BarnsleySafeguarding Children Partnership Policies and Procedures Manual

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Female Genital Mutilation (FGM)

AMENDMENT

In April 2024 a new section was added on Other Harmful Practices. The Health and Care Act 2022 has made it illegal to carry out, offer or aid and abet virginity testing or hymenoplasty in any part of the UK. It is also illegal for UK nationals and residents to do these things outside the UK. Information has also been added on Breast Flattening which is an offence as set out in CPS So-Called Honour-Based Abuse Legal Guidance.

Contents

1. Introduction and Context
2. Definition

3. Consequences of FGM

4. Justifications for FGM

5. Law in England, Wales and Northern Ireland
6. What are the Signs that a Child is at Risk?
7. FGM Mandatory Reporting Duty
8. Protection and Action to be Taken
9. Prevention
10. Training
11. NHS Data Sharing
12. Other Harmful Practices
13. Further Information

1. Introduction and Context

Female Genital Mutilation (FGM) is a procedure where the external female genitalia female genital organs are deliberately cut, injured or changed and there is no medical reason for this. It is a serious and violent crime which causes severe physical and psychological damage, and there may be immediate and/or long-term health consequences, including pain and infection, mental health problems, difficulties in childbirth and/or death.

FGM is a deeply rooted practice and a global issue, widely carried out in Africa and parts of the Middle East and Asia. It serves as a complex form of social control of women's sexual and reproductive rights.

The age at which FGM is carried out varies enormously according to the community. The procedure may be carried out on new-born girls,  during childhood, adolescence or just before marriage or during a woman's first pregnancy. This could be within the family home, community or in hospitals. There is no  religious justification for FGM. UNICEF (2023) estimates that over 200 million girls and women worldwide have undergone FGM and there are believed to be 70,000 girls at risk of FGM in the UK. These are girls born to women where FGM is present already within the family and have inherited the risk.

2. Definition

FGM has been classified by the World Health Organisation (WHO) into four types:

• Type 1 - Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);
• Type 2 - Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the 'lips' that surround the vagina);
• Type 3 - Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and
• Type 4 - Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area.

Under the Female Genital Mutilation Act (2003), FGM is a criminal offence - it is child abuse and is violence against women and girls and should be treated as such. It is secretive and organised crime.

3. Consequences of FGM

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

• Severe pain and shock;
• Wound infections;
• Urine retention;
• Injury to adjacent tissues;
• haemorrhaging;
• Genital swelling;
• Death. 1 in 10 girls die from FGM.

Long-term implications can include:

• Genital scarring;
• Genital cysts and keloid scar formation;
• Recurrent urinary tract infections and difficulties in passing urine;
• Possible increased risk of blood infections such as hepatitis B and HIV;
• Pain during sex, lack of pleasurable sensation and impaired sexual function;
• Psychological concerns such as anxiety, flashbacks and post traumatic stress disorder;
• Difficulties with menstruation (periods);
• Complications in pregnancy or childbirth (including prolonged labour, bleeding or tears during childbirth, increased risk of caesarean section); and
• Increased risk of stillbirth and death of child during or just after birth.

In addition to these health consequences there are considerable psycho-sexual, psychological and social consequences of FGM.

4. Justifications for FGM

FGM is a complex issue, and individuals and families who support it give a variety of justifications and motivations for this. FGM is a crime, a form of child abuse, and no explanation or motive can justify it. The justifications given may be based  on ignorance and fear for example, 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";
• Cleanses and purifies the girl;
• Gives the girl and her family a sense of belonging to the community;
• Fulfils a religious requirement believed to exist;
• Perpetuates a custom/tradition;
• Helps girls and women to be clean and hygienic;
• Is aesthetically desirable;
• Makes childbirth safer for the infant; and
• Rids the family of bad luck or evil spirits.

