionals should not discuss the referral with the parents/carers/family until a multi-agency action plan has been agreed.
2.2 On receipt of referral, if it is decided that the information requires a response under level 3 or level 4 of the levels of need document, a strategy discussion must be called within two working days or sooner as directed by the Duty Manager – see strategy discussion procedure. The strategy meeting will identify specialist help within Surrey and nationally (FORWARD London) to assist in the sensitive planning of enquiries. Sourcing specialists should not stop or delay any initial intervention from taking place. See also appendix 4 Useful Contacts.
2.3 If a referral is received concerning one female in a family, consideration must be given to whether other females in that family are also at similar risk. There should be consideration of other females from other associated families once concerns are raised about an incident or the perpetrator of FGM.
See Appendix 3 Decision making and flowchart for professionals in local authority children’s services
2.4 Children in Immediate Danger
Where the child appears to be in immediate danger of FGM and parents cannot satisfactorily guarantee that they will not proceed with it, and then an Emergency Protection Order should be sought.
When the immediate danger to the child has been addressed, a Strategy Meeting should be convened.
2.5 The Strategy Meeting should include:
- A Team Manager/Assistant Team Manager, to chair and co-ordinate the meeting;
- The allocated social worker responsible for the enquiry;
- A senior member of the Police Public Protection Investigation Unit DS level;
- A legal representative should be available for consultation;
- Appropriate health representation (for example the consultant paediatrician on call for Sexual Assault Referral Centre (SARC);
- A specialist in FGM from the statutory or voluntary sector if available;
- For children, the lead professional;
- Any other professional deemed appropriate by the Children’s Services manager.
2.6 An FGM Strategy Meeting should additionally cover the following issues:
- Family history and background information;
- Ensure safety of other female siblings or if indicated, close female relatives
- Scope of the investigation, what needs to be addressed and who is best placed to do this;
- Roles and responsibilities of individuals and organisations within the investigation, with particular reference to the role of the police;
- As to whether a medical examination/treatment is required and if so who will carry out what actions, by when and for what purpose;
- What action may be required if attempts are made to remove the child from the country;
- Identify key outcomes for the child and their family and implications and impact on the wider community.
2.7 Outcomes of Strategy Discussion
See also Enquiries under S47
See also Child & Family Assessment procedure.
S47 enquiries and Child and Family assessment should additional consider:
- Where a female has been identified as at risk or has been mutilated, it may not be appropriate to take steps to remove the child from an otherwise loving family environment. Experience has shown that often the parents themselves can experience pressure to agree to FGM and see it as the best thing they can do for their daughter’s marriageable status.
- It is also important to recognise that those seeking to arrange the mutilation are unlikely to perceive it to be harmful and, on the contrary, believe it to be legitimised by longstanding traditions.
- Parental/carer attitudes and understanding about the practice and where appropriate;
- Child/young person’s knowledge, understanding and views on the issue.
- Where the assessment is undertaken. It may be beneficial to talk to the family/affected female outside the home environment to encourage them to talk freely and acknowledge the impact FGM would have.
- An interpreter must be used in all interviews with the family, and more importantly the affected female, if their first language is not English. The interpreter must not be a family relation and must not be known by the family. The interpreter should be female and not known within their community.
- Appropriate communication aids must be offered for affected females who have difficulties communicating due to disability/illness and this should be documented within the record.
- All interviews should be undertaken in a sensitive manner, and should only be carried out once.
- Parental consent and the child's agreement should be sought before interviews take place. All attempts must be made to work in partnership with parents, and to endeavour for parents to retain full parental rights in these circumstances
- Medical examination, if necessary must only be undertaken with the child's and the parents' consent. Where parents do not consent, legal advice should be sought. In the majority of cases there should only be one medical examination of the child. In cases where subsequent medicals are required, clear reasons for this decision should be recorded as part of the assessment.
- If a medical/surgical procedure is required, and parents refuse consent, legal advice must be sought immediately.
- Following all enquiries into FGM, regardless of the outcome, consideration must be given to the therapeutic/counselling needs of the female and the family.
2.8 The Strategy Meeting should reconvene as agreed to discuss the outcomes and recommendations from the assessment and continue to plan the protection of the child. At all times the primary focus is to prevent the child undergoing any form of FGM by working in partnership with parents, carers and the wider community to address risk factors. However where the assessment identifies a continuing risk of FGM then, the first priority is protection and the local authority should consider the need for:
- Legal action;
- Criminal prosecution;
- An Initial Child Protection Case Conference.
