7.7 Female Genital Mutilation

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:

• perform FGM in England or Wales (section 1 of the 2003 Act);
• assist a girl to carry out FGM on herself in England or Wales (section 2 of the 2003 Act); and
• assist (from England or Wales) a non-UK national or UK resident to carry out FGM outside the UK on a UK national or UK resident (section 3 of the 2003 Act).

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).

A child for whom FGM is planned is at risk of Significant Harm through physical abuse and emotional abuse, which is categorised by some also as sexual abuse.

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:

• a child’s biological mother;
• a father who is married to the mother of the child when the child is born;
• an unmarried father registered on the child’s birth certificate at the time of their birth;
• guardians; and
• persons named in a Child Arrangements Order.

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 :

• Perform FGM outside the UK
• Assist a girl to perform FGM on herself outside the UK
• Assist from outside the UK a non –Uk national or UK resident to carry out FGM outside the UK on a national or UK resident.

These offences are to intended to cover taking a girl abroad to be subjected to FGM

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:

• Brings status and respect to the girl;
• Preserves a girl's virginity / chastity;
• Is a rite of passage;
• Gives a girl social acceptance, especially for marriage;
• Is deemed aesthetically acceptable;
• Upholds the family honour;
• Helps girls and women to be clean and hygienic.

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.

Female Genital Mutilation and other terms has been classified by the WHO (World Health Organisation) into four types:

• Type 1: Clitoridectomy Excision of the prepuce with or without excision of part or all of the clitoris.

• Type 2: Excision of the clitoris with partial or total excision of the labia minora (small lips which cover and protect the opening of the vagina and the urinary opening). After the healing process has taken place, scar tissue forms to cover the upper part of the vulva region.

• Type 3: Infibulation (also called Pharaonic Circumcision) This is the most severe form of female genital mutilation. Infibulation often (but not always) involves the complete removal of the clitoris, together with the labia minora and at least the anterior two-thirds and often the whole of the medial part of the labia majora (the outer lips of the genitals). The two sides of the vulva are then sewn together with silk, catgut sutures, or thorns leaving only a very small opening to allow for the passage of urine and menstrual flow. This opening can be preserved during healing by insertion of a foreign body.

• Type 4: Unclassified This includes all other procedures on the female genitalia including pricking, piercing or incising of the clitoris and or labia; stretching of the clitoris and or labia; cauterisation by burning of the clitoris and surrounding tissues; scraping of the tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purposes of tightening or narrowing it; pulling; and any other procedure that falls under the definition of female genital mutilation given above.

De-infibulation

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

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.

Women often expect re-infibulation after birth and therer are reports of medical practitioners being asked to perform this which is contrary to the FGMA 2003. In some countries women and girls are re-infibulated immediately after childbirth. Re-infibulation is more common in Sudan, Sierra Leone, Senegal, Somalia, Yemen, Tanzania and Kenya.  It is important to note that even when women ask to be re-infibulated, the practice is still illegal. (Ref: Joint letter in July 2019 to NHS Trusts and NHS CCGs from NHSE and NHSI, NPCC and CPS)

Safeguarding when re-infibulation is detected

Professionals should be aware of the potential safeguarding concerns that re-infibulation cases pose. Safeguarding risks exist as women who have had re-infibulation are highly likely to be part of a family that supports FGM and this will pose an immediate risk to any female children they have. A mother that has undergone FGM is one of the biggest single indicators that her daughter might be at risk of FGM. Professionals should complete a FGM screening tool if they have concerns and require the advice of the FGM Panel.

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:

• The severity and nature of the violence;
• The individual child’s innate resilience;
• The warmth and support the child receives in their relationship with their parent/s, siblings and other family members;
• The nature and length of the child’s wider relationships and social networks;
• Previous or subsequent traumas experienced by the child;
• Particular characteristics of the child’s gender, ethnic origin, age, (dis)ability, socio-economic and cultural background.

Short term implications for a child’s health and welfare

Short-term health implications can include: 

• Severe pain;
• Emotional and psychological shock (exacerbated by having to reconcile being subjected to the trauma by loving parents, extended family and friends);
• Haemorrhage;
• Wound infections including Tetanus and blood borne viruses (including HIV and Hepatitis B and C);
• Urinary retention;
• Injury to adjacent tissues;
• Fracture or dislocation as a result of restraint;
• Damage to other organs;
• Death.

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:

• Chronic vaginal and pelvic infections;
• Difficulties in menstruation;
• Difficulties in passing urine and chronic urine infections;
• Renal impairment and possible renal failure;
• Damage to the reproductive system including infertility;
• Infibulation cysts, neuromas and keloid scar formation;
• Complications in pregnancy and delay in the second stage of childbirth;
• Maternal or foetal death;
• Psychological damage; including a number of mental health and psychosexual problems including depression, anxiety, and sexual dysfunction;
• Increased risk of HIV and other sexually transmitted infections.