FGM is a traditional practice often carried out by a family who believe it is beneficial and is in a girl or woman's best interests. This may limit a girl's motivation to come forward to raise concerns or talk openly about FGM – reinforcing the need for all professionals to be aware of the issues and risks of FGM and the need to ask questions about FGM when they have concerns. In addition, women and girls who have undergone FGM may not fully understand what FGM is, what the consequences are, or that they themselves have had FGM.

FGM is a complex and sensitive issue that requires professionals to approach the subject carefully. Good communication is essential when talking to individuals who have had FGM, may be at risk of FGM, or who are affected by the practice. When speaking to families, the care of women and girls affected by FGM should be the primary concern, treating them as individuals, listening and respecting their dignity. Culture is not an excuse or defence for FGM. An accredited female interpreter may be required. Any interpreter should ideally be appropriately trained in relation to FGM, and should not be a family member, nor someone known to the individual or who has influence in the individual's community.

Professionals should not be afraid to ask about FGM, using appropriate and sensitive language. Avoiding this conversation enables the perpetration of FGM. Perpetrators may have threatened their victims to keep silent and instilled fear, allowing them to continue committing this crime undetected. Professionals should obtain the voice of the child through professional curiosity and not rely on the child to initiate a disclosure. It is not the responsibility of a child victim to report. It is our collective responsibility to identify and safeguard victims and bring offenders to justice.

5. Law in England, Wales and Northern Ireland

In England, Wales and Northern Ireland, criminal and civil legislation on FGM is contained in the Female Genital Mutilation Act 2003 ('the 2003 Act').

The Act:

1. Makes it illegal to practice FGM in the UK;
2. Makes 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;
3. Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;
4. Has a penalty of up to 14 years in prison and/or, a fine.

As amended by the Serious Crime Act 2015, the Female Genital Mutilation Act 2003 also includes:

1. An offence of failing to protect a girl from the risk of FGM - A person is liable if they are "responsible" for a girl at the time when an offence is committed. This covers both someone who has "parental responsibility" for the girl and has "frequent contact" with her, as well as any adult who has assumed responsibility for caring for the girl in the "manner of a parent". This could be for example family members, with whom she was staying during the school holidays;
2. Female Genital Mutilation Protection Orders ("FGMPO"). An FGMPO is a civil order which may be made for the purposes of protecting a girl against the commission of an FGM offence or protecting a girl against whom an FGM offence has taken place. Breaching an order carries a penalty of up to 5 years in prison. The terms of the order can be flexible and the court can include whatever terms it considers necessary and appropriate to protect the girl or woman including to protect a girl from being taken abroad, to order the surrender of passports; to enable the girl to obtain medical support.

3. Allowing for the lifelong anonymity of victims of FGM – prohibiting the publication of any information that could lead to the identification of the victim. Publication covers all aspects of media including social media;

4. Extra-territorial jurisdiction over offences of FGM committed abroad by UK nationals and those habitually (as well as permanently) resident in the UK;
5. Mandatory reporting which requires specified professionals to report known cases of FGM in under 18s to the police.

(Please note: in Scotland, FGM is illegal under the Prohibition of Female Genital Mutilation (Scotland) Act 2005).

See also: Making an Application for an FGM Protection Order (FGMPO) - Flowchart.

6. What are the Signs that a Child is at Risk?

Signs that a child may be at risk of FGM:

• A female child is born to a woman who has undergone FGM or whose older sibling or cousin has undergone FGM i.e. FGM is already within the family;
• The child's father comes from a community known to practise FGM;
• The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
• A woman / family believe FGM is integral to cultural or religious identity;
• A girl / family has limited level of integration within the UK community;
• The girl talks about a 'special procedure/ceremony' that is going to take place or attending a special occasion to 'become a woman';
• Parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
• A girl talks about a long holiday to her country of origin or another country where the practice is prevalent;
• Parents state that they or a relative will take the girl out of the country for a prolonged period;
• A parent or family member expresses concern that FGM may be carried out on the girl;
• A family is not engaging with professionals (health, education or other);
• A family is already known to social care in relation to other safeguarding issues;
• 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 - it is important to take into account the context of the discussion;
• A girl from a practising community is withdrawn from Personal, Social, Health and Economic (PSHE) education or its equivalent;
• A girl is unexpectedly absent from school or nursey/childcare provision.

