SCOPE OF THIS CHAPTER
This chapter outlines the key points in relation to concerns about Female Genital Mutilation (FGM), and the action to be taken.
FGM Mandatory Reporting – Factsheets for communities explaining the mandatory reporting duty (includes translated versions)
NSPCC FGM Helpline - The NSPCC have launched a free 24/7 service offering advice and support for professionals or members of the public who are concerned about young people at risk of Female Genital Mutilation, telephone 0800 0283550.
Home Office FGM Resource Pack - Contains comprehensive information for practitioners, including free e-learning on how to recognise and prevent FGM, case studies, examples of good practice from around the country and suggested questions for local areas when developing responses to FGM.
All NHS staff must take appropriate safeguarding action whenever they identify a child with or at risk of FGM by following local safeguarding arrangements. Healthcare professionals are not expected to investigate or make decisions upon whether a case of FGM was a crime or not. This is the role of the Police and Children's Social Care.
Since April 2014 NHS hospitals have been required to record and report information regarding cases of FGM. An enhanced data set became mandatory for all Acute Trusts from 1st June 2015, and all GPs and Mental Health Trusts to complete from 1st October 2015.
For further information, see Female Genital Mutilation Datasets and e-FGM educational programme - free for Healthcare professionals.
In March 2020, links were added added to a new Appendix 1a: Clinical Pathway for FGM medicals (Documents Library, Flowcharts) which summarises the clinical pathway for a child or young person requiring a Female Genital Mutilation (FGM) medical examination at the Queen's Medical Centre SARC service in Nottingham.
- Identifying Female Children and Women at Risk
- Responding to Concerns About FGM
- Appendix 1: Multi-Agency FGM Decision Making and Action Flowchart (Documents Library, Flowcharts)
- Appendix 1a: Clinical Pathway for FGM medicals (Documents Library, Flowcharts)
- Appendix 2: Types of FGM and the FGM Procedure (Documents Library, Other Useful Information)
- Appendix 3: Consequences of FGM (Documents Library, Other Useful Information)
- Appendix 4: International Prevalence of FGM (Documents Library, Other Information)
- Appendix 5: Names and Terms Used for FGM (Documents Library, Other Useful Information)
Female Genital Mutilation (FGM) is a form of child abuse and violence against female children and women, a serious public health concern and a human rights issue. Protecting female children and women from FGM worldwide is everybody's business.
The World Health Organisation (WHO) defines female genital mutilation 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".
FGM can be carried out at any age and is performed for a variety of complex reasons with a range of explanations and motives given by individuals and families who support the practice. The practice is not required by any religion. FGM is a traditional practice often seen as a beneficial by a family who believes that it is in the female child's or woman's best interests. This limits a female child's incentive to come forward to raise concerns or talk openly about FGM.
FGM is medically unnecessary, is extremely painful, terrifying and has life threatening physical and serious psychological health consequences both at the time the procedure is carried out and later in life. See Appendix 3: Consequences of FGM (Documents Library, Other Useful Information).
It is illegal in the UK to subject a female child or woman to female genital mutilation (FGM), to take a child abroad to undergo FGM or for any person to advise, help or force a female child to inflict FGM on herself. It is also an offence to fail to protect a female child from the risk of FGM, for each person who is responsible for the female child at the time the FGM occurred. Similar to victims of sexual offences, legislation also makes provision to protect the anonymity of victims of FGM. See Female Genital Mutilation Act 2003, Serious Crime Act 2015 and Prohibition of Female Genital Mutilation (Scotland) Act 2005.
The prevalence of FGM in the UK is difficult to estimate because of its hidden nature; it is likely to be significantly more prevalent than figures suggest. Female children and women in the UK who have undergone FGM may be British citizens born to parents from FGM practising communities, or they may be women living in Britain who are originally from those communities e.g. women who are refugees, asylum seekers, overseas students or the wives of overseas students.It is believed FGM happens to British female children in the UK as well as overseas, often but not always in the family's country of origin.
2. Identifying Female Children and Women at Risk
FGM may be an isolated incident of abuse within a family however it can be associated with other behaviours that discriminate against, limit or harm female children and women. These may include 'honour' based violence, forced marriage and domestic abuse. There remains a duty for all practitioners to act to safeguard female children and women at risk of or who have been subject to FGM. The professionals considered likely to identify FGM concerns or receive a disclosure about it from female children and young women (or their friends) that lead them to suspect that they are at risk include:
- Teachers, other school staff;
- Nurses and doctors based in the community i.e. Public Health Nurses (formerly called School Nurses and Health Visitors) and Doctors, Midwifes, Nursery Nurses, Community Nurses, GP's and Practice Nurses;
- Hospital based staff, particularly in Obstetrics, Gynaecology, Sexual Health and Genito-Urinary Medicine;
- Volunteers and members of community groups.