2.10 If the S47 Enquiry / Child and Family Assessment concludes that there is no clear evidence of risk to the child then Children’s Service will:
- Consult the child's GP and Health Visitor or School Nurse about this conclusion and invite her/him to notify children’s services if any further information challenges it;
- Notify appropriate professionals involved with the family of the enquiry and the stage at which it was concluded;
- Inform the family and the referrer that the enquiry has been concluded;
- Consider whether any child may be a Child in Need and if so, offer appropriate services and offer the family/carers any appropriate support services.
2.11 If the s47/Child and Family assessment concludes that no other females – either younger children or those in the extended family - are at risk
- Surrey Children’s Services will take no further action other than to liaise with health services to review any health concerns for the child who has undergone the procedure;
- If the FGM seems to have been performed in the UK, the police will seek information for the possible prosecution of the perpetrator;
- Children’s Service will notify the child's GP and Health Visitors/School Nurse and invite her/him to notify them if any changes in the situation give rise to further concerns, e.g. the mother giving birth to further girls;
Procedure for Safeguarding Children from FGM within Education / Leisure and Community and Faith Groups
See link to Making Referrals to Children’s Services.
See link to Mandatory reporting duty
See Appendix 2 Multi-agency risk assessment tool
3.1 Teachers, other school staff, volunteers and members of community groups may become aware that a female is at risk of FGM through a parent / other adult, a child or other children disclosing that:
- The procedure is being planned;
- An older child or adult in the family has already undergone FGM;
- Child discloses FGM.
3.2 A professional, volunteer or community group member who has information or suspicions that a female is at risk of FGM should consult with their agency or group’s designated safeguarding lead/adviser (if they have one) and should make an immediate referral to Surrey Children’s Services if they suspect a child may be at risk of FGM. In cases where professionals believe that a child is at immediate risk of FGM, the Police should be called.
The Referral should not be delayed in order to consult with the designated safeguarding lead/adviser, a manager or group leader, as multi-agency safeguarding intervention needs to happen quickly.
3.3 Once concerns are raised about FGM there should also be consideration of possible risk to other females in the practicing community.
3.4 Please ensure Children’s Services share this information with the child’s GP, other health relevant health professionals such as midwife, health visitor and school nurse.
3.5 If a young person under the age of 18 discloses to a professional that they have been subjected to FGM or a professional observes physical signs that FGM has been carried out, then mandatory reporting duty must be followed.
Procedure for Safeguarding Children from FGM within the Health Sector
See link to Mandatory reporting duty in healthcare: https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare
See appendix 2 Multi-agency risk assessment tool
4.1 Health professionals in GP surgeries, Sexual Health Clinics, Women’s Health, Emergency Departments (ED), Walk in Centre’s, Urgent Treatment Centre’s and Maternity Services are the most likely to encounter a girl or woman who has been subjected to FGM. All girls and women who have undergone FGM should be given information about the legal and health implications of practicing FGM. Health Professionals should remember that some women may be traumatised from their experience and have already resolved never to allow their daughters to undergo this procedure.
Health Professionals should deal with FGM in a sensitive and professional manner, and not exhibit signs of shock when treating patients affected by FGM. They should ensure that the mental health needs of a patient are taken into account.
4.2 GP’s and Practice Nurses should be vigilant to any health issues such as resistance to partake in cervical smear testing, recurrent urinary tract infections or vaginal infections that may indicate FGM has been carried out. Those that do attend for health checks or travel vaccinations from affected communities could be asked about FGM and advised about its health impacts and informed that it is illegal within the UK. They should be offered/referred for additional support. They should document if a female patient has:
- Undergone FGM;
- What type of FGM;
- If there is a family history of FGM;
- If any FGM-related procedure has been carried out on a women - (including de-infibulation).
- Consider if there are any other girls or women in the family at risk of FGM
4.3 Consideration should be given if there are any suspicions that a child is being prepared to be taken abroad for FGM, if the family belongs to a community that practises female genital mutilation, and preparations are being made to take the girl overseas. For example:
- Arranging vaccinations;
- Planning absences from school;
- The child is talking about a “special procedure” taking place.