These indicators are not exhaustive; if any of these risk factors are identified, professionals will need to consider what action to take. If a professional is unsure whether the level of risk requires a referral to Children's Social Care, they should discuss their concerns with the named/designated safeguarding lead in their organisation. The National FGM Centre's FGM assessment tool is a useful resource to help professionals determine whether a safeguarding referral needs to be made. All concerns and actions agreed should be detailed in the child's record. FGM should not be dealt with in silo by professionals. 

NB: This text is taken from Multi-agency statutory guidance on female genital mutilation Annexe B.1 Risk Factors

Signs that FGM may have already taken place:

It is also important to consider whether FGM may have already taken place, for example if:

• A girl asks for help;
• A girl confides in a professional that FGM has taken place;
• A mother/family member discloses that female child has had FGM;
• A girl has difficulty walking, sitting or standing or looks uncomfortable;
• A girl finds it hard to sit still for long periods of time, and this was not a problem previously;
• A girl spends longer than normal in the bathroom or toilet due to difficulties urinating;
• A girl spends long periods of time away from a classroom during the day with bladder or menstrual problems;
• A girl has frequent urinary, menstrual or stomach problems;
• A girl avoids physical exercise or requires to be excused from physical education (PE) lessons without a GP's letter;
• There are prolonged or repeated absences from school or college;
• A girl displays increased emotional and psychological needs, for example withdrawal or depression, and/or a significant change in behaviour;
• A girl is reluctant to undergo any medical examinations;
• A girl asks for help, but is not be explicit about the problem; and/or
• A girl talks about pain or discomfort between her legs.

Remember: this is not an exhaustive list of indicators.

Where there are concerns that FGM has taken place, the professional should inform their designated safeguarding lead, and an immediate referral should be made to Children's Social Care.

7. FGM Mandatory Reporting Duty

All professionals have a safeguarding duty to report FGM, however, some professionals have an additional mandatory duty.  Regulated health and social care professionals and teachers in England and Wales have a mandatory duty to report to the Police 'known' cases of FGM in under 18s which they identify in the course of their professional work.   Reports should be made using the non-emergency 101 telephone number.

'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 necessary for the girl's physical or mental health or for purposes connected with labour or birth.

Reports under the duty must be made as soon as possible after a case is discovered and within 24 hours.  Cases of failure to comply with the duty will be dealt with in accordance with the existing disciplinary performance procedures in place for each profession.

CAPTION: Mandatory Reporting note

Remember - Mandatory Reporting does not replace safeguarding children actions; if a professional has concerns that FGM has taken place, they should share this information with their safeguarding lead and make a referral to Children's Social Care.

For more information on the Mandatory Reporting Duty, please see:

Information for Professionals Subject the Duty and their Employers, Including on How to Make a Report

Information for Health Care Professionals in England

8. Protection and Action to be Taken

FGM is child abuse and should be treated as such. Professionals should intervene to safeguard girls who may be at risk of FGM or who have been affected by it.

Where there are concerns that a girl is at risk of FGM:

As soon as a girl is identified as at risk of FGM, information should be shared with other agencies (in accordance with local information sharing protocols and Information Sharing Advice for Practitioners Providing Safeguarding Services to Children, Young People, Parents and Carers - DfE. If a professional is unsure whether the level of risk requires referral to Children's Social Care at this point, they should discuss their concerns with the named/designated safeguarding lead in their organisation. The National FGM Centre's FGM assessment tool is a useful resource to help professionals determine whether a safeguarding referral needs to be made.

All concerns identified and actions agreed should be noted in the child's record.

Professionals must take into consideration that by alerting the girl's family to any concerns about FGM, they may place her at increased risk of harm and professionals should therefore take sufficient steps to minimise this risk. FGM Protection Orders (FGMPO’s) can be obtained without notice in the first instance (i.e. not informing perpetrators until the order has been obtained). It is expected that Social Care will lead on obtaining FGMPOs, via their Legal Services with police support. No victim/potential victim should be left to obtain their own order without professional support to ensure their safety and other safeguarding of females within that family.

