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3.10 Children and Female Genital Mutilation (FGM)

SCOPE OF THIS CHAPTER

For more detail, please refer to the non-statutory government Multi-Agency Guidelines on Female Genital Mutilation (issued in February 2011).

AMENDMENT

In November 2014 a link to Information Standards Board for Health and Social Care Female Genital Mutilation Prevalence Dataset Standard Specification was added to Section 13.3, Health.


Contents

  1. Definition
  2. Types of Female Genital Mutilation
  3. Legal Framework
  4. Prevalence
  5. Cultural Underpinnings
  6. Cultural Change in the UK
  7. Age and Procedure
  8. Names for FGM
  9. Consequences
  10. Professional Response
  11. Identifying a Child who has been Subject to FGM or who is at Risk of being Abused through FGM
  12. Identifying a Young Girl or Mother who has Undergone FGM
  13. Professionals and Volunteers from all Agencies Responding to Concerns
  14. LA Children’s Social Care

    Appendix 1: Multi Agency Child Protection Decision Making and Action Flowchart

    Appendix 2: Decision Making and Action Flowchart for Professionals in Health

    Appendix 3: Decision-making and Action Flowchart for Professionals in LA Education and Schools, and Professionals and Volunteers in the Voluntary Sector

    Appendix 4: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care

    Appendix 5: Recent Progress Internationally

    Appendix 6: Prevalence Profile and Legislation banning FGM in Africa

    Appendix 7: Glossary

    References and Resources

    Footnotes


1. Definition

1.1

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” (WHO, 1996)

It is illegal in the UK to subject a child to female genital mutilation (FGM) or to take a child abroad to undergo FGM.

FGM constitutes child abuse and causes physical, psychological and sexual harm.

1.2

Female Genital Mutilation can have devastating harmful consequences for a woman throughout her life. It causes long-term mental and physical distress, problems in pregnancy and childbirth, infertility and even death from infection or bleeding. It cannot be justified as a cultural or religious practise. Leaders of all main faiths have spoken out against it.

From a recent study commissioned by the Department of Health (2007) found that 20,000 girls under the age of 15 are potentially at risk from FGM in England and Wales, with nearly 66, 000 females aged between 15 - 49 having been subjected to the practise residing in the UK. Female Genital Mutilation is largely practised in 28 African countries, some of the main countries being Somalia, Sudan and Sierra Leone. It is also practised in South of Yemen and some parts of the United Arab Emirates.

Girls 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.

Coventry's population includes communities from practising countries where prevalence is high.


2. Types of Female Genital Mutilation

2.1

The World Health Organisation (WHO) have classified Female Genital Mutilation into four types:

  • Type 1- excision of the prepuce, with or without excision of part or all of the clitoris;
  • Type 2 - excision (Clitoridectomy) - 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 - 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 - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of 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 purpose of tightening or narrowing it; and any other procedure that falls under the definition given above.


3. Legal Framework

3.1 Female Genital Mutilation has been illegal in the UK since the Prohibition of Female Circumcision Act 1985. The Female Genital Mutilation Act 2003 came into force in March 2004.
3.2

The Female Genital Mutilation Act 2003 makes it a criminal offence for a person to excise, infibulate or otherwise mutilate the whole or any part of a girl’s labia majora, labia minora or clitoris, except:

  • In the case of a surgical operation which is considered necessary for the girl's physical or mental health if carried out by a registered medical practitioner; or
  • For purposes connected with labour or birth, and which is carried out by a registered medical practitioner or registered midwife (or a person training to become a registered medical practitioner or midwife);or
  • Where the surgical operation is performed outside the UK by someone exercising the same functions as an approved person.
3.3 The Act also makes it an offence for UK nationals and those with permanent UK residence to be taken overseas for the purpose of female circumcision, to aid and abet, counsel, or procure the carrying out of Female Genital Mutilation.
3.4 In addition to the offence of female genital mutilation the Act also makes it an offence to assist a girl to mutilate her own genitalia, and /or for any non-UK person to mutilate overseas a girl's genitalia.
3.5 The Act makes it illegal for anyone to mutilate girls and women for non-medical reasons, including traditional and cultural requirements used to justify a mental need for the operation
3.6 The Act also increases the maximum penalty for committing or aiding the offence to 14 years imprisonment and/or a fine.
3.7

In addition there are two international conventions, which contain articles, which can be applied to FGM. Signatory states, including the UK, have an obligation under these standards to take legal action against FGM:

  • The UN Convention on the Rights of the Child (1);
  • The UN Convention on the Elimination of All Forms of Discrimination against Women (2).
3.8 These conventions have been strengthened by two world conferences: the International Conference on Population and Development (ICPD, Cairo, September 1994) and the World Conference on Women (Beijing 1995)