4.4 Document in the appropriate health record any advice or leaflets provided. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made. Wherever possible, health professionals could assess the attitudes of extended family members towards the practice of FGM and should consult with their named professional for safeguarding and with the relevant Surrey Children’s Services Assessment Team about making a referral to them. (Female Genital Mutilation care for patients and safeguarding children, BMA (July 2011).
4.5 A question about FGM should be asked when a routine new patient history is being taken from girls and women from communities that practise FGM. Information on FGM could be included in a welcome pack which is given to new patients from practising communities.
Where a prospective mother has undergone FGM
4.6 Midwives and nurses should be aware of how to care for women and girls who have undergone FGM during the antenatal, intra-partum and postnatal periods. They should discuss FGM at the initial booking visit to all women who come from countries that practice FGM or if they are married to or in a relationship with men from FGM practising communities. They should document if the woman has:
- Undergone FGM;
- What type;
- If there is a family history of FGM;
- If any FGM-related procedure has been carried out on a women - (including de-infibulation).
- Consider if there are any other girls or women in the family at risk of FGM
4.7 They must document what plan is in place for delivery. Document that the woman has been advised about the health risks and the UK law relating to FGM. If available they should be given a leaflet in an appropriate language to support the advice given and signposted to support services. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made to Surrey Children’s Services following discussion with their named professional/safeguarding lead. All this information should be recorded in the appropriate health record and shared with health professionals (including the GP, School Nurse and the Health Visitor as appropriate).
4.8 If a girl or woman who has been de-infibulated requests re-infibulation/re-suturing after the birth of a child, and/or the child is female or there are daughters in the family, health professionals should consult with their named professional/safeguarding lead and with Surrey children’s Services about making a referral to them. Re-infibulation is illegal in the UK.
Whilst the request for re-infibulation is not in itself a safeguarding issue, the fact that the girl or woman is apparently not wanting/able to comply with UK law due to family pressure and / or does not consider that the procedure is harmful raises concerns in relation to female children she may already have or may have in the future.
Some women may be pressured to ask for re-infibulation by their partner. This would come under the category of Domestic Violence and Abuse and local safeguarding children and adult procedures must be followed – see Domestic Abuse.
Midwives and nurses should record this information in the appropriate health record to ensure that all relevant health professionals are aware of the FGM incident and any concerns for female children.
4.9 Health visitors are in a good position to reinforce information about the health consequences and the law relating to FGM. Health visitors should discuss the risks of FGM and document the parent’s response. If available, parents should be given a leaflet in an appropriate language to support the advice given and signposted to support services. Any concerns about a parent’s attitude (and that of their extended family members) towards FGM should be taken seriously and appropriate referrals made. Professionals should consult with their named professional/safeguarding lead about making a referral to Children’s Services and inform the family’s GP of the referral.
Health visitors should record this information in the appropriate health record to ensure that all relevant health professionals, including the GP, are aware of the FGM incident and any concerns for female children.
4.10 School Nurses are in a good position to reinforce information about the health consequences and the law relating to FGM. The school nurse should work closely with the child’s school supporting them with any concerns. The school nurse should be vigilant to any health issues such as recurrent urinary tract infection that may indicate FGM has been undertaken. If the school nurse has contact with any family that originates from a country where FGM is practised, they should discuss the risks of FGM and document the parent’s response along with any advice and leaflets provided to explain the law relating to FGM. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made in discussion with their named professionals/safeguarding lead.
4.11 Emergency Departments and Walk-in Centres need to be aware of the risks associated with FGM if girls/women from FGM practising countries attend, particularly with urinary tract infections (UTIs), menstrual pain, abdominal pain, or altered gait for example. Their assessment should include assessing the risks associated with FGM. This should be documented and professionals should consult with their child or adult named professional/safeguarding lead about making a referral to social care.
4.12 Health services for Asylum Seekers & Refugees. Where initial health assessments for asylum seekers and refugees are undertaken, the health professional should introduce a discussion about FGM. They should document if the female has undergone FGM and what type. They must also document that the woman has been told about UK law and if available given a leaflet in an appropriate language that explains the risks of FGM, the law and support services. All this information should be shared with appropriate health professionals (GP, Health Visitor). Professionals should consult with their named professional/safeguarding lead about making a referral to Surrey Children’s Services.
4.13 Specific NHS Actions – data recording:
It is now mandatory for any NHS healthcare professional to record within a patient’s clinical record if they identify through the delivery of healthcare services that a woman or girl has had FGM
The Female Genital Mutilation (FGM) Enhanced Dataset Information Standard (SCCI2026) was published on 1 April 2015. HSCIC is collecting data on FGM within England on behalf of the Department of Health (DH) and NHS England (NHSE). This is to support the DH and NHSE FGM Prevention Programme. The data is collected to improve the NHS response to FGM and to help commission the services to support women who have experienced FGM as well as safeguarding women and girls at risk of FGM. The full dataset contains 30 data items including: patient demographic data, specific FGM information, referral and treatment information.
To see the full dataset, visit: http://digital.nhs.uk/fgm Female Genital Mutilation Datasets.
Collection and submission of the new dataset becomes mandatory for all acute trusts from 1 July 2015, and all Mental Health Trusts and GPs from 1 October 2015. Reporting is quarterly and organisations have a month to submit their data before the extract for the report is taken.
5. Procedures for Police Officers/Police Staff
5.1 The Priorities for Surrey Police in responding to FGM are;
- To protect the lives of both adults and children at risk as a result of FGM
- To investigate all reports of FGM
- To facilitate effective action against offenders so they can be held accountable through the Criminal Justice System
- To adopt a proactive, multi-agency approach to preventing and reducing the harmful practice of FGM
5.2 Surrey Police will work in line with the College of Policing Approved Professional Practice Guidance and also the HM Government Multi-Agency Practice Guidelines on FGM.
5.3 If a report of FGM is made to police, the Duty Inspector will be made aware and the assistance of the Safeguarding Investigation Unit (SIU) will be sought. (In their absence this will be CID). Relevant safeguards will immediately be put in place to prevent any risk to that child.
Risk to other children (and adults) will also be considered and acted upon immediately.
5.4 Where necessary officers should consider using their Police Protection powers under S46 Children Act 1989. The child should be removed to a place of safety and immediate contact should be made with Surrey Children’s services / EDT.
5.5 A Strategy Meeting will be held at the earliest opportunity (or within 2 days at the latest), involving police, Children’s services, Health including SARC and on-call paediatrician and any other relevant agencies.
5.6 Children and Young People should be interviewed in line with Achieving Best Evidence guidance, to obtain the best possible evidence for use in any prosecution.
5.7 A medical examination will be required and this will be arranged through Children’s services. A Paediatrician should carry out the examination in line with local safeguarding procedures. All cases should be seen/referred to the SARC.
5.8 Surrey Police will work with partner agencies to ensure that the relevant support and guidance is provided to the victim and any family members.
In many communities, FGM is seen as acceptable due to religious or cultural beliefs. Surrey Police will work with partner agencies in order to educate communities about the Criminal Offences involved with FGM and the future health implications for any victim.
When an Adult Female has undergone / is about to undergo FGM
5.9 These incidents should be dealt with as a Form of Domestic Violence or Honour Based Violence. They will be dealt with by the Safeguarding Investigation Unit. Relevant Risk Assessments and Safeguards should be put in place and referrals to other agencies made as appropriate to ensure the victim has the right support. In all cases consideration must be given to the need to protect other girls or females related to/living with the victim.
5.10 Part of the Investigation should entail Identification or any UK based excisors, with a view to identifying further victims.
5.11 If the victim is an adult at risk(as defined by the Care Act 2014), the adult safeguarding process should be initiated as per the multi-agency procedures on the Surrey Safeguarding Adults Board website. The adult (or their advocate if they lack mental capacity) will be asked what outcome they want to achieve from the safeguarding process and they may desire that no further action is taken. In these circumstances, the adult safeguarding response will cease.
5.12 Immediate protection may be secured for a victim through obtaining a Female Genital Mutilation Protection Order. An application can be made to a Magistrates’ Court by a victim or Local Authority, for the purpose of protecting a girl or woman against the commission of a FGM offence, or to protect any girl or woman against whom such an offence has been committed. (See S.5A and Schedule 2 FGM Act 2003 as added by s73 Serious Crime Act 2015).
Links to Forced Marriage and Domestic Violence and Abuse
6.1 There can be a link between FGM and Forced marriage, particularly in adults/teenagers when the woman may be mutilated shortly before the marriage. Professionals should be alert to this and consider a joint response to the Forced Marriage through local protocols alongside protection from FGM – see Forced Marriage and HBV procedure.