A victim centred approach should be taken, based on a clear understanding of the needs and views of the child. There should be a focus on the girl’s right to justice. FGM is a clear violation of her human rights.

If, following a referral to Children's Social Care there is cause to believe that the child has suffered or is likely to suffer Significant Harm, a Section 47 Enquiry will be carried out in conjunction with the Police. A strategy discussion/meeting with Police/Health/Social Care will be held within 24-48 hours including nursery/school representatives where applicable.

FGM is carried out through ignorance and fear to control female autonomy. It is a form of honour-based abuse. FGM within a family often has links to domestic abuse, forced marriage, child marriage, witchcraft, honour based abuse and virginity testing.

Professionals will work in a sensitive but robust manner with families to explain the legal position around FGM in the UK. The families will need to understand that FGM and re-infibulation (the process of resealing the vagina after childbirth) is against the law, together with taking girls abroad for the purposes of FGM. The Health Passport - Statement Opposing FGM can be useful to share with families as it outlines what FGM is, the legislation and penalties involved and the help and support available. It is available in a range of languages.

Interpretation services should be used if English is not spoken or well understood, and the interpreter should not be an individual who is known to the family. It is good practice to establish the views of the interpreter on FGM in case they are from a practising family/community too.

The single biggest risk indicator of FGM is where a girl’s mother has undergone FGM herself, as it is already within the family and perpetrators are within the family or community

In such cases, monitoring is important to ensure that agencies respond appropriately if circumstances change, and other risk factors arise. 

When a girl is at imminent risk, legal intervention should be considered, including an Emergency Protection Order (EPO), an FGM Protection Order (FGMPO) or police powers of protection.

Professionals should remember that FGM can be carried out at any age, so identifying at birth that a girl is at risk of FGM means that safeguarding measures adopted may need to remain in place for a number of years over the course of her childhood.

In this situation, professionals should always take opportunities to discuss and understand changes to the girl's / family's circumstances and look out for changes in relation to any of the known risk factors. For example, if the professional becomes aware of new travel plans or the arrival of extended family members to live with the girl, this information should be shared with appropriate partner agencies without delay.

Where there are concerns that FGM has taken place - professionals should inform their named/designated safeguarding lead, and an immediate Referral should be made to the relevant local authority Children's Social Care department. (See Referrals Procedure).

Remember - Professionals subject to the FGM Mandatory Reporting Duty are also required to report 'known' cases of FGM in girls under 18 to the police.

Children's Social Care must liaise with Paediatric services where it is believed that FGM has already taken place to ensure that a Medical Assessment takes place, and the girl receives the care and support she needs. Enquiries will be made about other female family members who may need to be safeguarded from harm or who may have already suffered FGM, even if this occurred abroad prior to living in the UK. Criminal investigations into the perpetrators can also be commenced (see Section 5, Law in England, Wales and Northern Ireland).

National FGM Support Clinics have been established to offer a range of support services for women over 18 who have undergone FGM. Support for girls under 18 us available from a specialist paediatric service at University College London Hospitals (UCLH). UCLH can be contacted by email at UCLH.paediatricsafeguarding@nhs.net.

Support for children, young people and families is also available from the NSPCC or via the Blossom Clinic, Leeds

9. Prevention

Safeguarding children partners should actively seek and support ways to reduce the prevalence of FGM in practising communities within the UK. Services aimed at preventing FGM should be developed in consultation with expert voluntary sector organisations and FGM survivors. Practitioners should be trained to recognise and respond to concerns and endeavours should be made to raise awareness across the community. 

10. Training

Training should be available to enable professionals to discharge their safeguarding duties with regard to FGM, as for any other form of abuse. Training on FGM should include the following:

• An overview of FGM (what it is, when, where, how it is performed, who by);
• The UK law on FGM and child protection; It is Violence Against Women and Girls.
• The physical and psychological consequences of FGM;
• What to do when FGM is suspected or has been performed; and
• The role of different professionals and the importance of multi-agency working.

See also - E-learning for all professionals (including teachers, police, border force staff, and health visitors), developed by the Home Office, is available at Virtual College, Female Genital Mutilation: Recognising and Preventing FGM.

Health Education England offer e-learning, free to access by health and social care professionals.

11. NHS Data Sharing

NHS Digital collects data on FGM within in the NHS in England on behalf of the Department for Health and Social Care.

Data on the following is collected from NHS acute trusts, mental health trusts and GP practices:

• 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.

Aggregate information on the data collected is available online, see NHS Digital website.

Female Genital Mutilation Information Sharing (FGM- IS)

FGM-IS is a national IT system for healthcare professionals and administrative staff to record that a girl has a family history of FGM.

For more information please see NHS Digital - FGM.

12. Other Harmful Practices

Virginity testing and hymenoplasty can be precursors to child or forced marriage and other forms of family and/or community coercive behaviours, including physical and emotional control. The practices are degrading and intrusive. They can lead to extreme psychological trauma in the victim, and can provoke conditions including anxiety, depression and post-traumatic stress disorder. The practices have been linked to suicide and can be physically harmful.

Women and girls may themselves present to agencies requesting the procedures in an attempt to protect themselves from further harm and abuse, including shaming, disownment, physical abuse and possible honour-killings. Family and/or community members who are unaware of the change in law may also try to contact agencies seeking the procedures for their daughters and female relatives.

See Virginity Testing and Hymenoplasty: Multi-agency Guidance (DHSC) for good practice guidance and indicators that a woman or girl is at risk of or has been subjected to a virginity test and/or hymenoplasty.

It is important to find out if the woman or girl is in immediate danger. In an emergency, the police should be contacted without delay. If it is not an emergency but there is a concern that the individual is at risk, the organisation’s safeguarding procedures and any professional duties should be followed. This may involve a referral to social care services and/or the police should be made.

Virginity testing and hymenoplasty are forms of so called ‘honour-based’ abuse and violence against women and girls. Like forced marriage and female genital mutilation (FGM), the victims of these abuses are at risk of being subjected to further harm, whether that be psychological or physical. The same sensitivity and precautions apply as for other types of so called ‘honour’ based abuse.

Organisations should not involve families and community members in cases involving virginity testing and hymenoplasty, including trying to mediate with family or using a community member as an interpreter. Engaging with families and community members may increase risk of harm to the victim. The victim may be punished for seeking help and arrangements for procedures may be expedited.

The Health and Care Act 2022 has made it illegal to carry out, offer or aid and abet virginity testing or hymenoplasty in any part of the UK. It is also illegal for UK nationals and residents to do these things outside the UK.

In England and Wales and Northern Ireland, the offences will each carry a maximum penalty of a 5-year custodial sentence and/or an unlimited fine. There is a risk that women and girls may be taken abroad and subjected to virginity testing and hymenoplasty (as is often seen with so called ‘honour-based’ abuse offences, such as female genital mutilation or forced marriage). The offences, therefore, carry extra-territorial jurisdiction. This means that UK nationals and residents who carry out a virginity test or hymenoplasty outside the UK also commit an offence in the UK.

Breast flattening which is the painful and harmful practice of bringing a girl's breasts into contact with hard or heated objects (which may vary in nature but may include stones, belts, pestles and heated implements) to suppress or reverse the growth of breasts by destroying the tissue.

Breast flattening is often performed at first signs of puberty, usually by female family members professing to make a teenage girl look less womanly to avoid sexual interest, prevent pregnancy and rape, deter from sexual relationships outside marriage and dishonouring the family/community. Due to the type of instruments, force and lack of aftercare, there are significant physical and psychological consequences and risks related to this practice.

Breast flattening is a form of child abuse. See the CPS legal guidance on So-Called Honour-Based Abuse.