4. Prevalence

4.1 FGM is a deeply rooted tradition widely practised mainly among specific ethnic populations in Africa and parts of Asia, which serves as a complex form of social control of women’s sexual and reproductive rights.
4.2 The World Health Organisation estimates that between 130-140 million girls and women have experienced female genital mutilation and up to two million girls per year undergo some form of the procedure each year.
4.3 The great majority of affected women live in sub-Saharan Africa, but the practice is also known in parts of the Middle East and Asia.
4.4 FGM is practiced in more than 28 countries in Africa and in some countries in Asia and the Middle East, however in each of those countries the extent of the practice varies African countries with the highest likelihood of FGM being practised are Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Guinea, Mali, Sierra Leone, Somalia and Sudan (See Appendix 6: Prevalence Profile and Legislation banning FGM in Africa for a profile of prevalence and legislation banning FGM in African countries).
4.5 It appears that the Democratic Republic of Congo (DRC), Ghana, Niger, Tanzania, Togo, Uganda, and Yemen have the lowest incidence of FGM. However, within each of these countries there are specific ethnic communities in which the incidence of FGM is high. 
4.6 In England and Wales, women from non-African communities, which are most likely to be affected by FGM, include Yemeni, Iraqi Kurd and Pakistani women.


5. Cultural Underpinnings

5.1 Female genital mutilation is a complex issue. Despite the harm it causes, many women from FGM practising communities consider FGM normal to protect their cultural identity.
5.2 As a result of the belief systems of cultural groups who practice FGM, many women who have undergone this believe they appear more attractive than women who haven’t. Their perception is that normal female genitalia are both unattractive and unhygienic. In some cultures it is believed that a girl who has not undergone FGM, is unclean and not able to handle food or drink.
5.3 Infibulation (See Type 3 above) is strongly linked to virginity and chastity. It is used to safeguard girls from sex outside marriage and from having sexual feelings. In more traditional cultures it is considered necessary at marriage for the husband and his family to see her closed. In some instances both mothers will take the girl to be cut open just enough to have sex. Women also have to be cut open to give birth. The consequences of this are pain, bleeding, varying degrees of incapacity and psychological trauma.
5.4 Although FGM is practiced by secular communities, it is most often claimed to be carried out in accordance with religious beliefs. However, neither the Bible, nor the Koran justify FGM. In 2006, top Muslim clerics at an international conference on FGM in Egypt pronounced that FGM is not Islamic.
5.5

Parents who support the practice of female genital mutilation say that they are acting in the child’s best interests. The reasons they give include that it:

  • Brings status and respect to the girl;
  • Preserves a girl’s virginity/chastity;
  • Is part of being a woman;
  • Is a rite of passage;
  • Gives a girl social acceptance especially for marriage;
  • Upholds the family honour;
  • Gives the girl and her family a sense of belonging to the community;
  • Fulfils a religious requirement mistakenly believed to exist;
  • Perpetuates a custom/tradition;
  • Helps girls and women to be clean and hygienic;
  • Is cosmetically desirable; and
  • Is mistakenly believed to make childbirth safer for the infant.
5.6 It is because of these beliefs that girls and women who have not undergone FGM are often considered by practising communities to be unsuitable for marriage. Women who have attempted to resist exposing their daughters to FGM report that they and their families were ostracised by their community and told that nobody would want to marry their daughters.


6. Cultural Change in the UK

6.1 Some community groups/agencies report increasing instances where young men and women who have grown up in the UK and assimilated British cultural beliefs and attitudes are experiencing difficulties amongst their peer group e.g. young men rejecting girlfriends when they discover that she was subjected to FGM as a child or a girl discovering that not all girls are subjected to FGM. Young people who resist FGM can also experience conflict within their family and community.
6.2 See also Section 9.6, Mental health problems for the emotional and psychological impact of FGM reported by girls in the UK.


7. Age and Procedure

7.1 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.
7.2 FGM is usually carried out by the older women in a practising community. For them it is a way of gaining prestige and can be a lucrative source of income 
7.3 Arrangements for the procedure usually include the child being held down on the floor by several women and the procedure carried out without medical expertise, attention to hygiene and anaesthesia. The instruments used include unsterilised household knives, razor blades, broken glass and sharpened stones. In addition the child is subjected to the procedure unexpectedly.
7.4 Increasingly some health professionals are performing FGM in the belief that it offers more protection from infection and pain. However, the medicalisation of FGM is condemned by all international groups including the WHO.


8. Names for FGM

8.1 FGM is known by a number of names, including female genital cutting or circumcision. The term female circumcision is unfortunate because it is anatomically incorrect and gives a misleading analogy to male circumcision. The names ‘FGM’ or ‘cut’ are increasingly used at the community level, although they are still not always understood by individuals in practising communities, largely because they are English terms.
8.2 The Somali term for FGM is ‘Gudnin’ and the Sudanese the word for FGM is ‘Tahur’.
8.3 See Appendix 7: Glossary for the difference between male and female circumcision and other terms relating to FGM.


9. Consequences

9.1 Many women in practising communities appear to be unaware of the relationship between female genital mutilation and its harmful health and welfare consequences, in particular the complications affecting sexual intercourse and childbirth, which occur many years after the mutilation has taken place.
9.2 The health implications of the FGM procedure for a child can be severe to fatal, depending on the type carried out.
9.3

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.

9.4

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.

9.5

Long term implications for a girl or woman’s health and welfare

9.5.1 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 compared to women who had 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.
9.5.2 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.
9.5.3 Women with FGM Type 3 require special care during pregnancy and childbirth.
9.5.4

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.

9.6

Mental health problems

9.6.1 In FGM practicing 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.
9.6.2 Young women receiving psychological counselling in the UK report feelings of betrayal by parents, incompleteness, regret and anger. (3) 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. (4) There is increasing awareness of the severe psychological consequences of FGM for girls and women which become evident in mental health problems.
9.6.3 The results from research (5) in practicing African communities are that women who have undergone FGM have the same levels of Post Traumatic Stress Disorder 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.
9.6.4 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.


10. Professional Response

THERE ARE THREE CIRCUMSTANCES RELATING TO FGM WHICH REQUIRE IDENTIFICATION AND INTERVENTION

  • Where a child is at risk of FGM;
  • Where a child has been abused through FGM;
  • Where a prospective mother has undergone FGM.
10.1 Professionals and volunteers in most agencies have little or no experience of dealing with female genital mutilation. Individuals 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.
10.2

The appropriate response to FGM is to follow usual child protection procedures (see Section 14, LA children’s social care), to ensure:

  • Immediate protection and support for the child/ren; and
  • That the practice is not perpetuated.
10.3

An appropriate response to a child suspected of having undergone FGM as well as a child at risk of undergoing FGM could include (also see Section 13, Professionals and Volunteers from all Agencies Responding to Concerns and Section 14, LA Children’s Social Care responding to a concern):

  • Arranging for an 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.
10.4

An appropriate response by professionals who encounter a girl or woman who has undergone FGM includes (also see Section 13, Professionals and Volunteers from all Agencies Responding to Concerns and Section 14, LA Children’s Social Care for further information):

  • 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.

Case study: One woman’s story (6)

‘Margaret’ remembers that she wanted to undergo infibulation, she couldn’t go to school until it was done. But afterwards she was no longer able to do all the things she enjoyed as a child, climbing her favourite tree, playing football, riding a donkey and gymnastics, all these might tear the scar tissue.

Margaret says that in her teenage years she had very painful periods as a result of the infibulation. As a young married woman, she says, she had little feeling. Sex became a necessity just to satisfy her husband and produce children.

Margaret says ‘your childhood is gone - you’re disabled for life’


11. Identifying a Child who has been Subject to FGM or who is at Risk of being Abused through FGM

11.1

A child at risk of FGM

11.1.1 Professionals in all agencies, and individuals and groups in the community, need to be alert to the possibility of a child being at risk of, or having experienced female genital mutilation. There are a range of potential indicators that a child may be at risk of FGM, which individually may not indicate risk but if there are two or more present this could signal risk to the child.

11.1.2

Indications that FGM may be about to take place include:

  • The family comes from a community that is known to practise FGM. E.g. Somalia, Sudan and other African countries (see Appendix 6: Prevalence Profile and Legislation banning FGM in Africa). It may be possible that they will practice FGM if a female family elder is around;
  • Parents state that they or a relative will take the child out of the country for a prolonged period;
  • A child may talk about a long holiday to her country of origin or another country where the practice is prevalent, including African countries and the Middle East;
  • A child may confide to a professional that she is to have a ‘special procedure’ or to attend a special occasion;
  • A professional hears reference to FGM in conversation, for example a child may tell other children about it;
  • A child may request help from a teacher or another adult;
  • Any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family;
  • Any female child who has a sister who has already have undergone FGM must be considered to be at risk, as must other female children in the extended family.

11.2

Indications that FGM may have already taken place include:

  • A child may spend long periods of time away from the classroom during the day with bladder or menstrual problems if she has undergone Type 3 FGM;
  • There may be prolonged absences from school if she has undergone Type 3 FGM;
  • A prolonged absence from school with noticeable behaviour changes on the girl’s return could be an indication that a girl has recently undergone FGM;
  • Professionals also need to be vigilant to the emotional and psychological needs of children who may/are suffering the adverse consequence of the practice e.g. withdrawal, depression etc;
  • A child may confide in a professional;
  • A child requiring to be excused from physical exercise lessons without the support of her GP;
  • A child may ask for help;
  • Women or children visiting a GP surgery complaining of period pain.