All practitioners' in contact with children and their families must be aware of the indicators and risk factors for FGM, including country of origin, and where appropriate use their professional judgement to decide when to ask if they have had FGM.Practitioner's should also be aware that some female children and women at risk may not yet be aware of the practice or that it may have conducted on them.
Identifying risk of FGM
The most significant factor to consider when deciding whether a female child 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 county of origin; see Appendix 4: International Prevalence of FGM (Documents Library, Other Useful Information). Women may also marry into practising communities and then have to go through FGM. Alongside a female child or woman's community or country of origin there are a range of other factors that could indicate a risk that she will be subjected to FGM. These include:
- A female child is born to a woman who has undergone FGM;
- A female child has an older sibling or cousin who has undergone FGM;
- A female child's father comes from a community known to practise FGM;
- The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
- A woman/family believe FGM is integral to cultural or religious identity;
- female child/family has limited levels of integration within UK community;
- Parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
- A family is not engaging with professionals (health, education or other);
- A family is already known to Social Care in relation to other safeguarding issues;
- Any female child from a practising community withdrawn from Sex and Relationships Education or its equivalent as a result of her parents wishing to keep her uninformed about her body and rights;
- Parents seeking to withdraw their children from learning about FGM;
- Sections are missing from a female child's health red book (parent held record).
Indications FGM may be imminent
Consider factors above and specifically the points below:
- If a family elder is present, particularly if she is visiting from a country of origin, and taking a more active/influential role in the family;
- If there are references to FGM in conversation, e.g. a female child may tell other children about it or confide that she is about to have a 'special procedure' or to attend a special occasion to 'become a woman. See Appendix 5: Names and Terms Used for FGM (Documents Library, Other Useful Information);
- Parents state that they or a relative will take the female child out of the country for a prolonged period. This may be discussed within the school environment or travel clinics when asking for vaccinations in preparation for travel;
- A female child may talk about a long holiday to her country of origin or another country where the practice is prevalent. See Appendix 4: International Prevalence of FGM (Documents Library, Other Useful Information) and Legislation Banning FGM;
- A female child may request help from a teacher or another adult if she is aware or suspects she is at risk;
- A female child is unexpectedly absent from school;
- A parent or family member expresses concerns that FGM may be carried out on the female child.
The above is not an exhaustive list of risk factors. There may be additional risk factors to specific communities e.g. in certain communities FGM is closely associated to when a female child reaches a particular age.
Indications that FGM has already taken place
There are a number of indications that a female child or woman has already been subjected to FGM. This includes a female child or woman:
- Asking for help;
- Experiencing difficulty walking, sitting or standing and may appear to be uncomfortable;
- Finding it hard to sit still for longer periods of time, and this was not a problem previously;
- Having frequent urinary, menstrual or stomach problems;
- Avoids physical exercise or requires to be excused from physical education (PE) without a GP's letter;
- Spending long periods of time away from the classroom during the day with bladder or menstrual problems;
- Having prolonged or repeated absences from school or college;
- Spending longer than normal in the toilet due to difficulties urinating;
- Increased emotional or psychological needs e.g. withdrawal or depression or significant change in behaviour;
- Talks about a pain or discomfort between her legs;
- Asking for help, but may not be explicit about the problem; and/or
- Being reluctant to undergo any medical examinations.
A parent / other adult, a child or other children may also disclose that the child has been subjected to FGM.
If a woman who has been de-infibulated (surgical procedure to open up the closed vagina of FGM type 3) requests re-infibulation (when the raw edges of the FGM wound are sutured again to recreate a small vaginal opening similar to the original FGM Type 3 appearance) after the birth of a baby this should be treated as a child protection concern. Evidence that the woman has been previously re-infibulated following the births of older children should also be treated as a child protection concern.
Communicating with a Female Child, Women and their Families about FGM
FGM is a complex and sensitive issue which requires practitioners to approach the subject carefully; see Multi Agency Statutory Guidance on Female Genital Mutilation (HM Government, 2016) Annex C: talking about FGM. Practitioners should be sufficiently prepared to deal with FGM in a professional and sensitive manner, using simple language, asking straightforward questions and terminology that the female child or woman will understand. FGM is known by a number of names, and females are likely to use their own terms to describe what may happen or what has already happened. Practitioners should sensitively explore the language used to ensure that they understand what is being said. See Appendix 5: Names and Terms Used for FGM (Document Library, Other Useful Information). Practitioners should also be mindful that some female children and women may not be aware they have been subject to FGM as the procedure may have occurred during very early childhood.
Where an interpreter is required practitioners should always use an accredited female interpreter. Practitioners must not ask family members, individuals known to the family or an individual with influence in the community to act as an interpreter.