6.2 A woman/girl who has been subjected to FGM may have numerous gynaecological problems and this may make consummation of her marriage or sexual activity with her partner very uncomfortable/painful/impossible. In some communities it is expected that the man will ‘open’ the woman/girl before the wedding following type III FGM. This may be with a sharp instrument. The female may be frightened, not consent to this, suffer re traumatisation and fear/be ostracised from her community as her husband may not stay with her if she does not consent to this.
6.3 Women and girls may be raped within their relationship and suffer pain and re-traumatisation every time a partner demands sex. Some men may be more understanding and the couple may seek support. It is important to consider the wider support needs a woman may have including immigration, housing, debt, childcare and counselling support through community groups and domestic abuse specialist support. She may need to be referred to her local Multi Agency Risk Assessment Conference if the risk of forced marriage, serious injury or death is high.
Support for Girls and Women Affected by FGM
There are two main areas of support that should be offered to all women and girls affected by FGM - Counselling, and de-infibulation for type III. (see appendix for useful contacts)
Girls and women suffering from anxiety, depression or who are traumatised as a result of FGM should be offered counselling and other forms of therapy. All girls and women who have undergone FGM should be offered counselling to discuss how de-infibulation will affect them. Parents, husbands boyfriends, partners can also be offered counselling.
7.2 De-Infibulation/Reversal of FGM
This is a small procedure to open the scar carried out in a specialist clinic usually under local anaesthetic. The skin will be stitched at either side of the scar to keep it from healing together again and will usually heal very quickly. This should enable normal intercourse and child birth and reduce the number of infections a girl/woman may suffer. It does not replace tissue that has been removed and more scar tissue may form but it can improve a female’s quality of life.
Information Sharing in Relation to FGM
Given the need to potentially safeguard over a significant proportion of a girl’s childhood, it is appropriate to recognise here that there are a number of different responses to safeguard against FGM, and appropriate course of action should be decided on a case by case basis, with the expert input from all agencies involved. Sharing information in line with agreed policies and procedures is critical to safeguarding effectively.
Further reading on information sharing relating to FGM can be found in Multi-agency statutory guidance on female genital mutilation (HM Government 2016)
Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults
These questions and advice are guidance and each case should be dealt with sensitively and considered individually and independently.
All interventions should be accurately recorded by the persons involved in speaking with the child or adult. All recording should be dated and signed and give the full name and role of the person making the recording.
To Police Public Protection and Investigation Unit, Children’s Services and/or Health/Voluntary sector for medical follow up or support services.
FEMALE GENITAL MUTILATION
Decision making and flowchart for professionals in local authority children’s services (this should be read in conjunction with the detailed guidance above)
Appendix 4 Useful contacts
Surrey SARC http://www.solacesarc.org.uk
Tel: 0300 130 3038
Link to NHS choices for nearest FGM clinics and support http://www.nhs.uk/NHSEngland/AboutNHSservices/sexual-health-services/Pages/fgm-health-services-for-women.aspx
Foundation for Women’s Research and Development (FORWARD) Tel: 0208 960 4000 Email: firstname.lastname@example.org
AFRUCA – Africans Unite Against Child Abuse Tel: 0161 953 4711/4712 www.afruca.org
The NSPCC 24hour helpline to protect children and young people affected by FGM Tel: 0800 028 3550
Childline 24 hour helpline for children: 0800 1111
National 24 hour Domestic Violence Helpline 24-hour Helpline: 0808 2000 247
Surrey Domestic Abuse 24-hour Helpline - 01483 776822
THE INFORMATION IN THIS APPENDIX IS RELEVENT TO ADULTS ONLY
Female Genital Mutilation (FGM)
Surrey Safeguarding Adults Board Briefing
What to do if you have a concern
- If a woman is at imminent risk of FGM, the police should be notified by phoning 999, or in person at a police station. If the risk is not imminent then phone 101.
- If the woman is an ‘adult at risk’ as set out in the Care Act than you should also contact Adult Social Care under the usual safeguarding adults arrangements.
- If you have concerns a child is at risk of, or experienced FGM, this must be reported immediately to the police. It is important to also follow the procedures that are available on the Surrey Safeguarding Children’s Board website.
- Always consider whether there are other members of the family (adults or children) at risk and if so, report it.
Female Genital Mutilation (FGM) involves procedures that include the partial or total removal of the external female genital organs for cultural beliefs or other non-medical reasons. FGM requires a safeguarding response when the victim is an adult at risk of abuse and neglect (as defined in the Care Act). The definition of an adult at risk is:
- an adult has needs for care and support and
- the adult is experiencing, or at risk of, abuse or neglect and
- as a result of their care and support needs, the adult is unable to protect themselves from either the risk of, or the experience of abuse.
