1.4.22 Female Genital Mutilation (FGM)
SCOPE OF THIS CHAPTER
This chapter contains guidance for practitioners on identifying girls who may be at risk of Female Genital Mutilation (FGM), explains protective steps which can be taken in such cases and outlines the law in relation to FGM, including the mandatory reporting requirement.
1. Introduction and Definition
Female genital mutilation (FGM) is a collective term for procedures which include the removal of part or all of the external female genitalia for cultural or other non-therapeutic reasons. The practice 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 procedure is typically performed on girls aged between 4 and 13, but in some cases it is performed on new-born infants or on young women before marriage or pregnancy.
FGM has been classified by the World Health Organisation (WHO) into four types:
- Type 1 – Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);
- Type 2 – Excision: partial or total removal of the clitoris and 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.
For more detail, please refer to the Multi-Agency Statutory Guidance on Female Genital Mutilation (HM Government).
There is no Biblical or Koranic justification for FGM, and religious leaders from all faiths have spoken out against the practice.
FGM has been a criminal offence in the UK since 1985 when the Prohibition of Female Circumcision Act was passed. The Female Genital Mutilation Act 2003 replaced the 1985 Act and also made it an offence for UK nationals or permanent or habitual UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where the practice is legal.
FGM in the UK
FGM has been described as a 'hidden phenomenon', referring to the strong taboo associated with the practice and the cultural sensitivities involved in speaking out against it. It is also hidden in that it is under-reported in health and other information systems.
The hidden nature of this practice means it has been difficult to estimate the prevalence of FGM in the UK. A study based on 2001 census data in England and Wales estimated that 23,000 girls under the age of 15 could be at risk of FGM each year; and nearly 66,000 women are living with its consequences. FGM could be even more prevalent than these figures suggest due to population growth and immigration from practising countries since 2001.
Since April 2014, all NHS hospitals have been required to record if a patient has undergone FGM or if there is a family history of it, over time this data will help to provide a more robust indication of the prevalence of FGM among women and girls living in the UK.
2. Consequences of FGM
Depending on the degree of mutilation, FGM can have a number of short-term health implications:
- Severe pain and shock;
- Urine retention;
- Injury to adjacent tissues;
- Immediate fatal haemorrhaging.
Long-term implications can entail:
- Extensive damage of the external reproductive system;
- Uterus, vaginal and pelvic infections;
- Cysts and neuromas;
- Increased risk of Vesicovaginal Fistula;
- Complications in pregnancy and child birth;
- Psychological damage;
- Sexual dysfunction;
- Difficulties in menstruation.
In addition to these health consequences there are considerable psycho-sexual, psychological and social consequences of FGM.
3. Justifications of FGM
The justifications given for the FGM are multiple and reflect the ideological and historical situation of the societies in which it has developed. FGM is deeply embedded in some communities and is performed for cultural and social reasons. It is usually carried out on girls before they reach puberty, but in some cases it is performed on new-born infants or on women before marriage or pregnancy. It is often justified by the belief that it is beneficial for the girl or woman, but FGM is an extremely harmful practice which violates basic human rights.
- Custom and tradition;
- Religion, in the mistaken belief that it is a religious requirement;
- Preservation of virginity/chastity;
- Social acceptance, especially for marriage;
- Hygiene and cleanliness;
- Increasing sexual pleasure for the male;
- Family honour;
- A sense of belonging to the group and conversely the fear of social exclusion;
- Enhancing fertility.
4. Identifying Children at risk of FGM or who have been subject to FGM
If you are worried about a girl under 18 who is either at risk of FGM or who you suspect may have had FGM, you should share this information with Children's Social Care Services without delay. In addition, the if you are a practitioner in regulated profession such as healthcare, teaching or social work you must also notify the Police if you identify that an act of Female Genital Mutilation appears to have been carried out on a girl under the age of 18 (unless a colleague in the same agency has already notified the Police in connection with the same act of Female Genital Mutilation). See Section 5, FGM and the Law for more information on the Mandatory Reporting Requirement.
Practitioners should be mindful that alerting a girl's or woman's family to the fact that she has disclosed information about FGM may place her at increased risk of harm. However, it should not be assumed that all families from practising communities will want their girls and women to undergo FGM.
Risk Factors for FGM:
- The family belongs to a community in which FGM is practised, or they have limited levels of integration within UK community;
- The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
- If a female family elder is present, particularly when she is visiting from a country of origin, and taking a more active / influential role in the family;
- There are older girls or women in the family (e.g. older sister/s, mother) who have undergone FGM;
- The child talks about a 'special procedure/ceremony' s going to take place or a long holiday to her country of origin or another country where the practice is prevalent;
- Repeated failure to attend or engage with health and welfare services or the mother of a girl is very reluctant to undergo genital examination, including cervical smears;
- Parents requesting permission for their girls to be taken out of school two weeks before or after the summer holidays (recovery period can be up to 8-10 weeks);
- Where a girl from a practising community is withdrawn from Sex and Relationship Education they may be at risk from their parents wishing to keep them uninformed about their body and rights;
- The child talks about 'becoming a woman' or 'rites of passage';
- The child talks about new clothing or special outfits;
- The child becomes withdrawn or 'acting up' (out of character).
Practitioners should also consider whether any other indicators exist that FGM may have or has already taken place, for example:
- A prolonged absence from school with noticeable behaviour changes on the girl's return could be an indication that the girl has recently undergone FGM;
- The child has health problems, particularly bladder or menstrual problems;
- The child has difficulty walking, sitting or standing and may appear to be uncomfortable;
- A child requiring to be excused from physical exercise lessons without the support of her GP and very often using the excuse that Muslim girls can't exercise;
- A child may confide in a professional or ask for help.
Children's Social Care Services will liaise with Paediatric services where it is believed that FGM has already taken to determine if a Medical Assessment is required.
It should be remembered that although FGM is a one-off act of abuse to a child, it will have lifelong consequences, and can be highly dangerous at the time of the procedure and directly afterwards.
5. Law relating to Female Genital Mutilation
The Female Genital Mutilation (FGM) Act was introduced in 2003 and came into effect in March 2004. The act:
- Makes it illegal to practice FGM in the UK;
- Makes it illegal to take girls who are British nationals r permanent residents of the UK abroad for FGM whether or not it is lawful in that country;
- Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;
- Has a penalty of up to 14 years in prison and, or, a fine.
The 2003 Act only covered victims or perpetrators who are either UK nationals or permanent UK Residents. The Serious Crime Act 2015 Act extended this to cover those who are 'habitually resident' (on short, temporary stays) in the UK, including students and refugees.
Anonymity for victims
The 2015 Act provides lifelong anonymity for alleged victims of Female Genital Mutilation. It prohibits the publication of any information, in print, broadcast or social media, which would be likely to lead members of the public to identify an alleged victim.
Female Genital Protection Orders
Courts can make a protection order for individuals who are victims of or at risk of Female Genital Mutilation. This is similar to Forced Marriage Protection Orders. Individuals at risk, victims or relevant third parties (which can include local authorities) can apply for the orders, which can include requiring a person to surrender their passport and other such prohibitions and restrictions as the court considers appropriate.
Duty to protect
The 2015 Act introduced a new office for those responsible for girls under the age of 16 if they fail to protect them from Female Genital Mutilation. A 'responsible person' will have parental responsibility for the individual and frequent contact with them. A local authority which has assumed Parental Responsibility for a Looked After Child could fall within this scope.
Mandatory Reporting of FGM
Since 31st October 2015, regulated professionals in health and social care and teachers in England and Wales have been under a duty to report 'known' cases of FGM in under 18s which they identify in the course of their professional work to the Police.
'Known' cases are those where either a girl informs the person that an act of FGM – however described – has been carried out on her, or where the person observes physical signs on a girl appearing to show that an act of FGM has been carried out and the person has no reason to believe that the act was, or was part of, a surgical operation within Section 1(2)(a) or (b) of the FGM Act 2003.
In line with safeguarding best practice, professionals should contact the girl and / or her parents / guardians as appropriate to explain the report, why it is being made and what it means. Wherever possible this discussion should take place in advance of / in parallel to the report being made. The Multi-Agency Statutory Guidance on FGM contains information on how to speak to families about FGM.However, if you have concerns that informing the child / parents about the report may result in the risk of serious harm to the child or anyone else, or that then family may flee the county, you should not discuss it. Contact your safeguarding lead for advice in relation to any concerns you may have. See also Information Sharing Procedure.
A failure to report the discovery in the course of their work can result in a referral to the relevant professional body. The Home office has produced guidance for practitioners - see Mandatory Reporting of Female Genital Mutilation – procedural information to support this duty.
Procedure for Notifying West Yorkshire Police
Professionals should complete the West Yorkshire Police FGM Reporting Form and email to email@example.com. The mail box is monitored 24 hours a day, seven days a week and upon receipt the Police operator will create an incident log and also a child protection report. The child protection report will be forwarded to the appropriate Safeguarding Unit child protection team to initiate Police and partner investigation. Alternatively any reports can also be made by calling 101.
6. Protection and Action to be Taken
6.1 Identification and Referral
Where a practitioner identifies concerns about a girl who may have experienced FGM or who is at risk of FGM they should:
- Seek advice from their own agency safeguarding lead (if available at the time);
- Make a professional assessment of risk.
If it is decided that a child is at risk, the practitioner must make a referral to Children's Social Care Services without delay.
In addition, the if you are a practitioner in regulated profession such as healthcare, teaching or social work you must also notify the Police if you identify that an act of Female Genital Mutilation appears to have been carried out on a girl under the age of 18 (unless a colleague in the same agency has already notified the Police in connection with the same act of Female Genital Mutilation). See Section 5, Law Relating to Female Genital Mutilation for more information on the Mandatory Reporting Requirement.
FGM is a complex and sensitive issue that requires professionals to approach the subject carefully. An accredited female interpreter may be required. Any interpreter should ideally be appropriately trained in relation to FGM, and in all cases should not be a family member, known to the individual or someone with influence in the individual's community.
6.3 Initial Strategy Meeting
Children's Social Care Services will convene an initial strategy meeting in partnership with the Police and health colleagues at a minimum. The meeting should be chaired by a social work team manager.
A decision will be whether the child or young person, the unborn child, or sibling of a child in question has suffered or is likely to suffer significant harm as a consequence of FGM. If so, a Section 47 Enquiry will be initiated.
Where a child has been identified as suffering or likely to suffer significant harm, it may not always be appropriate to remove the child from an otherwise loving family environment. Parents and carers may genuinely believe that it is in the girl's best interest to conform to their prevailing custom.
Where a child appears to be in immediate danger of mutilation, legal advice should be sought and consideration should be given, for example, to seeking an a Female Genital Mutilation Protection Order, an Emergency Protection Order or a Prohibited Steps Order, making it clear to the family that they will be breaking the law if they arrange for the child to have the procedure.
Thought should be given to developing a safety and support plan in case the girl/woman is seen by someone 'hostile' at or near a meeting place, for example, agreeing in advance another reason why they are there.
If the strategy meeting concludes that the child has not suffered significant harm, then the outcome may be a Single Assessment under s17 Child in Need or advice to the referrer that the child's needs can be met through targeted and / or universal services. This may include the development of an Early Help Assessment.
6.4 Section 47 Enquiry
Children's Social Care Services will undertake a Section 47 Enquiry if they have reason to believe that a child is likely to suffer or has suffered FGM.
The Section 47 enquiry is carried out by the social worker in consultation with the Police,
6.5 Child Protection Medical Examination
Consent for a Child Protection Medical Examination should be sought. If consent is not given, legal advice must be sought. A Child Assessment Order may need to be applied for.
Parental consent is not required if a young person is Fraser Competent, i.e. a person aged 16 or 17, or a child under 16 who has the capacity to understand and make their own decisions, and may give (or refuse) consent to share information.
The Paediatrician who carries out the Child Protection Medical Examination should provide immediate verbal feedback on the outcome of the examination to the attending social worker (and / or Police officer is applicable). The Paediatrician should develop a written report for the second strategy meeting.
6.6 Second strategy meeting
A second strategy must be held with 10 working days of the Initial Strategy Meeting. The meeting should include the Police and relevant health practitioners and be chaired by the social work team manager. If possible, the Paediatrician who carried out the Child Protection Medical Examination should also attend. If this is not possible, they should provide their report on the outcome of the medical examination.
Attendees will consider information collected during the Section 47 enquiry and the Child Protection Medical Examination and decide on the outcome.
- The child has suffered or is likely to suffer significant harm and an Initial Child Protection conference is required;
- The child is not suffering or likely to suffer significant harm but requires services as a Child in Need. Children's Social Care Services will arrange a Child in Need Meeting;
- Legal advice needs to be sought from the Local Authority Legal Services; or
- No further action for Children's Social Care Services (consider referral to Early Intervention services).
7. NHS Actions
Since 2014 NHS hospitals have been required to record the following information:
- If a patient has had Female Genital Mutilation;
- If there is a family history of Female Genital Mutilation;
- If a Female Genital Mutilation-related procedure has been carried out on a patient.
Data is reported centrally to the Department of Health and Social Care on a monthly basis.
A midwife/obstetrician/gynaecologist/General Practitioner may become aware that Female Genital Mutilation has occurred when treating a female patient. This should trigger concern for other females in the household.
Appendix 1: Local FGM Procedures, Pathways and Strategies
Appendix 2: The Law
In England and Wales, criminal and civil legislation on FGM is contained in the Female Genital Mutilation Act 2003 ('the 2003 Act'):
- Makes it illegal to practice FGM in the UK;
- Makes it illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in that country;
- Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;
- Has a penalty of up to 14 years in prison and, or, a fine.
As amended by the Serious Crime Act 2015, the Female Genital Mutilation Act 2003 now includes:
- Creating a new offence of failing to protect a girl from FGM with a penalty of up to 7 years in prison or a fine or both. - A person is liable if they are "responsible" for a girl at the time when an offence is committed. This will cover someone who has "parental responsibility" for the girl and has "frequent contact" with her and any adult who has assumed responsibility for caring for the girl in the manner of a parent. This could be for example family members, with whom she was staying during the school holidays;
- Introduced Female Genital Mutilation Protection Orders ("FGMPO") - breaching an order carries a penalty of up to five years in prison. The terms of the order can be flexible and the court can include whatever terms it considers necessary and appropriate to protect the girl or woman;
- Allowing for the lifelong anonymity of victims of FGM – prohibiting the publication of any information that could lead to the identification of the victim. Publication covers all aspects of media including social media;
- Extended the extra-territorial reach of Female Genital Mutilation (FGM) offences to include "habitual residents" of the UK.
Appendix 3: Further Information
Mandatory Reporting of Female Genital Mutilation – procedural information