All practitioners have a responsibility to ensure that families know that FGM is illegal, and should ensure that families know that the authorities are actively tackling the issue. This knowledge alone may deter families from having FGM performed on their children and save female children and women from harm.Practitioners should be aware that alerting the female child's or woman's family to the fact that she is disclosing information about FGM may place her at risk of harm.
There have been reports of cases where individuals have been subjected to both FGM and forced marriage. If you are concerned that a child may be subject to a forced marriage a referral to Children's Social Care should be made; see Forced Marriage Procedure.
Where practitioners believe that an individual has undergone FGM, they also must consider the risks to other female children and women who may be related to, or living with her and/or her family. As FGM is an inter-generational practice, their female children and young women may be likely to suffer significant harm.
3. Responding to Concerns About FGM
Anyone who has concerns that a female child or young woman may be at risk of FGM or who has information or suspicions that a female child or young woman has been subjected to FGM should consult with their agency designated/named professional for child protection. See Derby City and Derbyshire Thresholds Document (see Documents Library, Guidance Documents).
Any information that a female child or young woman is at risk of or has undergone FGM must result in a referral to Children's Social Care. Social Care should also be informed when a woman who has been de-infibulated requests re-infibulation after the birth of a baby or when there is evidence that the woman has been previously re-infibulated following the births of older children. Practitioners should not attempt to investigate cases themselves however they must fully record all information / observations / disclosures made; this information may be used as criminal evidence and used in court in the future. See Making a Referral to Social Care Procedure.
Where a female child is thought to be at immediate risk of FGM, practitioners should be alert to the need to act quickly before the child is abused through the FGM procedure in the UK, or taken abroad to undergo the procedure.
In addition to a referral to Social Care, all regulated professionals (as defined in Section 5B (2) (a), (11) and (12) of the FGM Act 2003) working within health or social care, and teachers also have a mandatory reporting duty (See Mandatory Reporting of Female Genital Mutilation – procedural information - Home Office). Under this duty, 'known' cases of FGM where a female child under 18 informs the person that an act of FGM has been carried out on her, or where physical signs appear to show that an act of FGM was carried out, must be reported to the Police on 101. (This is a personal responsibility in addition to the referral to Children's Social Care). The professional who identifies FGM/receives the disclosure should make the report by the close of the next working day. The Home Office has produced factsheets (including translated versions) for local communities explaining the mandatory reporting duty. Click here to access the factsheets. Further guidance on talking about FGM, including preparing to speak to individuals and families can be found in the Multi Agency Statutory Guidance on FGM.
Resources explaining healthcare professionals' duty to report cases of female genital mutilation (FGM) in under 18s are available on FGM: Mandatory Reporting in Healthcare.
Where there is reasonable cause to suspect that a child is suffering, or likely to suffer, Significant Harm Children's Social Care will hold a Strategy Discussion / Meeting involving Police, Health and other agencies as appropriate (including those with specialist experience of working with families who have experienced FGM). A strategy discussion / meeting must be held if:
- There is suspicion that a female child or young woman, under the age of 18, is at risk of FGM;
- It is believed that a female child or young woman is at risk of being sent abroad for that purpose; or
- There are indications that a female child or young woman has undergone FGM.
If emergency action is needed this will usually take place following an immediate strategy discussion.
The strategy discussion / meeting will consider relevant matters including:
- Agreeing what further information is required about the child and family and how it should be obtained and recorded;
- Agreeing who should be interviewed, by whom, for what purpose, and when;
- Agreeing, in particular, how the child's wishes and feelings will be ascertained so that they can be taken into account when making decisions;
- Plan any intervention, including any medical examinations, with consideration of the cultural factors such as the significance it has in terms of cultural identity, please refer to Appendix 1: Multi-Agency FGM Decision Making and Action Flowchart and Appendix 1a: Clinical Pathway for FGM medicals;
- Consider taking legal advice as to the options for protection available, including obtaining a FGM Protection Order. The primary focus is to prevent the female child undergoing any form of FGM, removal from home should be considered only as a last resort;
- If the strategy discussion / meeting decides that the female child is in immediate danger of FGM and/or practitioners consider that her parents will allow or facilitate FGM in the near future then a FGM Protection Order and/or an Emergency Protection Order or Interim Care Order should be sought;
- Consider carefully whether to continue enquiries or whether to assess the need for support services for a female child who has already suffered FGM and how any criminal investigation will be conducted;
- Plan appropriate action which recognises that FGM is a one-off event of physical abuse. (Whilst in no way minimising the grave permanent sexual, physical, and emotional consequences for a female child who experiences FGM);
- Consider the need for enquiries to be made about the risks to other female children in the family i.e. sisters, cousins or the community;
- Establish whether an accredited female interpreter will be required, to be used in all interviews with the family.