FGM is medically unnecessary, extremely painful and has serious health consequences, both at the time when the mutilation is carried out and in later life. The age at which girls undergo FGM varies enormously according to the community. The procedure may be carried out when the girl is new born, during childhood or adolescence, just before marriage or during the first pregnancy.
FGM is illegal under the Female Genital Mutilation Act 2003. UK communities that are most at risk of FGM include Kenyan, Somali, Sudanese, Sierra
Leonean, Egyptian, Nigerian and Eritrean. Non-African communities that practise FGM include Yemeni, Afghani, Kurdish, Indonesian and Pakistani.
Where victims or potential victims can go for support or advice
NSPCC FGM 24 hour helpline 0800 028 3550 / email@example.com
Forward - 0208 960 4000 / firstname.lastname@example.org
Daughters of Eve www.dofeve.org
Other relevant legislation
- Female Genital Mutilation Act 2003
There is a link between some legislation, procedures and guidance which means on some occasions, more than one process will need to be followed at the same time. Where an adult at risk is subject to any of the following, the safeguarding procedures must be considered in addition to any other procedures.
Multi-agency statutory guidance on female genital mutilation (HM Government 2016)
Working Together to Safeguard Children (HM Government 2015)
Framework for the Assessment of Children in Need and their Families in Wales (2001)
UNICEF (2016) Female Genital Mutilation/ Cutting: a Global Concern
HM Government - FGM the Facts
Macfarlane A, Dorkenoo E. (2015) Prevalence of Female Genital Mutilation in England and Wales:
National and local estimates. London: City University London and Equality Now
Women's Policy: Female Genital Mutilation - Women's Health Equity Act of 1996: Legislative Summary and Overview (July 12, 1996)
British Medical Association - Female Genital Mutilation: caring for patients and safeguarding children (2011)
Toubia, N. Female Genital Mutilation: A Call for Global Action, Women, Ink (New York,1993)
Koso-Thomas, O: The Circumcision of Women: A Strategy for Eradication (Zed Books, London, 1987
Department of Health (2015) FGM risk and safeguarding guidance for professionals
Mandatory reporting link
useful information/training resources
A Call to End Violence against women and girls Action Plan 2014
Female Genital Mutilation – resource pack
The Home Office has launched free online training produced by the virtual college. It can be accessed at https://www.FGMelearning.co.uk/
This course is useful for anyone who is interested in gaining an overview of FGM, particularly frontline staff in healthcare, police, border force and children’s social care
Healthcare professionals can also access free online training at http://www.e-lfh.org.uk/home/
RCPCH child protection manual 2014 http://www.rcpch.ac.uk/child-protection-publications Physical signs of CSA 2015 http://www.rcpch.ac.uk/physical-signs-child-sexual-abuse
FGM: Caring for patients and child protection (BMA, July 2011)
Royal College of Nursing- FGM educational resource (2006);
Female genital mutilation and its management; Royal College of Obstetricians and Gynaecologists 2015
GMC hot topic FGM http://www.gmc-uk.org/guidance/27723.asp
FGM: mandatory reporting in healthcare; https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare
 Multi-agency statutory guidance on female genital mutilation (HM Government 2016)
 Working Together to Safeguard Children (HM Government 2015)
 Framework for the Assessment of Children in Need and their Families in Wales (2001)
 UNICEF (2016) Female Genital Mutilation/ Cutting: a Global Concern
 HM Government - FGM the Facts
 Macfarlane A, Dorkenoo E. (2015) Prevalence of Female Genital Mutilation in England and Wales: National and local estimates. London: City University London and Equality Now
 Women's Policy: Female Genital Mutilation - Women's Health Equity Act of 1996: Legislative Summary and Overview (July 12, 1996)
 British Medical Association - Female Genital Mutilation: caring for patients and safeguarding children (2011)
 Toubia, N. Female Genital Mutilation: A Call for Global Action, Women, Ink (New York,1993)
 Koso-Thomas, O: The Circumcision of Women: A Strategy for Eradication (Zed Books, London, 1987
 DoH FGM risk and safeguarding guidance for professionals 2015
 DoH Female Genital Mutilation Risk and Safeguarding (2016)