1.3.3 Female Genital Mutilation
These procedures should be read in conjunction with the following:
These procedures take account of the following national guidance publications:
This chapter was updated in Octopber 2015 to include local developments implemented through the MKSCB FGM Strategy. The chapter was further updated in April 2016 to reflect the Serious Crime Act 2015 amendments to the Female Genital Mutilation Act 2013 making it an offence of failing to protect a girl from FGM, creating a civil law measure Female Genital Mutilation Protection Order (FGMPO) and offering lifelong anonymity to victims, where an alleged offence may have been committed. The Female Genital Mutilation and its Management: Royal College of Obstetricians and Gynaecologists guidelines have been updated. To reflect the updated April 2016 statutory multi-agency guidance on Female Genital Mutilation, amendments were made in May 2016. .
Also, from the 31st October 2015, regulated professionals in health and social care professionals, and teacher in England and Wales have a duty to report ‘known’ cases of Female Genital Mutilation (FGM) in under 18s to the police.
- 1. Legal Status
- 2. Cultural Underpinnings
- 3. Types of Female Genital Mutilation and Procedures
- 4. Implications of Female Genital Mutilation for a Child's Health and Welfare
- 5. Professional Response
- 6. NHS Actions
- 7. Mandatory Reporting of FGM
- 8. Identifying a Child who is at Risk of FGM or who may have been Subjected to FGM Using the FGM Screening Tool
- 9. Responding to FGM: Immediate Concern about a Child at Risk of FGM or that may have undergone FGM - Referral to Milton Keynes Multi-Agency Safeguarding Hub
- 10. Responding to FGM: Non-immediate Concern about a Child – Referral to Multi-Agency FGM Consultation Panel
- 11. Physical and Mental Health Care and Treatment Pathway for those affected by FGM
- 12. Monthly Multi-Agency FGM Consultation Panel Meetings
- 13. Reducing the Prevalence of Female Genital Mutilation
- 14. Further Advice
1. Legal Status
The World Health Organisation (WHO) defines female genital mutilation (FGM) as: "all procedures (not operations) which involve partial or total removal of the external female genitalia or injury to the female genital organs whether for cultural or other non-therapeutic reasons" (WHO, 1996).
Under section 1(1) of the 2003 FGM Act, a person is guilty of an offence if they excise, infibulate or otherwise mutilate the whole or any part of a girl’s labia majora, labia minora or clitoris. Section 6(1) of the 2003 Act provides that the term “girl” includes “woman” so the offences in sections 1 to 3 apply to victims of any age.
Other than in the excepted circumstances set out in sections 1(2) and (3), it is an offence for any person (regardless of their nationality or residence status) to:
Provided that the FGM takes place in England or Wales, the nationality or residence status of the victim is irrelevant.
Any person found guilty of an offence under section 1, 2, or 3 of the 2003 Act is liable to a maximum penalty of 14 years’ imprisonment or a fine (or both).
Significant Harm is defined as a situation where a child is suffering, or is likely to suffer, a degree of physical, sexual and / or emotional harm (through abuse or neglect) which is so harmful that there needs to be compulsory intervention by child protection agencies into the life of the child and their family.
Failing to protect a girl at risk of FGM
Those who have parental responsibility and the means by which they can acquire it are set out in the Children Act 1989 (in the case of England and Wales). It includes, for example:
Extra Territorial Offences
Section 4(1) of the 2003 Act extends section 1 to 3 to extra-territorial acts so that it is also an offence for a UK national or UK resident to :
These offences are to intended to cover taking a girl abroad to be subjected to FGM
2. Cultural Underpinnings
Female genital mutilation (FGM) is a complex issue. Despite the harm it causes, many women from FGM practising communities consider FGM normal to protect their cultural identity.
Although FGM is practised by secular communities, it is most often claimed to be carried out in accordance with religious beliefs. However, neither the Bible nor the Koran supports the practice of FGM. In addition to giving religious reasons for subjecting their daughters to FGM, parents say they are acting in a child's best interests because it:
The age at which girls are subjected to female genital mutilation varies greatly, from shortly after birth to any time up to adulthood. The average age is 10 to 12 years.