The strategy discussion / meeting must establish if either parents or the female child has had access to information about the harmful aspects of FGM and the law in the UK. If not, the parents/child should be given appropriate information regarding the law and harmful consequences of FGM.
Where FGM has been carried out, the Police Child Abuse Investigation Unit will have the lead role for the criminal investigation however this should be co-ordinated with Children's Social Care to ensure the investigation and Section 47 Enquiry is undertaken in the best interests of the child. This would include the planning and timing of a medical examination.
The following additional issues should help inform the analysis and decision making:
- What are the views of the woman about the importance of FGM to her and what has her experience been?
- Does she consider FGM to have been harmful to her, or to others who have undergone FGM?
- What is her view about whether her daughters should be subject of FGM?
- What is her view of the importance of FGM to her partner / husband and extended family?
- Have other female children or women in her extended family experienced FGM?
- Is she being forced against her will or does she feel under pressure from a partner / husband for her female children to be subject of FGM?
- Is she being forced against her will or is there pressure from extended family members and friends for her female children to be subject of FGM?
- How isolated or dependent is the woman within her community, will she or her daughters face rejection if they are not subject of FGM?
- Is the woman particularly isolated as a refugee and what impact does this have on the decisions she makes about the acceptance within her community of FGM being carried out on her daughters?
It will be important to assess how willing or reluctant the woman is to discuss these issues. If an interpreter has been used, how successful has the communication been? Is further discussion needed to clarify information?
Practitioners should discuss with the woman any concerns she may have about FGM being discussed with her partner / husband. Where ever possible the assessment should include the views of the partner / husband. If concerns exist about the practicalities of obtaining information from them, in individual cases, the absence of this information should be weighed up alongside what is known and a judgement made as to whether this is significant. There may be conflicting views within the family and the practitioner should consider if this is likely to increase the risk to the female child.
Women who have been de-infibulated and request re-infibulation after the birth of a baby or where there is evidence that the woman has been previously re-infibulated following the births of older children should be seen as a risk. This is because the woman is apparently not wanting to comply with UK law and/or does not consider the process to be harmful, and this raises concerns in relation any female children she may already have or may have in the future.
In all cases if there is a concern about one child, the child's sisters, and other female children in the extended family should be considered to be at risk.
Every attempt should be made to work with the parents on a voluntary basis to prevent the abuse. Practitioners must be aware that most decisions about FGM are made by multiple family members, including mothers, father, grandparents and aunts. Often the prime motivating factor for the continuation of FGM is inter-generational peer convention and peer pressure amongst women. Factual aspects such as health risks as well as fear of legal sanctions can motivate the abandonment of FGM. Agencies should look at every possible way that parental co-operation can be achieved, including the use of community organisations and /or community leaders to facilitate the work with the family. It is important that the views of these organisations or leaders are known and approved.
A written agreement should be undertaken with the parents not to arrange FGM to be performed on the female child; this should highlight that FGM is illegal, the harmful aspects of FGM and the actions that will be taken should future concerns arise. The child's interest is always paramount and any agreement must be carefully monitored and enforced.
To facilitate appropriate awareness of the risk and ensure effective monitoring, it is important for key practitioners (particularly those in health and education) to be made aware of the potential risk to a female child and the written agreement with the parents. Where concerns arise that a female child is at increased risk of FGM or that she has been subject to FGM, an immediate re-referral to Children's Social Care should be made. Please also refer to Appendix 1: Multi-Agency FGM Decision Making and Action Flowchart and Appendix 1a: Clinical Pathway for FGM medicals.
If no agreement is reached with parents, the first priority is protection of the female child and the least intrusive legal action should be taken to ensure her safety. The primary focus is to prevent the female child undergoing any form of FGM, rather than removal of the child from the family.
Where the female child is believed to be overseas, Children's Social Care will liaise with the Foreign and Commonwealth Office / Border Agency.
A female child judged to be suffering or likely to suffer Significant Harm as a consequence of anticipated FGM should be made the subject of a child protection plan, under the category of risk of physical abuse, at the Initial Child Protection Conference.
A female child who has already undergone FGM should not normally be subject to a Child Protection Conference or require a Child Protection Plan unless additional child protection concerns exist. However, she should be offered counselling and medical help.
All female children and women who have undergone FGM should be given information about the legal and health implications of FGM and support services available to them including mental health support. Those who have undergone Type 3 FGM should also be informed that de-infibulation is an option and the benefits of this. Where appropriate boyfriends / partners and husbands should also be offered counselling, they can be supportive when the harmful aspects of FGM and the law is explained to them.
Women over the age of 18 years should be reviewed under the safeguarding adults at risk process but any adult assessment must address any potential risk of FGM to any other women or female children living in the family as well as the extended family network.
For details of safeguarding adults processes please see: