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2.2.10 Safeguarding Girls and Young Women at Risk of Abuse through Female Genital Mutilation


Contents

1. Introduction
2. Definition
3. Principles
4. FGM in the UK
5. Consequences of FGM
6. Justifications of FGM
7. Identifying Children at risk of FGM or who have been subject to FGM
8. Asking difficult questions
  8.1 Additional Resources for communicating about FGM
  8.2 Preparing to Speak to Individuals and Families
9. Law relating to Female Genital Mutilation
  9.1 Extending protection to more young women
  9.2 Anonymity for victims
  9.3 Duty to protect
  9.4 Female Genital Mutilation Protection Orders (FGMPO)
  9.5 Female Genital Surgery
  9.6 Re-Infibulation
  9.7 Extra-Territorial Offences  
10. Mandatory Reporting of FGM
11.  Referring Concerns about FGM
  11.1 Referring to the MASH
. 11.2 Referring to South Yorkshire Police
12. Use of an Interpreter
13. Child Protection Processes
  13.1 Initial Strategy Meeting
  13.2 Paediatric Assessment (Child Protection Medical)
  13.3 Second Strategy Meeting
14. Responding to FGM – The Role of Health Practitioners
15. Role of Leisure / Community / Voluntary and Faith Groups
16. Responding to FGM – The Role of Education practitioners
17. Working with Communities to End FGM
18. Adult Disclosure of FGM
19. Breast Ironing / Flattening
20. Resources


1. Introduction 

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 15, but in some cases it is performed on new-born infants or on young women before marriage or pregnancy.


2. Definition

The World Health Organisation (WHO) (2008) classifies FGM as follows:

Type I — Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)

  • When it is important to distinguish between the major variations of Type I mutilation, the following subdivisions are proposed: Type Ia, removal of the clitoral hood or prepuce only; Type Ib, removal of the clitoris with the prepuce.

Type II — Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)

  • When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora;
  • Note also that, in French, the term ‘excision’ is often used as a general term covering all types of female genital mutilation.

Type III — Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)

  • Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora.

Type IV — All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization

The rights of women and girls are enshrined by various universal and regional instruments including the Universal Declaration of Human Rights, the United Nations Convention on the Elimination of all Forms of Discrimination Against Women, the Convention on the Rights of the Child, the African Charter on Human and Peoples’ Rights and Protocol to the African Charter on Human and Peoples’ Rights on the rights of women in Africa. All these documents highlight the right for girls and women to live free from gender discrimination, free from torture, to live in dignity and with bodily integrity.

There is no Biblical or Koranic justification for FGM and religious leaders from all faiths have spoken out against the practice.


3. Principles

An effective local response to FGM should be underpinned by two key principles:

  • Safeguarding is everyone’s responsibility: each professional and organisation should play their part;
  • A victim-centred approach should be taken: based on a clear understanding of the needs and views of girls and women affected by FGM.

The following principles should be adopted by all agencies in relation to identifying and responding to those at risk of, or who have undergone FGM, and their parent(s) or guardians:

  • The safety and welfare of the child is paramount;
  • All agencies should act in the interests of the rights of the child, as stated in the United Nations Convention on the Rights of the Child (1989);
  • FGM is illegal in the UK;
  • FGM is an extremely harmful practice - responding to it cannot be left to personal choice;
  • Accessible, high quality and sensitive health, education, police, social care and voluntary sector services must underpin all interventions;
  • As FGM is often an embedded social norm, engagement with families and communities plays an important role in contributing to ending it;
  • All decisions or plans should be based on high quality assessments – see Children's Assessment Protocol.


4. FGM in the UK

It is estimated that 65,000 girls aged 13 and under are at risk of FGM in the UK (HM Government, 2014). UK communities most at risk include Kenyan, Somalian, Sudanese, Sierra Leonean, Egyptian, Nigerian and Eritrean. Non-African countries that practise FGM include Yemen, Afghanistan, Kurdistan, Indonesia, Malaysia, Turkey, Thailand (South) and Pakistan. Please note this list is not exhaustive. For more information about the language and terminology used in these countries, see Traditional and local terms for FGM.

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.

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. 

For more detail, see FGM Multi Agency Practice Guidelines (HM Government, 2016).


5. Consequences of FGM

Depending on the degree of mutilation, FGM can have a number of short-term health implications:

  • Severe pain and shock;
  • Infection;
  • Urine retention;
  • Injury to adjacent tissues;
  • Immediate fatal haemorrhaging.

Long-term implications can include:

  • Extensive damage of the external reproductive system;
  • Uterus, vaginal and pelvic infections;
  • Cysts and neuromas;
  • Increased risk of Vesico Vaginal 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.


6. 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.

Reasons include:

  • 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.

As with justifications for all types of abuse, these are NOT ACCEPTABLE.


7. Identifying Children at risk of FGM or who have been subject to FGM

If a practitioner is worried about a girl under 18 who is either at risk of FGM or they suspect may have had FGM, they must share this information with the Multi-Agency Safeguarding Hub (MASH) via a telephone call (See Local Contacts to MASH) and Multi-Agency Referral Form (MARF). In addition, the practitioner must notify the police (FGM Notification) when they identify that an act of Female Genital Mutilation appears to have been carried out on a girl under the age of 18 (if they work in regulated professions such as healthcare, teaching and social work). For more information see Section 10, Mandatory Reporting of FGM.

If the risk of harm is imminent, emergency measures may be required. See Section 11, Referring Concerns about FGM.

Alerting the girl’s or woman’s family to the fact that she is disclosing 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.

Professionals should consider the following risk factors for FGM:

  • The family belongs to a community in which FGM is practised or have limited level 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;
  • 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);
  • A parent or family member expresses concern that FGM may be carried out on the girl;
  • A girl requests help from a teacher or another adult because she is aware or suspects that she is at immediate risk of FGM;
  • A girl talks about FGM in conversation, for example, a girl may tell other children about it (see Traditional and local terms for FGM for commonly used terms in different languages) – it is important to take into account the context of the discussion;
  • Where a girl from a practising community is withdrawn from Personal, Social, Health and Economic (PSHE) 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);
  • Sections are missing from a girl’s Red book;
  • A girl has attended a travel clinic or equivalent for vaccinations / anti-malarials.

Practitioners should also consider whether any other indicators exist that FGM may have already taken place, for example:

  • Difficultly walking, sitting or standing;
  • Spending longer than normal in the bathroom or toilet due to difficulties urinating;
  • Soreness, infection or unusual presentation noticed by practitioner when changing a nappy or helping with toileting;
  • Spending long periods of time away from the classroom during the day with bladder or menstrual problems;
  • Having frequent unusual menstrual problems;
  • Prolonged or repeated absence from school or college;
  • A prolonged absence from school or college with personal or behaviour changes e.g. withdrawn, depressed;
  • Being particularly reluctant to undergo normal medical examinations;
  • Asking for help or advice but not being explicit about the procedure due to embarrassment or fear.

Although this 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. 


8. Communicating about FGM

Good communication is essential when talking to individuals who have had FGM, may be at risk of FGM, or are affected by the practice.

Professionals should ensure that they enquire sensitively about FGM. The topic of FGM may arise in a variety of settings, including a GP’s surgery as part of a medical consultation, a home environment during a health visitor’s post-natal visit, or at school. Conversations may take place with the girl or woman who may be affected by FGM, a parent or other family member. How the conversation is opened and the language used will vary according to the setting and who the conversation is with, however, the key principles set out below should apply in all cases.

Talking about FGM can be difficult and upsetting. Professionals may wish to speak with their supervisor if they are affected by what they have heard.

It is important to acknowledge and understand the motives, demographics and consequences of FGM. Equally, it is important that professionals take the time to think about their own concerns, feelings and values, so they can discuss FGM with clarity and confidence. A lack of awareness may mean that a professional is unable to relate to the girl or woman/their family, which may lead to a failure to discuss the issue appropriately and result in distress for the girl or woman.

If, as a result of talking about FGM with an individual or family, a professional identifies that a girl is at risk of FGM or has undergone FGM, then appropriate action should be taken.  See Section 11, Referring Concerns about FGM.


8.1 Additional Resources for communicating about FGM

Health and social care professionals in England can complete the e-learning session, ‘Communication Skills for FGM consultations’ at www.e-lfh.org.uk which provides advice and training to support these discussions.

Professionals in England can watch a video on NHS Choices where women who have had FGM discuss how they would like to see professionals hold sensitive conversations about FGM: NHS.uk

8.2 Preparing to Speak to Individuals and Families

Adhering to key standards will enable professionals to hold conversations in a sensitive and appropriate way. These include:

  • Making the care of women and girls affected by FGM the primary concern, treating them as individuals, listening and respecting their dignity;
  • Working with others to protect and promote the health and well-being of those in their care, their families and carers, and the wider community; and
  • Being open and honest, acting with integrity and upholding the reputation of the profession.

When initiating a conversation about FGM, professionals should:

  • Ensure that the conversation is opened sensitively;
  • Be aware of the specific circumstances of the individual when a discussion about FGM needs to take place; and
  • Be non-judgmental.

Creating and maintaining a good rapport with the girl or woman is essential. This can be achieved by:

  • Allowing the girl or woman to speak - actively listening, gently encouraging, and seeking the girl or woman’s permission to discuss sensitive areas;
  • Not being afraid to ask about FGM, using appropriate and sensitive language. It is not unusual for women to report that professionals have avoided asking questions about FGM, and this can lead to a breakdown in trust. If a professional does not give a girl or woman the opportunity to talk about FGM, it can be very difficult for a girl or woman to bring this up herself;
  • Asking only one question at a time – it can be difficult to think through the answers to several questions at the same time;
  • Making sure there is appropriate time to listen - a girl or woman may relate information she has not disclosed previously. Interrupting her story part way through because of a lack of time is likely to cause distress and may either damage the relationship with her, or affect her relationship with professionals in future;
  • Preparing by understanding what written materials are available to support conversations, and what other community and third-sector organisations are able to offer support and additional information within the area. For resources and advice on how to find services, see Section 20, Resources.

It is important that professionals understand the appropriate language to use and maintain a professional and non-judgmental approach to engage with the individual effectively in what may be a challenging and upsetting situation.

Professionals should:

  • Ensure that a female professional is available to speak to, if the girl or woman would prefer this;
  • Use culturally sensitive language - be aware that different communities may have different terms for FGM (see Traditional and local terms for FGM);
  • Be sensitive to the intimate nature of the subject;
  • Be sensitive to the fact that the individual may be loyal to their parents, extended family and community;
  • Remember that women or girls may not be aware that they have had FGM - professionals may need to explain that FGM is the cause of symptoms;
  • Consider some of the following ways to start a discussion about FGM:

“I can see in your notes from the obstetrician or midwife that you have been cut. Could you tell me a bit more about this?”

“I know that (some) women in your country have been cut. How do you feel about this? Could you tell me a bit more?”

“You have talked about your cutting and the traditions in your country. Is there anything else you want to tell me about this?”

“How do you, and how does your partner, feel about female genital cutting? How do the people around you feel about this? Are you still in touch with relatives in your country? How do they feel about it? At what age is it usually performed?”

Professionals have a responsibility to ensure women and families understand that FGM is illegal in the UK, and to explain the harmful consequences it can have. See Section 5, Consequences of FGM


9. Law relating to Female Genital Mutilation

FGM has been a criminal offence in the UK since the Prohibition of Female Circumcision Act 1985 was passed. The Female Genital Mutilation Act 2003 replaced the 1985 Act and 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. 

The Female Genital Mutilation (FGM) Act was introduced in 2003 and came into effect in March 2004. The Act:

  • Made it illegal to practice FGM in the UK;
  • Made 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;
  • Made 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 Serious Crime Act 2015 amended the FGM Act 2003 and introduced the following new measures:

  • Extension of extra-territorial liability to ‘habitual’ UK residents;
  • Lifelong victim anonymity;
  • Parents’ and guardians’ liability for failing to protect a child from FGM;
  • Civil protection orders for FGM;
  • Mandatory reporting for relevant professionals.

9.1 Extending protection to more young women

The 2003 Act only covered victims or perpetrators who are either UK nationals or permanent UK Residents. The 2015 Act extends this to cover those who are 'habitually resident' (on short, temporary stays) in the UK, including students and refugees.

9.2 Anonymity for victims

The 2015 Act introduces 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.

9.3 Duty to protect

The 2015 Act provides for 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

9.4 Female Genital Mutilation Protection Orders (FGMPO)

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. For more information see Female Genital Mutilation (FGM) Protection Orders – application by member of the public (HM Courts & Tribunal Service, July 2015) and get a female genital mutilation protection order factsheet.

Examples of the types of orders the court might make are:         

  • To protect a victim or potential victim at risk of FGM from being taken abroad;
  • To order the surrender of passports or any other travel documents, including the passport/travel documentation of the girl to be protected;
  • To prohibit specified persons (`respondents’) from entering into any arrangements in the UK or overseas for FGM to be performed on the person to be protected;
  • To include terms which relate to the conduct of the individuals named in the order both inside and outside of England and Wales; and
  • To include terms which cover individuals who are, or may become involved in other respects (or instead of the original respondents) and who may commit or attempt to commit FGM against a girl.

Orders may also be made against people, who are not named in the application. This is in recognition of the complexity of the issues and the numbers of people who might be involved in the wider community.

A court can also make an FGMPO without application being made to it in certain family proceedings. In addition, a criminal court can also make an FGMPO, without application, in criminal proceedings for a genital mutilation offence where the person who would be a respondent to any proceedings for an FGMPO is a defendant in the criminal proceedings.

An FGMPO can be made in such criminal proceedings to protect a girl at risk, whether or not they are the victim of the offence in relation to the criminal proceedings. For example, the younger sister of the victim of a genital mutilation offence could also be protected by the court in criminal proceedings.

Where an agency has obtained an FGMPO it should consider which, if any, other agencies need to be aware of the FGMPO, i.e. those not served with a copy of the order by the court, and whether it is necessary for that information to be shared in order to secure the protection of the girl at risk. Care should, however, be exercised in sharing information, particularly if it could have the adverse effect of leading to either reprisals for the victim and/or other members of their family.

9.5 Female Genital Surgery

The 2003 Act contains no specific exemption for ‘cosmetic’ surgery or female genital cosmetic surgery (FGCS). If a procedure involving any of the acts prohibited by section 1 of the 2003 Act is not necessary for physical or mental health or is not carried out for purposes connected with childbirth then it is an offence (even if the girl or woman on whom the procedure is carried out consented).

The Royal College of Obstetricians and Gynaecologists is clear in its guideline (Female Genital Mutilation and its Management (Green-top Guideline No. 53), published on 10 July 2015) that “All surgeons who undertake FGCS must take appropriate measures to ensure compliance with the FGM Act”.

As set out above, it is for the police to investigate any alleged offence and for the CPS to decide whether a prosecution under the 2003 Act is appropriate and it would ultimately be for a criminal court to determine, as and when the point arises for decision in a particular case, if non-medically indicated genital surgery constitutes mutilation and is therefore an offence under the 2003 Act.

9.6 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. 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.

The first prosecution for FGM in February 2015, which concerned an alleged act of re-infibulation, provides support for that view. Although the case did not result in a conviction, it is clear that the court, by agreeing that the evidence should be considered by a jury, proceeded on the basis that re-infibulation is covered by section 1 of the 2003 Act.

9.7 Extra-Territorial Offences

Section 4(1) of the 2003 Act extends sections 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 (sections 4 and 1 of the 2003 Act)
  • Assist a girl to perform FGM on herself outside the UK (sections 4 and 2 of the 2003 Act)
  • Assist (from outside the UK) a non-UK national or UK resident to carry out FGM outside the UK on a UK national or UK resident (sections 4 and 3 of the 2003 Act).

The extra-territorial offences are intended to cover taking a girl abroad to be subjected to FGM. By virtue of section 1(4) of the 2003 Act, the exceptions set out in sections 1(2) and (3) also apply to the extra-territorial offences. Section 4(1A) of the 2003 Act provides that an offence under section 3A can be committed wholly or partly outside the UK by a person who is a UK national or UK resident.


10. Mandatory Reporting of FGM

For more information about Mandatory Reporting see

FGM Referral Pathway Flowchart

FGM Mandatory Reporting Flowchart (DoH)

Mandatory Reporting of Female Genital Mutilation – procedural information (Home Office, 2015)

From the 31st October 2015, regulated professionals who identify in the course of their professional work as health and social care professionals and teachers in England and Wales have a duty to report 'known' cases of FGM to the police if the girl or young woman is under 18 years.

Regulated professionals are health and social care professionals regulated by the:

  • General Chiropractic Council;
  • General Dental Council;
  • General Medical Council;
  • General Optical Council;
  • General Osteopathic Council;
  • General Pharmaceutical Council;
  • Health and Care Professions Council (whose role includes the regulation of social workers in England);
  • Nursing and Midwifery Council.

Teachers – this includes qualified teachers or persons who are employed or engaged to carry out teaching work in schools and other institutions, and, in Wales, education practitioners regulated by the Education Workforce Council.

Identification of Cases

The guidance sets out that the duty applies to cases discovered in the course of professional work:

  • Most professionals will only visually identify FGM as a secondary result of undertaking another action. There is no expectation that a practitioner would carry out genital examinations unless this was part of their job role to do so;
  • If a girl (under the age of 18 years) discloses to a relevant professional that she has had FGM (whether she uses the term ‘female genital mutilation’ or any other term or description, e.g. ‘cut’) then the mandatory reporting duty applies. If, in the course of delivering safe and appropriate care to a girl the expectation for the professional’s role is that they would usually ask if she has had FGM, then the professional should continue to do so;
  • The duty applies to cases directly disclosed by the victim; if a parent, guardian, sibling or other individual discloses that a girl under 18 has had FGM, the duty does not apply and a report to the police is not mandatory. However a safeguarding referral will most probably be required in these circumstances. For more information see Referring Safeguarding Concerns about Children.

'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 prosecution and/or referral to their professional body.

See the Home Office guidance for more information - Mandatory Reporting of Female Genital Mutilation – procedural information to support this duty.


11. Referring Concerns about FGM

11.1 Referring to the MASH

For more information see Referring Safeguarding Concerns about Children.

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 (as 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 (Multi-Agency Safeguarding Hub – MASH) without delay. For more information see Referring Safeguarding Concerns about Children.

Information about a girl or woman having undergone FGM or being at risk should trigger concern for other females in the household, extended family and community, such as

  • Sisters;
  • Daughters or daughters she may have in the future;
  • Extended female family members, including cousins and grand-daughters.

A practitioner making a referral to MASH should be informed of the outcome and the reasons for any decisions made within one working day by telephone and within three working days in writing. Both the MASH worker and the referrer should record the outcome of any discussion and agreement about any ongoing action required by the referrer. For more information see Referring Safeguarding Concerns about Children, What to Expect After a Referral has been Made to Children's Social Care.

11.2 Referring to South Yorkshire Police

In addition to making a Referral to the MASH, if the practitioner is a regulated professional, (see Section 10, Mandatory Reporting of FGM) they must notify the police when they identify that an act of Female Genital Mutilation appears to have been carried out on a girl under the age of 18. The professional should call South Yorkshire Police on 999 if there is an immediate risk (the child is about to leave the country via the airport or port); or 101 in all other cases. 

When contacting the police, the regulated professional should explain that they are making a report under the FGM mandatory reporting duty (FGM Notification). The report should include information to confirm what actions have been undertaken, or will be undertaken, including safeguarding actions.

Both reports (Children Social Care and the Police) should be made as soon as possible; normally by close of business on the next working day. Longer timeframes are allowed under exceptional circumstances but always discuss with your local safeguarding lead or the MASH.

Non-regulated professionals / practitioners (e.g. nursery nurse, healthcare assistants, and youth workers) should also contact the police but it is not a mandatory duty. If the practitioner believes that reporting would lead to a risk of serious harm to the child or anyone else, they should not discuss it but instead contact their agency’s designated safeguarding lead for advice. 

The practitioner should discuss the referral with the family / child to let them know the report is being made unless it places the girl or another person at risk of significant harm. Wherever possible, the practitioner should have this discussion in advance of/in parallel with the report being made.


12. Use of an Interpreter

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, ideally female if the girl or woman prefers, and in all cases MUST NOT be a family member, not be known to the individual, and not be someone with influence in the individual’s community.  Consider using an interpreter from outside the local area who does not have local community links.


13. Child Protection Processes

13.1 Initial Strategy Meeting

A Strategy Meeting should be convened when there is risk of significant harm to a girl (or other girls) because of FGM. Children's Social Care Services will convene an initial Strategy Meeting in partnership with police and health colleagues at a minimum. For more information see Strategy Discussions/Meetings.

A decision will be made as to whether the girl, sister or female member of the extended family or community has suffered or is likely to suffer significant harm as a consequence of FGM. If so, a Section 47 Enquiry will be initiated. This also applies to an unborn child who may be assessed at risk of FGM after she is born. Children's Social Care Services will undertake an assessment and, jointly with the Police, will undertake a Section 47 Enquiry. For more information see Section 47 Enquiries.

Where a child appears to be in immediate danger of mutilation, legal advice should be sought and consideration should be given (see Section 9, Law relating to Female Genital Mutilation), for example, to seeking 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 girl to have the procedure.

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. This will form part of the assessment.

If the Strategy Meeting concludes that the child has not suffered significant harm, then the outcome may be a Child in Need Assessment or advice to the referrer that the child's needs can be met through early help or universal services.  For more information see Assessment and Early Help.

13.2 Paediatric Assessment (Child Protection Medical)

Children’s Social Care Services will liaise with the Paediatric services where it is believed that FGM has already taken place to ensure that a Medical Assessment is conducted. For more information see Paediatric Assessment for Section 47 Enquiry (Child Protection Medical).

Written consent for a Paediatric Assessment 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 aged 16 or 17 and has capacity to make their own decisions (Mental Capacity Act 2005.)

The Paediatric Assessment is undertaken jointly by the designated FGM health professional and consultant paediatrician. They should provide immediate verbal feedback on the outcome of the examination to the attending Social Worker (and / or Police officer is applicable) and provide a written report for the second strategy meeting.

13.3 Second Strategy Meeting

A second strategy must be held with 10 working days of the Initial Strategy Meeting where appropriate. The meeting should include the Police and relevant health practitioners and be chaired by the Social Work Team Manager. If possible, the designated FGM health professional and consultant paediatrician who carried out the Paediatric Assessment should also attend. If this is not possible, they should provide their report on the outcome of the Paediatric Assessment.

Attendees will consider information collected during the Section 47 enquiry and the Paediatric Assessment and decide on the outcome:

  • If the child has suffered or is likely to suffer Significant Harm, an Initial Child Protection Conference is required;
  • If the child is not suffering or likely to suffer significant harm but requires services as a Child in Need, or Early Help Assessment;
  • Whether 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 Help)  


14. Responding to FGM – The Role of Health Practitioners

For more information see Section 11, Referring Concerns about FGM.

Health professionals, especially midwife/obstetrician/gynaecologist/General Practitioner / school nurse may become aware that Female Genital Mutilation has occurred when treating a female patient.

All girls/women who have undergone FGM should be given information about the legal and health implications of practising FGM.

Information about a girl or woman who has undergone or is at risk of FGM should be clearly recorded in the medical notes (and, where possible, diagrammatically) recorded by maternity and health visiting professionals, GPs and practice nurses. A flag should be recorded on the electronic case files to ensure health professionals in the future will be aware of the risk to the girl or woman or any of her female relatives.

If a girl or woman who has been de-infibulated requests re-infibulation after childbirth, health professionals should ensure the mother receives appropriate information about the legal and health implications of practising FGM. They should consult their safeguarding lead and refer to the MASH - see Section 11, Referring Concerns about FGM and Referring Safeguarding Concerns about Children.

Since April 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.

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. For more information see FGM Dataset.

For further information, see Female Genital Mutilation and its Management: Royal College of Obstetricians and Gynaecologists 2015 and FGM: A Guide for Health Care Professionals (NHS England).


15. Role of Leisure / Community / Voluntary and Faith Groups

All agencies and organisations must have a lead person whose role includes responsibility for FGM (this will often be the designated safeguarding lead). This person should have relevant experience, expertise and knowledge and additional training. Their role should include ensuring that cases of FGM are handled, monitored and recorded properly and they can be approached to discuss and direct difficult cases.

Community groups have a valuable role to play in responding to FGM. This may include:

  • Supporting women’s access to specialist care
  • Disseminating information in schools
  • Supporting and supplementing professional training programmes.

When developing services and projects, organisations should consider working with appropriate community groups and survivors to help make sure the services provided both meet the needs of service users, and that their staff understand the issues related to FGM.

Appropriately trained professionals can help to address fears and misconceptions that may deter those affected by FGM from engaging with statutory services.

Professionals with specialist knowledge of FGM may also wish to consider how they can assist community groups, for example, by speaking at community-based events.


16. Responding to FGM – The Role of Education practitioners

Teachers, other school staff, volunteers and members of community groups may become aware that a girl is at risk of FGM through her disclosure or her disclosure to another child or young person, or a parent/other adult about the procedure being planned or that it has already happened to an older girl in the family. The practitioner should consult with their designated safeguarding lead and then take action.

Teachers are regulated professionals and should note the obligations as outlined in Section 10, Mandatory Reporting of FGM. A non-regulated professional, volunteer or community group member who has information or suspicions that a girl is at risk of FGM should consult with their agency’s safeguarding lead and refer to the MASH - see Section 11, Referring Concerns about FGM and Referring Safeguarding Concerns about Children.

If the girl appears to be in acute physical and/or emotional distress, or the plans for FGM appear to be imminent, the call to the MASH and Police should be immediate. See Local Contacts for MASH and Police.

Professionals in all agencies must record information about FGM which may be relevant. This includes education or nursery staff who identify a girl may be at risk of FGM because an older sister or female cousin has had the procedure.

A “flag” should be recorded on the girls’ school and local authority education file to ensure that the risk that has been identified is clearly seen if the girl moves between schools or local authorities.


17. Working with Communities to End FGM

So-called cultural practices, such as FGM, can be deeply embedded in practising communities and working to end them requires both top down direction and a community-led approach. Maintaining a continued dialogue with affected communities may help to ensure that prevention and support interventions are accepted.

It is important to highlight that FGM is illegal, child abuse, a form of violence against women and girls, a human rights violation and a manifestation of gender inequality. However, communication on FGM also needs to be framed respectfully.

Some of the ways organisations and professionals can help to end FGM include:

  • Involving individuals and families in discussions about how FGM can be ended within their family and wider community
  • Talking to all groups, including men, boys and community leaders about FGM and its consequences
  • Encouraging individuals to report suspected cases of FGM, and highlighting the anonymous means for doing this, such as the NSPCC helpline, for those unwilling to provide information to the authorities
  • Signposting to organisations that can provide support and advice to those who wish to end the practice within their family or community (for information on organisations working on FGM see Section 20, Resources for more information).


18. Adult Disclosure of FGM

There is no requirement for automatic referral of adult women with FGM to the MASH, adult social care services or the police.

Healthcare professionals should be aware that a disclosure may be the first time that a woman has discussed her FGM with anyone. Referral to the police must not be introduced as an automatic response when identifying adult women with FGM, and each case must continue to be individually assessed.

If the woman discloses information that suggests the practice is continuing and that girls in her family or community are at risk of FGM, a referral needs to be made. If the adult victim was born in the UK and FGM has been carried out recently, or where she has attended for a second or subsequent child and FGM has been carried out on her again, then professionals need to make a referral as both these cases are criminal offences. For more information see Section 11, Referring Concerns about FGM and Referring Safeguarding Concerns about Children.

When treating an adult woman with FGM, it should be considered whether she is at risk of further violence, and therefore whether she herself needs protection and support, as well as whether she has any daughters, whether there are girls within her care, or in her extended family or wider network who may also need protection. A woman may disclose information about FGM and she may be considered to be at risk because of additional vulnerability such as learning or other disability or mental ill-health. The woman should be dealt with under the Safeguarding Adults procedures.

Each woman should be signposted to appropriate counselling and support to address how FGM has affected her. The healthcare or other professional should seek to support women by offering referral to community groups for support, clinical intervention or other services as appropriate: for example, through an NHS FGM clinic. The wishes of the woman must be respected at all times. A woman may disclose that she has undergone FGM in the past and would like to access support and/or services. This should be treated in the same way as any disclosure of historical abuse.

Following discussion with the girl/woman on their individual circumstance, and with their agreement, consideration should be given to providing educative information to their boyfriend, partner or husband as appropriate to help him understand the consequences of FGM for girls and women. Any potential impact of this on the girl or woman should be taken into account before pursuing this further, because there is a risk of domestic violence, honour-based violence and FGM procedure being expedited if a disclosure is made to other family members.

For more information see Safeguarding Children and Young People from Forced Marriage and Safeguarding Children and Young People from Honour Based Violence and Safeguarding Children at Risk because of Domestic Abuse.


19. Breast Ironing / Flattening

Breast Ironing also known as “Breast Flattening” is the process whereby young pubescent girls breasts are ironed, massaged and/or pounded down through the use of hard or heated objects in order for the breasts to disappear or delay the development of the breasts entirely. It is believed that by carrying out this act, young girls will be protected from harassment, rape, abduction and early forced marriage and therefore be kept in education.

Much like Female Genital Mutilation (FGM), Breast Ironing is a harmful cultural practice and is child abuse. Professionals working with children and young people must be able to identify the signs and symptoms of girls who are at risk of or have undergone breast ironing. Similarly to Female Genital Mutilation (FGM), breast ironing is classified as physical abuse therefore professionals must make a referral to the MASH –see Section 11, Referring Concerns about FGM.

The United Nations (UN) states that Breast Ironing affects 3.8 million women around the world and has been identified as one of the five under-reported crimes relating to gender-based violence. The custom uses large stones, a hammer or spatulas that have been heated over scorching coals to compress the breast tissue of girls as young as 9 years old. Those who derive from richer families may opt to use an elastic belt to press the breasts so as to prevent them from growing. The mutilation is a traditional practice from Cameroon designed to make teenage girls look less "womanly” and to deter unwanted male attention, pregnancy and rape.

The practice is commonly performed by family members, 58% of the time by the mother.  In many cases the abuser thinks they are doing something good for their daughter, by delaying the effects of puberty so that she can continue her education, rather than getting married.

There is no specific law within the UK around Breast Ironing, however it is a form of physical abuse and if professionals are concerned a child may be at risk of or suffering significant harm they must make a referral to the MASH – for more information see Referring Safeguarding Concerns about Children.

20. Resources

Information for everyone

For all girls and women, provide them with information and advice, or direct them to appropriate resources:

Information on local and national voluntary sector organisations working with communities on FGM, including a postcode search function which signposts local support services, is available at: GOV.UK.

FORWARD - Foundation for Women's Health Research and Development is committed to gender equality and safeguarding the rights of African girls and women.

FGM Leaflet for Patients (DoH)

Female Genital Mutilation NSPCC Helpline

Female Genital Mutilation (FGM) Protection Orders – application by member of the public (HM Courts & Tribunal Service, July 2015)

Coventry University (Centre for Communities and Social Justice) have created a new app for young people to explain FGM and what to do if you are worried about yourself, a friend or family member. Called Petals it is available online and you can find out more about the project HERE

E-learning for all professionals (including teachers, police, border force staff, and health visitors), developed by the Home Office, is available at www.fgmelearning.co.uk.

Health and social care professionals in England can complete the e-learning session, ‘Communication Skills for FGM consultations’ at www.e-lfh.org.uk which provides advice and training to support these discussions.

Professionals in England can watch a video on NHS Choices where women who have had FGM discuss how they would like to see professionals hold sensitive conversations about FGM on NHS.uk.

Research Report

Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change (Unicef Report, 2013)

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