3. Types of Female Genital Mutilation and Procedures
Female Genital Mutilation and other terms (see glossary) has been classified by the WHO into four types:
De-infibulation is a minor surgical procedure to divide the scar tissue sealing the vaginal entrance in Type 3 FGM. De –infibulation is sometimes termed a’ reversal ‘of FGM. This, however, is incorrect as it does not replace genital tissue or restore normal genital anatomy and function.
Re-infibulation is when the raw edges of the FGM wound are sutured again following childbirth, recreating a small vaginal opening similar to the original FGM Type 3 appearance.
Section 1 of the 2003 Act does not refer explicitly to re-infibulation but, as a matter of common sense, if it is an offence to infibulate it must equally be an offence to re-infibulate.
4. Implications of Female Genital Mutilation for a Child's Health and Welfare
The health implications for a child of the FGM procedure can be severe to fatal, depending on the type of FGM carried out.
As with all forms of child abuse or trauma, the impact of FGM on a child will depend upon such factors as:
Short term implications for a child’s health and welfare
Short-term health implications can include:
Long term implications for a girl or woman’s health and welfare
The longer term implications for women who have been subject to FGM Types 1 and 2 are likely to be related to the trauma of the actual procedure. Nevertheless, analysis of World Health Organisation data has shown that as compared to women who have not undergone FGM, women who had been subject to any type of FGM showed an increase in complications in childbirth, worsening with Type 3. Therefore, although Type 3 creates most difficulties, professionals should respond proactively for all FGM types.
The health problems caused by FGM Type 3 are severe – urinary problems, difficulty with menstruation, pain during sex, lack of pleasurable sensation, psychological problems, infertility, vaginal infections, specific problems during pregnancy and childbirth, including flashbacks.
Women with FGM Type 3 require special care during pregnancy and childbirth.
The long term health implications of FGM include:
Mental health problems
In FGM practising communities, the procedure is generally performed on pre-pubescent and adolescent girls usually without anaesthetics and with instruments such as razor blades. Case histories and personal accounts from women note that FGM is an extremely traumatic experience for girls and women that stays with them for the rest of their lives.
Young women who have received psychological counselling in the UK, reported feelings of betrayal by parents, incompleteness, regret and anger . It is possible that as young women become more informed about FGM and/or cross the threshold from traditional Africa to the modern sector this problem may be more frequently identified . There is increasing awareness of the severe psychological consequences of FGM for girls and women which become evident in mental health problems.
The results from research  in practicing African communities are that women who have undergone FGM have the same levels of Post Traumatic Stress Disorder (PTSD) as adults who have been subject to early childhood abuse. Also that the majority of the women (80%) suffer from affective (mood) or anxiety disorders.
The fact that FGM is ‘culturally embedded’ in a girl or woman’s community appears not to protect her against the development of Post Traumatic Stress Disorder and other psychiatric disorders.
 Haseena Lockhat, 2004, ‘Female Genital Mutilation: Treating the Tears’, London: Middlesex University Press
 Excised girls requiring psychological counselling was highlighted by women’s organization attending a recent Equality Now ‘Annual Meeting for Grassroots Activism to End Female Genital Mutilation’ which took place from the 20-22 October 2005 in Nairobi, Kenya.
 Behrendt, A. et al, 2005, ‘Posttraumatic Stress Disorder and Memory Problems after Female Genital Mutilation’, Am J Psychiatry 162:1000-1002, May
5. Professional Response
There are three circumstances relating to FGM which require identification, assessment and possible intervention.
Professionals and volunteers in most agencies have little or no experience of dealing with female genital mutilation. Coming across FGM for the first time they can feel shocked, upset, helpless and unsure of how to respond appropriately to ensure that a child, and/or a mother, is protected from harm or further harm.
The appropriate response to FGM is to follow usual child protection procedures to ensure:
An appropriate response to a child suspected of having undergone FGM as well as a child at risk of undergoing FGM could include:
An appropriate response by professionals who encounter a girl or woman who has undergone FGM includes:
A range of resources is available to practitioners, including ‘guidance for health visitors’, ‘FGM – the Law’, schools leaflet, and ‘advice and support for practitioners’ and other general FGM resources.
6. NHS Actions
Since April 2014 NHS hospitals have been required to record:
- 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.
Since September 2014 all acute hospitals have been required to report this data centrally to the Department of Health on a monthly basis. This was the first stage of a wider ranging programme of work in development to improve the way in which the NHS will respond to the health needs of girls and women who have suffered Female Genital Mutilation and actively support prevention.
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.
The Multi agency statutory guidance on female genital mutilation updated in April 2016 includes further NHS England considerations in relation to using NHS electronic IT systems, to increase the effectiveness of Sharing FGM risks for individual children. The FGM Risk Indicator System (RIS) sits within the summary care record and has the ability to hold the following information.
- an indicator that a girl is potentially at risk of FGM;
- the date that the FGM safeguarding risk assessment was carried out; and
- the date that the FGM risk indicator was added on to the system.
The FGM RIS should be used in conjunction with local safeguarding frameworks and processes. Use of the FGM RIS will not change professional responsibilities in regard to multi agency working when assessing FGM risks.
The FGM panel will consider FGM RIS as part of the suggested outcomes communicated back to the practitioner who completed the FGM screening tool.
7. Mandatory Reporting of FGM
From the 31st October 2015, regulated professionals in health and social care professions and teachers in England and Wales have 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.
A failure to report the discovery in the course of their work could result in a referral to their professional body. The Home office has produced guidance Mandatory Reporting of Female Genital Mutilation – procedural information to support this duty.
8. Identifying a Child who is at Risk of FGM or who may have been Subjected to FGM Using the FGM Screening Tool
The Milton Keynes Safeguarding Children Board has approved a screening tool (see, FGM Screening Tool) for FGM to assist all professionals in identifying children at risk of being abused through FGM, or children who may have been subjected to FGM. The screening tool also includes indicators to help professionals in their decision-making about whether or not a child is at risk of FGM. The screening tool is kept under review and developed as knowledge and understanding of the risk factors and symptoms in different practising communities, increase in the UK.
The Screening tool is divided into four parts:
Professionals need only complete the part that applies to the child or adult they are working with.
Professionals who are completing the screening tool must allocate a reference number that is identifiable for that agency, this is so that the cases can be considered anonymously.
If risks are identified the initial response should be for the practitioner to discuss directly with the individual/parent/family to establish their understanding and views – practitioners may find the MKSCB FGM resource ‘Advice and Support for Practitioners’ useful. The practitioner must ensure that the individual/parent/family understand that FGM is legal and that they will be liable to a maximum penalty of 14 years’ imprisonment or a fine (or both).
Having completed the FGM screening tool and identified any risk indicators, professionals should seek consultation and advice from their agency’s FGM operational lead or their designated safeguarding lead. Where no such designation exists they should seek advice from Children’s Social Care via the Milton Keynes Multi-Agency Safeguarding Hub (email: children@Milton-keynes.gov.uk/tel: 01908 253169/70 (Out-of-Hours: 01908 265545).
In instances where:
The FGM multi-agency Consultation Panel meeting is held monthly and practitioners are welcome to attend to discuss their identified concerns regarding the woman/child they are working with. This meeting assists professionals in deciding the appropriate multi agency actions to take in promoting the safeguarding of existing or future children, based on the completed FGM screening tool. The Panel will support and advise the practitioner on next steps or any further action to be taken by the practitioner or any other agency based on the level of risk identified. Also see the MKSCB website to access resources for professionals.
9. Responding to FGM: Immediate Concern about a Child at Risk of FGM or that may have undergone FGM - Referral to Milton Keynes Multi-Agency Safeguarding Hub
Where there has been an immediate concern about a child at risk of FGM or that may have undergone FGM a referral to Children’s Social Care via the Milton Keynes Multi-Agency Safeguarding Hub (MK MASH). A copy of the completed FGM screening tool should be attached to the MASH Referral Form.
Every attempt should be made to work with parents on a voluntary basis to prevent the abuse. It is the duty of the investigating team to look at every possible way that parental cooperation can be achieved, including the use of community organisations and/or community leaders to facilitate the work with parents/family. However, the child's interest is always paramount.
10. Responding to FGM: Non-immediate Concern about a Child – Referral to Multi-Agency FGM Consultation Panel
If a professional suspects that a child may be at risk of FGM, the FGM Screening Tool should be used to identify the relevant risk factors and record the evidence behind the concerns.
Having completed the screening tool, if the risks do not appear to be immediate, or if the professional is uncertain as to the level of risk, they should consult with their designated safeguarding lead/FGM lead. The Screening tool should be emailed to FGM@milton-keynes.gov.uk for multi-agency consideration at the monthly Multi-Agency FGM Consultation Panel meeting.
11. Physical and Mental Health Care and Treatment Pathway for those affected by FGM
Any professional in contact with members of the public may meet women or young people with FGM who are seeking advice or help. In this circumstance, the professional or volunteer should assist the woman/young person to make contact with a healthcare professional. This may not be straightforward, as some people who are recent arrivals to the UK may not be automatically able to access GP services, depending on their legal status.
Healthcare professionals in GP surgeries, maternity services, gynaecology, physiotherapy, urology, mental health, family planning and sexual health clinics are the most likely to encounter an adult woman, child or young person who has been subjected to FGM. However, any health professional could come into contact with victims.
Health professionals encountering a woman, child or young person who has undergone FGM should be alert to the risk of FGM in relation to her:
All women, children and young people who have undergone FGM (and their boyfriends/partners or husbands/fathers) must be given information and advice about the harmful effects of FGM. Within key clinical services (including maternity/gynaecology, paediatrics, urology, sexual health and emergency medicine) and primary care, there are named health contacts/leads for FGM.
Healthcare professionals may wish to seek support from their named lead for FGM for the consultation.
All women, children and young people with FGM should be offered a referral to a specialist FGM clinic and support from mental health services in regard to the mental and emotional impact FGM can have on women, children and young people.
In regard to a pregnant woman, child or young person who has undergone FGM the GP will record that information on the System one safeguarding template. Midwives completing the red book (Child’s health record) should write under the section pertaining to family history that “the child is from a culture where FGM/C is prevalent”. On discharge from maternity services the midwife is responsible for handover of this information to the woman’s health visitor.
12. Monthly Multi-Agency FGM Consultation Panel Meetings
The monthly multi-agency FGM Consultation Panel meetings provide the opportunity for professionals to discuss and assess the risk factors in the case (using the MKSCB FGM Screening Tool) and come to a consensus about the appropriate course of action and whether there are safeguarding concerns which would justify information-sharing without parental consent. The ranges of outcomes include:
At present, consultations take place at a monthly multi-agency FGM Consultation Panel meeting. It is attended by a Children’s Social Care –MASH, Children’s Social Care Children and Family Practice, Health and Education. The practitioners completing the FGM screening tool are welcome to attend the Multi Agency FGM Consultation Panel meeting if they wish to.
The case is presented to the panel anonymously by the use of the assigning a reference number by the practitioner to the screening tool. This reference number will be used in all subsequent communication between the Panel and the referring practitioner. The panel, once it has considered the case, will record the outcome of the panel’s discussion and any recommended actions on the panel outcome proforma on the last page of the screening tool. The lead practitioner involved with the woman, child or family will receive a copy of the outcomes and recommendation. A record of each screening tool will be kept by the FGM Consultation Panel using the identified reference number and the agency who submitted the case for consideration, along with the outcome.
If the panel identified the risk to be an immediate risk of FGM in a case, the panel will contact the practitioner via telephone (if not present at the meeting) and request a referral be made to Children’s Social Care via the MASH the same day and requesting that the practitioner informs the parents.
If the screening tool risk assessment indicates the child may at immediate risk of FGM, do not wait for the next FGM Consultation Panel meeting, a referral should be made to MK MASH.
13. Reducing the Prevalence of Female Genital Mutilation
Milton Keynes Safeguarding Children Board is committed to promoting awareness in the local area, particularly amongst local communities which practice FGM, that female genital mutilation is abusive to children and not legal in the UK.
See the Milton Keynes Safeguarding Children Board (MKSCB) Strategy to Prevent FGM 2015 - to follow for details of organisations able to advise on this form of community outreach work.
14. Further Advice
In June 2013, a new helpline was launched, with the aim of protecting children in the UK from FGM. The helpline is open 24 hours a day and can be contacted, by telephone on 0800 028 3550 or by emailing email@example.com. The service, which is anonymous, offers support to anyone who has been a victim of FGM or who is worried about a child, For more details please see the NSPCC FGM Helpline website
Other useful contacts are: