Section 1 – Understanding Female Genital Mutilation
- Identifying girls at risk of FGM
Section 2 – Female Genital Mutilation – Legal Context
- FGM is illegal in the UK
- Responding to FGM
- Legal interventions
- Child at Risk of FGM
- Child has undergone FGM
- Community Education
Section 3 – Female Genital Mutilation – Links
- Links with domestic abuse and ‘honour based violence’
- Links to Female Genital Mutilation and Forced Marriage
- Specialist groups which can provide advice and support for agencies
Date: 12 June 2015
Expires: When rescinded or replaced
Section 1 – Understanding Female Genital Mutilation
What is female genital mutilation (FGM)?
Female genital mutilation (FGM) involves procedures that include the partial or total removal of the external female genital organs for cultural or other non-therapeutic reasons. It is illegal in the UK. The offence will also apply outside England, Wales and Northern Ireland to a person subject to service law, or a civilian subject to service discipline.
FGM is known by a number of names including ‘female genital cutting’, ‘female circumcision’ or ‘initiation’. The term female circumcision suggests that the practice is similar to male circumcision but it bears no resemblance to male circumcision, has serious health consequences and no medical benefits. FGM is also linked to domestic abuse, particularly in relation to ‘honour based violence’.
This document is intended to raise awareness of the crime of FGM and assist professionals who work with children and families in decision making when they become aware of a girl or young woman at risk of FGM, or when they become aware of a girl or young woman who has already undergone FGM.
Types of FGM
FGM has been classified by the World Health Organisation:
Type 1- Clitoridectomy: partial or total removal of the clitoris (the small sensitive erectile part of the female genitalia) In rare cases the prepuce (hood of the clitoris) only is removed.
Type 2- Excision: partial or total removal of the clitoris and the labia minora, with or without the excision of the labia majora. (The labia are the ‘lips’ surrounding the vagina) (80% cases)
Type 3- Infibulation: narrowing of the vaginal opening by cutting and stitching the labia, with or without removal of the clitoris. (15% cases)
Type 4- Other: all other harmful procedures to the female genitalia for nonmedical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area.
FGM is deeply rooted in tradition widely practiced among specific ethnic populations in Africa and parts of the Middle East and Asia. Data from Somalia, Guinea, Djibouti, Sierra Leone, Egypt, Sudan, Eritrea and Mali show a prevalence of over 80% but it is also widely practiced in other African countries. However, FGM has been found in communities in Iraq, Israel, Oman, the United Arab Emirates, the Occupied Palestinian Territories, India, Indonesia, Malaysia and Pakistan.
The World Health Organisation (WHO) estimates that between 100 and 140 million girls and women have been subjected to FGM and that around 3 million girls undergo some form of the procedure each year in Africa alone.
FGM’s prevalence in the UK is difficult to estimate due to its hidden nature but is estimated that over 20000 girls under the age of 15 years could be at risk in England and Wales and nearly 66000 women living in England and Wales are living with the consequences. FGM could be even more prevalent than these figures suggest due to population growth and immigration from practising countries since 2001.The distribution of cases is likely to be uneven and will mirror the distribution of particular practicing communities.
Why Is Female Genital Mutilation Performed?^
FGM is a complex issue. It is often seen as a natural and beneficial practice by a loving family who believe that it is in the girl’s best interests.
A number of factors have been identified:
- To maintain cultural identity.
- Religion; in the mistaken belief that it is a religious requirement.
- Social acceptance especially for marriage.
- Preservation of virginity/chastity.
- Increasing sexual pleasure for the male.
- Men’s control of female reproductive functions.
- Hygiene and cleanliness.
- Family honour.
- Fear of social exclusion.
Many women believe that FGM is necessary to ensure acceptance in their community. They are often unaware that it is not practised in most of the world. FGM serves as a complex form of social control of women’s sexual and reproductive rights.
At What Age is FGM Performed?^
The age at which FGM is performed varies from area to area. It can be performed on female infants who are a few days’ old, female children and adolescents and occasionally on mature women. However the majority of cases are thought to take part between the ages of 5 and 8 years.
Who Performs FGM?^
The practice of female genital mutilation is often perpetrated by an older woman in the practicing community and can be a way of her gaining prestige and making a good income. It is performed with crude blunt instruments such as often unsterilised household knives or razor blades but broken glass and stones are also used and often without anaesthetic. The more affluent may have the procedure performed in a health care facility by qualified health personnel.
Effects of FGM^
FGM can cause both short term and long term complications. Some of these are as a result of the procedure being performed in unhygienic circumstances.
- Severe pain.
- Shock – both emotional and psychological as well as medical.
- Wound infection including tetanus and blood borne viruses such as HIV and hepatitis B and C.
- Damage to organs around clitoris and labia.
- Urine retention.
- Fracture of bones or dislocation of joints as a result of restraint.
- Damage to other organs.
Long-term implications can entail:
- Damage to the reproductive system including infertility.
- Chronic vaginal and pelvic infections.
- Cysts and abscesses.
- Complications in pregnancy and child birth, including death.
- Psychological damage.
- Painful sexual intercourse.
- Sexual dysfunction.
- Difficulties in menstruation.
- Difficulties in passing urine and chronic urine infections.
- Renal impairment and possible renal failure.
- Increased risk of HIV and other sexually transmitted infections.
There is increasing awareness of the severe psychological consequences of FGM which can be life long. There is evidence to suggest that girls having undergone FGM suffer from post traumatic stress disorder with flash backs and many suffer from anxiety and mood disorder. The feeling of betrayal, incompleteness, anger and regret are themes reported by young women undergoing counselling.
Identifying girls at risk of FGM^
A girl from a practicing community may be at risk of FGM but it cannot be assumed that all families from practicing communities will want their females to undergo FGM.
The risk of FGM to an individual is greater when the community is less well integrated into British society, when their own mother or sister has been the subject of FGM or when they have been withdrawn from Personal, Social and Health Education or Personal and Social Education lessons at school. The withdrawal from such lessons may be the parents’ way of keeping the girl uninformed of her rights and her own body.
A girl may be taken out of the country for a holiday for the procedure to be carried out abroad with time for recovery, but there is also evidence that FGM is carried out in the UK.
Alerts to imminent FGM may include:
- A visiting female elder being in the UK from the country of origin.
- A professional hearing reference to FGM e.g. having a ‘special procedure’.
- A disclosure or request for help if the girl is aware or suspects she is at risk.
- Parents taking the child out of the country for a prolonged period.
- The girl talking about a long holiday to one of the countries where FGM is practiced.
FGM may already have taken place but it is important that this is recognised so that help can be offered to the girl, other family members at risk can be safeguarded and so that a criminal investigation can be carried out.
Indications that FGM has already been carried out may be suspected if;
- A girl seems to have difficulty walking, sitting or standing.
- A girl spends longer then normal in the bathroom/toilet due to difficulties urinating.
- A girl spends long periods away from the classroom with bladder or menstrual problems.
- A girl misses a lot of time off school or college.
- A girl has a change in behaviour.
- A girl being unduly reluctant to have a normal medical examination.
- A girl confides in someone or may ask for help but not be explicit due to fear or embarrassment.
Section 2 – Female Genital Mutilation
FGM is illegal in the UK.^
The Female Genital Mutilation Act 2003 applies to England, Wales and Northern Ireland and a person, whatever their nationality or residence status, is guilty of an offence under this Act if they excise, infibulate or otherwise mutilate the whole or any part of a girl’s or woman’s labia majora, labia minora or clitoris within the UK. The offence will also apply outside England, Wales and Northern Ireland to a person subject to service law, or a civilian subject to service discipline.
Necessary operations by a registered medical practitioner or midwife for medical reasons or related to child birth are specific exclusions under the Act.
It is also an offence to assist a girl or woman in mutilating her own genitalia.
Under the 2003 Act, it is an offence for a UK national to assist in FGM abroad and for a girl to be taken abroad for FGM to take place.
Anyone found guilty under the 2003 Act will be liable to a maximum penalty fine or up to 14 years imprisonment or both.
FGM is a human rights issue (Article 3 of the European Convention on Human Rights and the 1989 United Nations Convention on the Right of the Child, Part 1, Article 37)
Responding to FGM^
Girls and young women at risk of FGM need to be safeguarded. Anyone who has information that a child is potentially or actually at risk of significant harm should inform the Central Referral Team or the police. An assessment of the risks to the child will then be undertaken.
Staff in education settings, obstetrics and midwifery services need to be aware of the potential risks to girls and women from communities known to practice FGM.
Professionals need to be aware of the sensitive and complex nature of FGM. Often the family do not see FGM as an act of abuse and in all other ways provide a loving environment. Removal of the girl from the family home may not be appropriate.
Each case needs to be responded to depending on the particular circumstances and level of danger at the time.
If an individual has undergone FGM, professionals must consider whether other girls are at risk.
When talking about FGM professionals it is good practice to:
- Ensure a female professional is available if the girl prefers.
- Make no assumptions.
- Be sensitive to the fact that the girl may still be loyal to her family.
- Be non judgemental and stick to facts e.g. the legal position and health implications.
- Gain accurate information and keep accurate records.
- Use simple, non-loaded and value-neutral terminology.
- Ask direct questions to avoid confusion.
If an interpreter is required, they should have received training in relation to FGM, must not be a family member nor have any influence in the girl’s community.
If a medical examination is required, this should be carried out by an appropriately trained person. For children this should be carried out under safeguarding procedures by a senior paediatrician, preferably one with experience of dealing with FGM.
From October 2015 it is a mandatory requirement for health professionals to record and report FGM – see Appendix 1.
Professionals may feel uncomfortable about disclosing information about FGM, but law and policy allow for disclosure when it is in the public interest or where a crime may have been committed. Professionals should follow the Information Sharing Protocol (SIBFG 3341) regarding confidentiality and disclosure.
Professionals should intervene to safeguard girls who may be at risk of FGM or have been affected by it. This is by using the relevant existing statutory procedures. There may be a joint investigation which would be handled in line with the Safeguarding Board procedures.
It might also be appropriate, in certain circumstances, for the police to remove and accommodate a child (section 22A of the Armed Forces Act 1991) where there is reasonable cause to believe that a child or young person under 18 years likely to suffer significant harm. British Forces Germany Central Referral Team would be informed by the police and initiate child protection enquiries.
BFSWS might also apply for an Emergency Protection Order where appropriate.
Practising communities where FGM is deeply embedded in the culture may resent the imposition of western values on them. Professionals nonetheless must be aware that FGM can be very harmful and is not a matter that can be left to personal preference or culture.
It is important however, that any community education is sensitive to the cultural norms and pressures applied to parents and children. Professionals involved will have to be aware of language and terminology. Each individual case will need to be carefully assessed.
Families involved may need to be referred to appropriate counselling services, to deal with any psychological conflicts that may arise.
It is imperative for agencies to recognise that many families, who are considering perpetrating this practice, have a considerable cultural dilemma. Families should be warned that this is an illegal practice in UK and that they are liable to prosecution if they proceed. This can take away the decision from the family and therefore reduce criticism from within their own community.
A specialist trained advisor (if available) may be needed to visit families where FGM is suspected.
Links with domestic abuse and ‘honour based violence’^
Definition of Honour-Based Violence (HBV)
The terms 'honour crime', 'izzat' or 'honour-based violence' embrace a variety of crimes of violence (mainly but not exclusively against women), including assault, imprisonment and murder where the person is being punished by their family or community. They are being punished for actually, or allegedly, undermining the family or community believes to be the correct code of behaviour. In transgressing against this correct code of behaviour, the person shows that they have not been properly controlled to conform by their family and this is to the 'shame' or 'dishonour' of the family.
Forced marriage and honour-based violence are human rights abuses and fall within the Government's definition of domestic violence. Forced marriage is defined as a marriage conducted without the full consent of both parties and where duress is a factor. There is a clear distinction between forced marriage and an arranged marriage. In arranged marriages, the families may take a leading role in arranging the marriage, but the choice whether or not to accept remains with the prospective spouses. In a forced marriage, one or both spouses do not consent to the marriage. The young person could be facing physical, psychological, sexual, financial or emotional abuse to pressure them into accepting the marriage.
Links to Female Genital Mutilation and Forced Marriage^
‘Honour-based' violence can include the following issues:
- Forced marriage (FM)
- Female genital mutilation (FGM)
- Honour killings (murder)
- Domestic imprisonment
- Dowry-related abuse
As a result, FGM and FM are types of abuse that fall into the category of Honour Based Violence (HBV).
Training with regard to the recognition of female genital mutilation may be needed. Access to on-line training is available at BFGNet.de - training. Sensitivity in managing the patients, referral facilities for reversal surgery, pre-birth examination and information gathering would have to contain awareness that women may not recognise female genital mutilation as surgery and indeed may not consider it abnormal. It is important that enquiries are made as early as possible in pregnancy in order to identify FGM in order to refer women for a medical opinion. Similarly it is important to stress that re-infibulation is illegal.
There will be issues for all staff involved regarding training and case management including cultural sensitivity issues and staff may find it beneficial to discuss individual cases at supervision.
There is a clear need to build up relationships with families to overcome the initial hostility which intervention generates. There is also a need to emphasise the positive aspects of the family’s culture, since for many FGM is usually practised out of a positive regard for a woman’s future status within her community.
Workers who are dealing with these issues will need specific support because it may be that if they are members of a similar community to the families they are working with, they may be seen as outsiders and treated with particular hostility.
Health Visitors and School Health staff will need to have an a awareness of the problem, both from the point of view of offering potential counselling services and also for raising awareness in direct contact with families and children.
Specialist groups which can provide advice and support for agencies:^
Central Referral Telephone number:
Central Referral Team: 0049(0) 800 724 3176
Foundation for Women’s Health, Research and Development (FORWARD)
765 - 767 Harrow Road
Telephone: +44 (0)20 8960 4000
Agency for Culture and Change Management
1 Arundel Gate
Telephone: +44 (0)114 275 0193
6 Buckingham Street
Telephone: +44 (0)20 7839 5456
Female genital mutilation is a safeguarding issue which will need to be managed consistently. All staff involved in the safeguarding of children must recognise this.
The practice of female genital mutilation tends to run in families and therefore if one family member is identified as being at risk of undergoing FGM or has undergone FGM, risks to other female family members must be recognised.
Any concerns regarding female genital mutilation must be acted upon in accordance with local policy and guidance. The referrer however, must feel reassured that a sensitive strategy will follow, including the sensitive management of any subsequent investigation and child protection conference.
Dorkenoo, E., Morison, L. and Macfarlane, A. (2015) Updating and improving estimates of the prevalence female genital mutilation in England and Wales city.ac.uk
HM Government (2016) Multi-agency statutory guidance on female genital mutilation London: The Stationery Office.
HM Government (2014a) Declaration on female genital mutilation (PDF). London: The Stationery Office.
NHS Choices (2013) Female genital mutilation. London: Department of Health.
NSPCC (2014) Fact Sheet on Female Genital Mutilation, available from: http://www.nspcc.org.uk/Inform/resourcesforprofessionals/minorityethnic/female-genital-mutilation_wda96841.html
SIBFG 3341 Information Sharing Protocol, available at BFGNet.de - Information Sharing Protocol
World Health Organization (WHO) (2013) Female genital mutilation: fact sheet no 241. Geneva: World Health Organization.
Access to on-line FGM training is available at BFGNet.de - training.
Tackling FGM in the UK Intercollegiate recommendations for identifying, recording and reporting (2013) , Royal College of Midwives.
Female Genital Mutilation Risk and Safeguarding – Guidance for professionals https://www.gov.uk/government/publications/safeguarding-women-and-girls-at-risk-of-fgm published by the Department of Health in March 2015
Copies of Patient Information leaflets in English and other languages available from DH Orderline http://www.orderline.dh.gov.uk/ All language versions are available to download and other useful information for patients is available at NHS choices here
NHS Specialist Services for Female Genital Mutilation provides NHS specialist clinic contact details for women and girls who have experienced FGM.
Roles and Responsibilities of Primary Health Care Professionals
Form 1a - Roles and responsibilities of health professionals
All clinical staff MUST record on DMICP when it is identified that a patient has had FGM.
If it can be determined what type of FGM the patient has (according to the WHO classifications as outlined below) this MUST be recorded.
Where it is not possible to determine the type of FGM, then “Female Genital Mutilation” MUST still be recorded on DMICP.
World Health Organisation FGM classifications:
|Type 1||Partial or total removal of the clitoris and/or prepuce (clitoridectomy)|
|Type 2||Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)|
|Type 3||Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitoris (infibulation)|
|Type 4||All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization|
DMICP Read Codes
|K578||Female Genital Mutilation||FGM is diagnosed but specific type is unknown|
|K5780||Female Genital Mutilation Type 1||Specific FGM type is diagnosed|
|K5781||Female Genital Mutilation Type 2||Specific FGM type is diagnosed|
|K5782||Female Genital Mutilation Type 3||Specific FGM type is diagnosed|
|K5783||Female Genital Mutilation Type 4||Specific FGM type is diagnosed|
|7F1B5||Deinfibulation of vulva to facilitate delivery|
|7D045||Deinfibulation of vulva|
|History of Female Genital Mutilation||A past finding or diagnosis of FGM e.g. a historic deinfibulation procedure has been observed|
|Family history of Female Genital Mutilation||It is made known that FGM occurred in associated family members and / or wider social grouping e.g. mother, aunts, guardians, cousins, non-blood relatives|
|13VY||At risk of Female Genital Mutilation|
|671E2||Discussion about Female Genital Mutilation with carer|
|67DQ||Discussion about Female Genital Mutilation|
Form 1b Dataset for Completion by GP when FGM identified
Form 1b Countires
Safeguarding Risk Assessment Guidance
The aim is to help make an initial assessment of risk, and then support the on-going assessment of women and children who come from FGM practising communities (using parts 1 to 3)
- Do you or your partner come from a community where cutting or circumcision is practised? Please remember you might need to consider that this relates to the patient’s parent’s country of origin).
- Have you been cut? It may be appropriate to use other terms or phrases.
If you answer YES to questions (1) or (2) please complete one of the risk templates.
PART ONE:– For an adult woman (18 years or over)
- PREGNANT WOMAN – ask the introductory questions.
If the answer is YES to either question, use part 1(a) to support your discussions.
- NON-PREGNANT WOMAN where you suspect FGM.
For example if a woman presents with physical symptoms or emotional behaviour that triggers a concern (e.g. frequent urinary tract infections, severe menstrual pain, infertility, symptoms of PTSD such as depression, anxiety, flashbacks or reluctance to have genital examination etc.); or if FGM is discovered through the standard delivery of healthcare (e.g. when placing a urinary catheter, carrying out a smear test etc.), ask the introduction questions.
If the answer is YES to either question, use part 1(b) to support your discussions.
PART TWO:– For a CHILD (under 18 years)
Ask the introductory questions (see above) to either the child directly or the parent or legal guardian depending upon the situation.
If the answer to either question is yes OR you suspect that the child might be at risk of FGM, use part 2 to support your discussions.
PART THREE:– For a CHILD (under 18 years)
Ask the introductory questions (see above) to either the child directly or the parent or legal guardian depending upon the situation.
If the answer to either question is yes OR you suspect that the child has had FGM use part 3 to support your discussions.
In all circumstances:
- The woman and family must be informed that FGM is illegal in the UK and the health consequences of practising FGM.
- Ensure all discussions are approached with due sensitivity and are non-judgemental.
- Any action must meet all statutory and professionals responsibilities in relation to safeguarding, and be in line with BFG / EJSU multi-agency child protection procedures.
- Using this guidance does not replace the need for professional judgement in relation to the circumstances presented.
The framework is designed to support healthcare professionals to identify and consider risks relating to female genital mutilation, and to support the discussion with the patient and family members.
It should be used it to help assess whether the patient you are treating is either at risk of harm in relation to FGM or has had FGM, and whether your patient has children who are potentially at risk of FGM, or if there are other children in the family/close friends who might be at risk.
If when asking questions based on this guide, any answer gives you cause for concern, you should continue the discussion in this area, and consider asking other related questions to further explore this concern. Please remember either the assessment or the information obtained must be recorded within the patient’s healthcare record. The templates also require that you record when and by whom it and at what point in the patient’s pathway this has been completed.
Having used the guide, you will need to decide:
- Do I need to make a referral through my local safeguarding processes, and is that an urgent or standard referral?
- Do I need to seek help from my local safeguarding lead or other professional support before making my decision? Note, you may wish to consult with a colleague from CRT / JRT for additional support.
- If I do not believe the risk has altered since my last contact with the family, or if the risk is not at the point where I need to refer to an external body, then you must ensure you record and share information about your decision accordingly.
An URGENT referral should be made, out of normal hours if necessary, if a child or young adult shows signs of very recently having undergone FGM. This may allow for the police to collect physical evidence.
An urgent referral should also be made if the healthcare professional believes that there are plans perhaps to travel abroad which present a risk that a child is imminently likely to undergo FGM if allowed to leave your care.
In urgent cases, the Central Referral Team / Joint Response Team will consider what action to take. One option is to take out an Emergency Child Protection Order (EPO). If required, an EPO is an order made under Section 44 of the Children Act 1989 enabling a child to be removed to a place of safety where there is evidence that the child is in “imminent danger”.
In many other situations if a child or young adult under 18 years of age is discovered to have had FGM, a referral should be made To the Central Referral Team and it is likely that this can be made during normal working hours and standard procedures, when the risk presented does not have an imminent or urgent element identified.