Children and young females are most vulnerable to suffering FGM during the early part of the school summer holiday, as this is the most likely time they are sent to countries of origin or are mutilated in the UK, to ensure the lengthy recovery period takes place over the school break. Therefore a change in a child's behaviour in the lead up to school holidays maybe noticeable or a change in their behaviour on return to school after the break.

11.2.1 Health professionals such as midwives, obstetricians, gynaecologists, paediatricians, paediatric surgeons and general practitioners may become aware that Female Genital Mutilation has taken place while treating a patient. This should alert professionals to raise urgent concerns about other females in the household


12. Identifying a Young Girl or Mother who has Undergone FGM

12.1

Health professionals gathering information

12.1.1 Health professionals in GP surgeries, sexual health clinics and maternity services are the most likely to encounter a girl or woman who has been subjected to FGM.
12.1.2 If the girl/woman is from a community which traditionally practices FGM, information gathering should be approached sensitively. A question about FGM should be incorporated when the routine patient history is being taken. A female interpreter may be required. The interpreter should be appropriately trained in relation to FGM and must not be a family member.
12.1.3 A suitable form of words should be used, ‘circumcised’ is not medically correct and although ‘mutilation’ is the most appropriate term, it might not be understood or it may be offensive to a woman from a practising community who does not view FGM in that way. Different terminology will be culturally appropriate to the different cultures.
12.1.4 A health professional may make an initial approach by asking a woman whether she has undergone FGM saying: ‘I’m aware that in some communities women undergo some traditional operation in their genital area. Have you had FGM or have you been cut?’ To ask about infibulation health professionals can use the question: ‘are you closed or open?’ This may lead to the woman providing the terminology appropriate to her language/culture.
12.1.5 Asking the right questions in a simple, straightforward and sensitive way is key to establishing the understanding, information exchange and relationship needed to plan for the girl/woman’s wellbeing and the welfare and wellbeing of any daughters she may have, or female children she may have access to.
12.1.6 As well as gathering information, discussion should be had with the mother/father or young girl (if they are of an appropriate age to understand) explaining that this practise is illegal in the UK and in a number of African countries, information about why it is illegal and penalty for those carrying out the procedure or aiding the carrying out of the procedure should also be given (for further information go to Legal Framework of this procedure).

12.2

Pregnancy and childbirth

12.2.1 At an antenatal booking the holistic assessment may identify women who have undergone FGM. Midwives and Obstetricians should then plan appropriate care for pregnancy and delivery (7)
12.2.2 Women with FGM Type 3 require special care during pregnancy and childbirth, especially if it is first pregnancy or the woman has had a previous caesarean section or re-infibulation took place in the past. Early antenatal registration is important in providing midwives with the opportunity to plan for this. Women may not know which type of FGM they have undergone, it is therefore best practice to examine the woman during the booking. Unfortunately many women only access services very late in their pregnancy.
12.2.3 The plan should be an extension of NICE guidelines that midwives are already familiar with i.e. history taking, offering individual care and being culturally sensitive. However the woman should be told that ideally she should be de-infibulated (8) during 2nd trimester.

12.3

Counselling

12.3.1 All girls/women who have undergone FGM (and their boyfriends/partners or husbands) must be told that re-infibulation is against the law and will not be done under any circumstances. Each woman should be offered counselling to address how things will be different for her afterwards.
12.3.2 Counselling sessions should be offered and arranged, taking into account that the woman may not want to make the arrangements about it when her boyfriend/partner or husband or other family members are present. Professionals should be aware that there may be coercion and control involved which may have repercussions for the girl/ woman.
12.3.3 Boyfriends/partners and husbands should also be offered counselling, they are usually supportive when the reality is explained to them.
12.3.4

Health professionals should communicate equally the disadvantages of infibulation and the benefits of remaining open after childbirth. It:

  • Is more hygienic;
  • Means that sex will be much more comfortable and better once both partners get used to it;
  • Will make future births much easier and less risky;
  • Increases the likelihood of conception;
  • Reduces the chances of neonatal death (9).
12.3.5 Once girls/women know all the facts and the benefits of remaining open most of them are happy to remain so. Health professionals should not, however assume that this means that the woman will be more able to resist the pressure from the community to subject any daughter/s she may have to FGM.


13. Professionals and Volunteers from all Agencies Responding to Concerns

13.1

Summary response

13.1.1

Any information or concern that a child is at immediate risk of, or has undergone, female genital mutilation should result in a child protection referral to LA Children’s Social in line with the Referrals Procedure of the CSCB Inter-agency procedures.

Where a child is thought to be at 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.

See Appendix 1: Multi Agency Child Protection Decision Making and Action Flowchart.

13.2

Education/ leisure and community and faith groups

Concerns that a child is at risk of being abused through FGM

13.2.1

Teachers, other school staff, volunteers and members of community groups may become aware that a child is at risk of FGM through a parent/other adult, a child or other children disclosing that:

  • The procedure is being planned;
  • An older child in the family has already undergone FGM.

School nurses are in a particularly good position to identify FGM or receive a disclosure about it.

13.2.2 A professional, volunteer or community group member who has information or suspicions that a child its at risk of FGM should consult with their agency or group’s designated Child Protection Adviser (if they have one) and should make an immediate referral to LA Children’s Social Care, in line with the Referrals Procedure.
13.2.3 The referral should not be delayed in order to consult with the designated Child Protection Adviser, a manager or group leader, as multi-agency safeguarding intervention needs to happen quickly.
13.2.4

If there is a concern about one child, consideration must be given to whether siblings are at similar risk. Once concerns are raised about FGM there should also be consideration of possible risk to other children in the practicing community.

13.2.5

Concerns that a child has already been abused through FGM

Teachers, other school staff, volunteers and members of community groups may become aware that a child has been subjected to FGM through:

  • A child presenting with the signs and symptoms described in section 8 above;
  • A parent/other adult, a child or other children disclosing that the child has been subjected to FGM.
13.2.6 A professional, volunteer or community group member who has information or suspicions that a child has been subjected to FGM should consult with their agency or group’s designated Child Protection Adviser (if they have one) and make a referral to LA Children’s Social Care, in line with Section 14, LA Children’s Social Care below and the Referrals Procedure.
13.2.7 If the child appears to be in acute physical and/or emotional distress, they should make an immediate referral to LA Children’s Social Care (in line with Section 14, LA Children’s Social Care, using the Referrals Procedure and to the local Health Service.
13.2.8 If there is a concern about one child, the child’s siblings and the children in the extended family, should be considered to be at risk.
13.2.9 Once concerns are raised about FGM in relation to one child/family there should also be consideration of possible risk to other children in the practicing community.

13.3

Health

NHS Actions

 

From April 2014 NHS hospitals will be required to record:

  • If a patient has had Female Genital Mutilation;
  • If there is a family history of Female Genital Mutilation;
  • If a Female Genital Mutilation-related procedure has been carried out on a patient.

By September 2014 all acute hospitals must report this data centrally to the Department of Health on a monthly basis. This is 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 further information, see Information Standards Board for Health and Social Care Female Genital Mutilation Prevalence Dataset Standard Specification.

 

Concerns in relation to a mother who has undergone FGM

13.3.1

Health professionals encountering a girl or woman who has undergone FGM should be alert to the risk of FGM in relation to her:

  • Younger siblings;
  • Daughters she may have in the future;
  • Extended family members.
13.3.2

Health professionals in GP surgeries, sexual health clinics and maternity services are the most likely to encounter a girl or woman who has been subjected to FGM. All girls and women who have undergone FGM should be given information about the legal and health implications of practising FGM.

Health visitors, are in a good position to reinforce information about the health consequences and the law relating to FGM. Currently FGM information is not always provided on post-natal discharge reports and is not recorded routinely in health visiting records. Health visitors should seek to record this information wherever possible.
13.3.3 If a girl or woman who has been de-infibulated requests re-infibulation after the birth of a child, where the child is female, or there are daughters in the family, health professionals should consult with their designated Child Protection Adviser and with LA Children’s Social Care about making a referral to them. 
13.3.4 After childbirth a girl/woman who has been de-infibulated may request and continue to request, re-infibulation. This should be treated as a child protection concern. This is because whilst the request for re-infibulation is not in itself a child protection issue, the fact that the girl or woman is apparently not wanting to comply with UK law and/or consider that the process is harmful, raises concerns in relation girl child/ren she may already have or may have in the future. Professionals should consult with the designated Child Protection Adviser and with LA Children’s Social Care about making a referral to them (see Section 14, LA Children’s Social Care).
13.3.5 If the girl or woman is a mother or prospective mother, her child/ren or unborn child should be considered at risk of significant harm. The health professional should consult with their designated Child Protection Adviser and should make a referral to LA Children’s Social Care, in line with Section 14, LA Children’s Social Care and the Referrals Procedure.
13.3.6 If the girl or woman has the care of female children, these children should be considered children at risk of significant harm, the designated Child Protection Adviser should be consulted and a referral made to LA Children’s Social Care, as above.
13.3.7 See also the BMA Guidance: FGM: Caring for patients and child protection (10)

13.4

The Police

13.4.1 The Police have a key role in the investigation of serious crime.
13.4.2 The Child Abuse Investigation Unit (CAIUs) have an awareness of FGM. The police response recognises the need for an effective investigative response to what is regarded as an extremely severe form of child abuse, recognising the immediate and long term pain, suffering and risks to health associated with this practice.
13.4.3 Where FGM has been practised the CAIU will take a lead role in the investigation of this serious crime, working to common joint investigative practices and in line with strategy agreements.
13.4.4 The police investigation will extend to identifying established excisors and investigating these with a view to identifying further victims.


14. LA Children’s Social Care

14.1 Children’s Social Care will investigate (initially) under Section 47 of the Children Act (1989).
14.2 If a referral is received concerning one child, consideration must be given to whether siblings are at similar risk.
14.3 Once concerns are raised about FGM there should also be consideration of possible risk to other children in the practicing community. Professionals should be alert to the fact that any one of the girl children amongst these could be identified as being at risk of FGM and will then need to be responded to as a child in need or a child in need of protection.

14.2

Section 47 Enquires

Strategy meeting 

14.2.1 On receipt of a referral a strategy meeting must be convened within two working days, and should involve representatives from police, Children’s Social Care, education, health and any voluntary services that could provide specialist information and advice regarding FGM. Health providers or voluntary organisations with specific expertise must be invited; and consideration may also be given to inviting a legal advisor.
14.2.2 The strategy meeting must first establish if either parents or 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. 
14.2.3 An interpreter and, if possible a community advocate, appropriately trained in all aspects of FGM must be used in all interviews with the family. A female interpreter should be used, who is not a family relation.
14.2.4 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 co-operation 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.
14.2.5 If no agreement is reached, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child’s safety.
14.2.6 The primary focus is to prevent the child undergoing any form of FGM, rather than removal of the child from the family.

14.3

Children at immediate risk of harm

14.3.1 If the strategy meeting decides that the child is in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, then an emergency protection order should be sought.

14.4

If a child has already undergone FGM

14.4.1 A strategy meeting must be convened within two days. The strategy meeting will consider how, where and when the procedure was performed and the implication of this.
14.4.2 If the child has already undergone FGM the strategy meeting will need to consider carefully whether to continue enquiries or whether to assess the need for support services. If any legal action is being considered, legal advice must be sought.
14.4.3 A second strategy meeting should take place within ten working days of the referral, with the same chair. This meeting must evaluate the information collected in the enquiry and recommend whether a child protection conference is necessary, in line with the Child Protection Conferences Procedure.
14.4.4 A girl who has already undergone FGM should not normally be subject to a child protection conference or registered unless additional child protection concerns exist. However, she should be offered counselling and medical help. Consideration must be give to any other female siblings at risk.
14.4.5 Along side police involvement, a visit should be made to the family to acknowledge the conflict between their culture and the law of the UK. This is particularly important if there are other female children in the family.
14.4.6

If it appears that no other children are at risk:

  • Children's Social Care Services will take no further action other than to consider any of the physical and emotional concerns for the child who has undergone the procedure;
  • If the operation seems to have been performed in the UK, the police will seek information for the possible prosecution of the perpetrator;
  • Children's Social Care Services will notify the child's GP and midwifery services to invite them to notify them if any changes in the situation give rise to further concerns, e.g. the mother giving birth to further girls.
14.4.7 At the strategy meeting consideration needs to be given to the risks to other female children. The strategy meeting should consider, how, where and when the procedure was performed and its implications for other female children in the family.
14.4.8

In this situation any action taken should focus on:

  • The position of any younger girls in the family;
  • The family's willingness to co-operate with the agencies concerned, you should try to gain written agreement from the family that they will not let their child undergo the procedure;
  • Health education and other work with the family to reduce the risk to other members of the family;
  • Community reaction to the child and family; and
  • Whether the family will need support in the face of community pressure;
  • If the family’s primary language is not English, an interpreter must assist at any interview with them. The interpreter must be female.


Appendix 1: Multi-agency Child Protection Decision-making and Action Flowchart

Click here to view Multi-agency Child Protection Decision-making and Action Flowchart


Appendix 2: Decision-making and Action Flowchart for Professionals in Health

Click here to view Decision-making and Action Flowchart for Professionals in Health Working with Women      


Appendix 3: Decision-making and Action Flowchart for Professionals in LA Education and Schools, & Professionals and Volunteers in the Voluntary Sector

Click here to view Decision-making and Action Flowchart for Professionals in LA Education and Schools, & Professionals and Volunteers in the Voluntary Sector


Appendix 4: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care

Click here to view Decision-making and Action Flowchart for Professionals in LA Children’s Social Care


Appendix 5: Recent Progress Internationally

Female Genital Mutilation not Islamic - say top Egyptian clerics

The Foundation for Women’s Health Research and Development (FORWARD) and the London Central Mosque Trust & the Islamic Cultural Centre (ICC) welcome the break through announcements by top Muslim clerics to disassociate Islam from Female Genital Mutilation (FGM). The declaration was announced on 22 November 2006 during an international conference on FGM in Cairo, Egypt.

The Grand Sheikh of al-Azhar, the highest Sunni Islamic institution in the world, Sheikh Mohammed Sayyid Tantawi categorically stated “FGM has neither been mentioned in Quran nor Sunnah (11)”. This statement was reaffirmed by the top official cleric and Grand Mufti of Egypt, Sheikh Ali Gomma who said “Prophet Mohammed didn’t circumcise his four daughters”. Sheikh Yousif Algaradawi, a prominent Islamic figure, also addressed the conference by avowing that “FGM is not an Islamic requirement”. These statements have come from the highest Islamic figures in the world which should be binding for all FGM practicing communities who are Sunni Muslims.

These announcements have long been waited for by FORWARD and ICC who are working jointly to eradicate FGM in the UK where some Muslims mistakenly think that FGM is an Islamic requirement.

For the last two decades FORWARD has maintained its position that the only way to eradicate FGM is to engage with FGM practicing communities particularly the religious and community leaders.

FORWARD and ICC urge all Imams and Muslim clerics in the UK and Europe to take notice of the declarations made in Cairo and follow the example of their counterparts in Egypt. We would urge all UK clerics to make similar statements and to actively educate their followers that female genital mutilation is not an Islamic requirement.

The FGM Act 2003 makes FGM illegal in the UK and anywhere in the world for UK citizens and permanent residents. The penalty for carrying out, aiding, abetting or counselling to procure FGM is 14 years imprisonment, a fine or both.

WEST AFRICA: Communities choose health over tradition

On 3rd December 2006 150 communities in Guinea collectively abandoned the practice of female genital cutting - a landmark declaration in a country where more than 97 percent of women undergo the ritual.

Delegations led by women from each village converged on the central Guinean town of Lalya to speak about genital excision and participate in the declaration. All of Guinea’s ethnic groups practice genital cutting, despite a law that forbids it.

The Senegal-based NGO Tostan organised the Guinea declaration after working with communities to show how traditional practices such as genital cutting are harming individuals and communities.

Khady Bah Faye, Tostan’s communications officer, said that the Guinea declaration shows that momentum against the harmful practice is growing in Africa. She said Tostan has also been getting requests for assistance from the Gambia, Burkina Faso and Benin. The NGO has also worked in Mali and is about to begin in Mauritania.

More than 1,800 communities in Senegal, where excision is practiced among 28 percent of the population, have publicly abandoned genital cutting in the past nine years, Faye said. She said the continued rate of abandonment after at least two years was 65-80 percent.

“This has been a practice that has gone on for 2,000 years and yet it is going to take an understanding by people who believe this is part of their culture to understand the dangers to women so it can be eliminated,” said Ann Veneman, executive director of the United Nations children’s agency (UNICEF).


Appendix 6: Prevalence Profile and Legislation banning FGM in Africa

These figures are offered only to give an indication of the scale the practice of FGM, they are figures for Africa, not for communities in the UK for which prevalence data is not available.

Country Prevalence Illegal / since
Benin 30% Not yet
Burkino Faso 72% 1996
Cameroon 20% None
Chad 60% Went before parliament in 2001, not yet in place
Central African Republic 43% 1966
Djibouti 98% 1995
Egypt 97% 1959, there are grey areas, but in 1997 court upheld govt banning of FGM
Eritrea 90% No specific banning law for fear of driving the practice underground
Ethiopia 90% 1994
Gambia Approx. 70% None
Ghana 15% 1994
Guinea 99% Late 1980’s
Guinea Bissau Approx. 50% 1995 govt proposal to ban was defeated
Ivory Coast 45% 1998
Liberia 60% None
Mali 93% None, but draft legislation and govt campaigns against
Mauritania 25% Not illegal, but banned in hospitals
Niger 5% Not yet, draft legislation
Nigeria 50% In some areas since 1999
Senegal 20% 1999
Sierra Leonie 90% None
Sudan 91% 1956, rescinded in 1983. Opposed by govt but not in law
Somalia 98% In some areas since 1999
Kenya 38% 2001
Tanzania 18% 1998, however not enforced
Togo 12% 1998
Uganda 5% Considering banning, children’s legislation can be used
Yemen 23% Not illegal, but banned in hospitals

Source: Female Genital Mutilation: Treating the Tears, Haseena Lockhat (2004)


Appendix 7: Glossary

Glossary of Terms

  1. Female Genital Mutilation is sometimes called female circumcision or female cutting;
  2. The main differences between FGM and male circumcision is:

    The clitoris and foreskin have different functions, the clitoris is a specialist sexual organ and the foreskin is a protective part of the male sexual apparatus, FGM or female circumcision results in greater functional impairment and clinical complications are higher for females then males;
  3. Type 1, Female Genital Mutilation may be known to some communities as ‘Sunna’. Sunna is an Islamic word used to describe an action by the Prophet Mohammed;
  4. Infibulation is derived from the name given to the Roman practice of fastening a ‘fibular’ or ‘clasp’ through the large lips of a female genitalia (usually within marriage) in order to prevent illicit sexual intercourse;
  5. De-infibulation is the name for having FGM reversed and opening the entry to the vagina again;
  6. Re-infibulation is the term used when women seek to be restored to their previous state usually following child birth;
  7. The term “closed” refers to type 3 Female Genital Mutilation where there is a long scar covering the vaginal opening. This term is particularly understood by the Somali and Sudanese communities.


References and Resources

  1. Female Genital Mutilation: Treating the Tears, Haseena Lockhat, 2004;
  2. Female Genital Mutilation, Comfort Momoh, 2005;
  3. Female Genital Mutilation Bill 2003;
  4. Human Rights Act (1998);
  5. London Child Protection Procedures, Edition 2;
  6. The Children Act. (1989) and the Children Act 2004;
  7. The Criminal Justice (Terrorism and Conspiracy) Act 1988;
  8. Webb E., Hartley B. (1994) Female Genital Mutilation: a dilemma in child protection. Archives of the Diseases of Childhood 70: 441-444;
  9. Working Together to Safeguard Children (2013);
  10. World Health Organisation, estimated prevalence rates of Female Genital Mutilation updated May 2001: click here to access the World Health Organisation Website;
  11. United Nations Convention on the Rights of the Child (1989);
  12. Safeguarding Children at risk of abuse through female genital mutilation, London Safeguarding Children Board, 2007;
  13. Male and Female circumcision, Medical, Legal and Ethical considerations in Paediatric Practise, George C Dennison, Fredrick Mansfield Hodges, Marylin Fayre Milos, 1999;

    Resources for health professionals;
  14. Protecting Children and Young People - the Responsibilities of all Doctors' (GMC 2012);
  15. Mwangi-Powell F (ed). Female genital mutilation: Holistic care for women. A practical guide for midwives. London: FORWARD, 2001;
  16. FGM Royal College of Nursing Educational Resource for Nursing and Midwifery Staff 2006;
  17. Royal College of Midwives. Female genital mutilation (female circumcision). Position paper no. 21. London: Royal College of Midwives, 1998;
  18. Royal College of Obstetricians and Gynaecologists. Setting Standards to improve women’s health, Female genital Mutilation, Statement No 3 May 2003;
  19. Royal College of Obstetricians and Gynaecologists. Female Circumcision (Female Genital Mutilation), June 1997;
  20. Hedley R, Dorkenoo E. Child protection and female genital mutilation: Advice for health, education, and social work professionals. London: FORWARD, 1992;
  21. Toubia N. Caring for women with circumcision: A technical manual for health care providers. New York: Rainbo, 1999;
  22. World Health Organisation, 1997, Management of Pregnancy, Childbirth and the Postpartum Period, Report of a WHO Technical Consultation Geneva, 15-17 October 1997;
  23. American College of Obstetricians and Gynaecologists. Female circumcision/female genital mutilation: Clinical management of circumcised women. Washington, DC: ACOG, 1999;
  24. FORWARD Another form of abuse London: FORWARD, 1992. This video, produced by FORWARD with funding from the Department of Health, gives a general introduction to female genital mutilation and its health implications. It also includes an interview with a woman who had genital mutilation performed on her.

Agencies offering help and advice:

Agency for Culture and Change Management:

ACCM UK website
info@accmuk.com

Tel: 01234 356910
Mobile: 0771 2482568

info@accmsheffield.org
www.accmsheffield.org
Tel 01142 750193

Foundation for women’s research and development (FORWARD):

Unit 4
765-767 Harrow Rd
London NW10 5NY
Tel: 020 8960 4000
Fax: 020 8960 4014
Email: forward@forwarduk.org.uk
Internet: www.forwarduk.org.uk

International planned parenthood federation

Regent’s College
Inner Circle
Regent’s Park
London NW1 4NS
Tel: 020 7487 7900
Fax: 020 7487 7897
Email: info@ippf.org
Internet: www.ippf.org


Footnotes

  1. Office of the High Commissioner for Human Rights: Convention on the Rights of the Child;
  2. Convention on the Elimination of All Forms of Discrimination against Women;
  3. Haseena Lockhat, 2004, ‘Female Genital Mutilation: Treating the Tears’, London: Middlesex University Press;
  4. 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;
  5. Behrendt, A. et al, 2005, ‘Post-traumatic Stress Disorder and Memory Problems after Female Genital Mutilation’, Am J Psychiatry 162:1000-1002, May;
  6. Female Genital Mutilation DVD, Department of Health, 2006;
  7. Royal College of Obstetricians and Gynaecologists, 2003 and Royal College of Midwives, 1998;
  8. Whilst professionals may be aware that they cannot re-infibulate, the two edges must be over-sown or they may naturally knit back together and the result is the same as infibulation;
  9. World Health Organisation, June 2006: See NewScientist website;
  10. A saying or action ascribed to Prophet Mohammed (peace be upon him) or an act approved by the prophet.

End