Click here for the MK Health Pathway

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 [2]. 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 [3]. 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 [4] 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.

[2] Haseena Lockhat, 2004, ‘Female Genital Mutilation: Treating the Tears’, London: Middlesex University Press

[3] 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.

[4] Behrendt, A. et al, 2005, ‘Posttraumatic Stress Disorder and Memory Problems after Female Genital Mutilation’, Am J Psychiatry 162:1000-1002, May

There are four  circumstances relating to FGM which require identification, assessment and possible intervention.

• Where a child is at risk of FGM;
• Where a child has been abused through FGM;
• Where a pregnant woman has undergone FGM.
• Where a non-pregnant woman over 18 has undergone FGM

 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:

• Immediate protection and support for the child/ren; and
• That the practice is not perpetuated.

An appropriate response to a child suspected of having undergone FGM as well as a child at risk of undergoing FGM could include:

• Arranging for a professional interpreter if this is necessary and appropriate;
• Creating an opportunity for the child to disclose, seeing the child on their own;
• Using simple language and asking straightforward questions;
• Using terminology that the child will understand e.g. the child is unlikely to view the procedure as abusive;
• Being sensitive to the fact that the child will be loyal to their parents;
• Giving the child time to talk;
• Getting accurate information about the urgency of the situation, if the child is at risk of being subjected to the procedure;
• Giving the message that the child can come back to you again.

An appropriate response by professionals who encounter a girl or woman who has undergone FGM includes:

• Arranging for a professional interpreter and not agreeing to friends/family members interpreting on their behalf;
• Being sensitive to the intimate nature of the subject;
• Making no assumptions;
• Asking straightforward questions;
• Being willing to listen;
• Being non-judgemental (condemning the practice, but not blaming the girl/woman);
• Understanding how she may feel in terms of language barriers, culture shock, that she, her partner, her family are being judged;
• Giving a clear explanation that FGM is illegal and that the law can be used to help the family avoid FGM if/when they have daughters.

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.

A FGM Screening Tool is available to download from the Resources page of the MK Together website.  The aim of the FGM screening tool is 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:

• Part one: Pregnant Woman;
• Part Two: Non–pregnant woman;
• Part Three: Female child under 18 years, at risk of FGM;
• Part Four: Female Child under 18 years who may have been subjected to FGM.

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 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:

• No immediate risk of harm has been identified this completed screening tool should be submitted to the multi-agency FGM Panel via MKCCG.fgm@nhs.net
• Risk of immediate harm/ risks indicate may have been subject of FGM, make a referral to the Multi-Agency Safeguarding Hub, using the multi-agency referral form which can be downloaded from the Milton Keynes Council website: Milton Keynes Council | Children and Families MARF. Attach your completed FGM screening tool and email both to:children@Milton-keynes.gov.uk /tel: 01908 253169/70

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. 

See Flowchart: ‘Child/Young Person – Risk of FGM Identified/Subject of FGM’.

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.

If a professional suspects that a child may be at risk of FGM, the MK 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 MKCCG.fgm@nhs.net for multi-agency consideration at the monthly Multi-Agency FGM Consultation Panel meeting.

See Flowchart: ‘Child/Young Person – Risk of FGM Identified/Subject of 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:

• Immediate and long term physical, psychological and psycho-sexual health;
• Daughters or daughters she may have now and in the future;
• Younger siblings;
• Female extended family members.

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.

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 MK 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:

• A practitioner offering further advice, guidance or services, including on-going preventative work;
• A period of further assessment or monitoring;
• A named referral to Children’s Social Care as there are immediate child safeguarding concerns (see below);
• No further action.

At present, consultations take place at a monthly multi-agency FGM Consultation Panel meeting. It is attended by MK Council Children’s Services, Health and Police. 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 be at immediate risk of FGM, do not wait for the next FGM Consultation Panel meeting, a referral should be made to MK MASH.

The MK Together Partnership 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.

Female Genital Mutilation (FGM) Helpline

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, phone 0800 028 3550 or by email fgmhelp@nspcc.org.uk. The service, which is anonymous, offers support to anyone who has been a victim of FGM or who is worried about a child.

Other useful contacts are:

• http://nationalfgmcentre.org.uk/fgm/fgm-resources/
• https://www.gov.uk/government/publications/female-genital-mutilation-resource-pack/female-genital-mutilation-resource-pack
• https://www.e-lfh.org.uk/