14.14 Female Genital Mutilation

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Contents

• Definitiion(Jump to)
• Types of FGM(Jump to)
• Factors indicating that girls are at risk(Jump to)
• What to do if a child is suspected to be at risk of FGM(Jump to)
• Further information(Jump to)

Definitiion

What is Female Genital Mutilation (FGM)? 

World Health Organisation (WHO) February 2024 [1] Female genital mutilation (WHO.int)

• More than 230 million girls and women alive today have undergone female genital mutilation (FGM) in 30 countries in Africa, the Middle East and Asia where FGM is practiced.
• FGM is mostly carried out on young girls between infancy and age 15.
• FGM is a violation of the human rights of girls and women.

• Female genital mutilation (FGM) 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 has no health benefits for girls and women and cause severe bleeding and problems urinating, and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. In many settings, health care providers perform FGM due to the belief that the procedure is safer when medicalised^{2}. WHO strongly urges health care providers not to perform FGM.

World FGM Map – National FGM Centre

FGM is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death. In several settings, there is evidence suggesting greater involvement of health care providers in performing FGM due to the belief that the procedure is safer when medicalized. WHO strongly urges health care providers not to perform FGM and has developed a global strategy and specific materials to support health care providers against medicalisation.

In 2015 a 2-year BPSU epidemiological surveillance study was commenced to identify prevalence data of FGM in the UK for children in the UK. This identified 103 children with FGM in the UK, but it was acknowledged that this was likely an under representation. 25% of cases were performed by a health professional or in a healthcare setting such as a clinic.  Epidemiological surveillance study of female genital mutilation in the UK | Archives of Disease in Childhood (bmj.com)

Types of FGM

The WHO has classified FGM into 4 major 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.

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.

Factors indicating that girls are at risk

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 guidelines on FGM for those with statutory duties to safeguard children and vulnerable adults (Please refer to Annex C – Talking about FGM in this national guidance as this has helpful pointers and resources on talking to children and families).

 A further question guide regarding questions to ask girls and families around FGM can be found on the National FGM centre website. Question-Guide-FGM.pdf

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. Department of Health guidance on FGM risk and safeguarding include the following potential risk factors may:

• Child or women’s mother has undergone FGM.
• Other female members have had FGM.
• Father comes from a community known to practice FGM.
• A female family elder is very influential within the family and is / will be involved in the care of the girl.
• 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
• Girl withdraws from PHSE lessons.
• Any other safeguarding alert already associated with the family.

Significant or immediate risk factors are:

• 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 in another 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 are already known to social services.

The signs that a girl under 18 years has had FGM include:

• Girl is reluctant to undergo any medical examination.
• 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.
• Increased emotional and psychological needs e.g. withdrawal, depression, or significant change in behaviour.
• Girl avoiding physical exercise or requiring to be excused from PE lessons without a GP’s letter.
• Girl has spoken about having been on a long holiday to her country of origin/ another country where the practice is prevalent.
• Girl spends a long time in the bathroom/toilet/long periods of time away from the classroom.
• Girl talks about pain or discomfort between her legs.

What to do if a child is suspected to be at risk of FGM

If one or more indicators for FGM are identified, the professional should consider whether the level of risk requires referral. It should be discussed with the named/designated safeguarding lead.

If one or more serious or immediate risk are identified, or the other risks are sufficient to be considered serious, a referral should be made in accordance with the SSCP referral procedures.

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.

Any child under 18 who has undergone FGM must be referred to the police under the Mandatory Reporting duty using the 101 non-emergency number. More information on Mandatory Reporting.

Children with suspected FGM should be referred to The Surrey Sexual Assault referral Centre (SARC) for an examination if indicated. Home - The Solace Centre (surreysolace.org)

Mandatory Reporting

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.

For further information please visit Mandatory reporting of female genital mutilation procedural information .

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 2023). More information is available in Working Together to Safeguard Children 2023.  

Specific NHS Actions – data recording:

FGM Enhanced Dataset

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.

Reporting is quarterly and organisations have a month to submit their data before the extract for the report is taken. The following organisations have to meet the requirements of the FGM Enhanced dataset standard as of 1 October 2015:

• General Practice
• Mental Health Trust
• Acute Trusts (mandatory since 1 July 2015)

To see the full dataset, visit NHS Digital FGM enhanced dataset.

Female genital mutilation information service – (FGM-IS)

Female Genital Mutilation Information Sharing (FGM-IS) is a national IT system for NHS staff that supports the early intervention and ongoing safeguarding of girls, under the age of 18, who have a family history of Female Genital Mutilation (FGM) Providing an opportunity to strengthen local safeguarding frameworks and processes.

Further information

Female Genital Mutilation information sharing June 2024

Female Genital Mutilation (FGM) Statistics - UNICEF Data March 2024

Female Genital Mutilation (who.int) February 2024

FGM enhanced dataset from health and Social Care Information Centre January 2024

FGM – National FGM Centre

FGM pocket guide March 2016

FGM protection orders factsheet December 2016

FGM – the facts leaflet (publishing.service.gov.uk)

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

Mandatory reporting of female genital mutilation procedural information January 2020

National FGM support clinics September 2022

Safeguarding women and girls at risk of FGM- Practical help to support NHS organisations developing new safeguarding policies and procedures for female genital mutilation (FGM).January 2017

Working together to safeguard children 2023: statutory guidance (publishing.service.gov.uk) December 2023

Useful contacts

NSPCC FGM 24 hour helpline 0800 028 3550 / fgmhelp@nspcc.org.uk

Forward   Foundation for Women’s Health Research & Development (FORWARD)- 0208 960 4000 / support@forwarduk.org.uk

Daughters of Eve www.dofeve.org

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