Female Genital Mutilation (FGM)

1. Definition

Female Genital Mutilation (FGM) is a procedure where the female genital organs are deliberately cut, injured or changed and there is no medical reason for this. It is frequently a very traumatic and violent act and can cause harm in many ways. The practice can cause severe pain, 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, widely carried out among specific ethnic populations 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 infants, during childhood, adolescence, just before marriage or during a woman's first pregnancy. There is no Biblical or Koranic justification for FGM and religious leaders from all faiths have spoken out against the practice. The exact number of girls and women alive today who have undergone FGM is unknown; however, UNICEF estimates that over 200 million girls and women worldwide have undergone FGM.

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.

2. 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;
• 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;
• Sections are missing from a girl's Red book.

A girl's risk can usually be identified at birth, through ante-natal care and delivery of the child. NHS professionals can and should have identified that the mother has had FGM and recorded this on the FGM Information Sharing System (see Section 7, NHS Data Sharing).

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 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. See Section 4, Protection and Action to be Taken. All concerns and actions agreed should be detailed in the child's record.

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, 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.

Professionals should not be afraid to ask about FGM, using appropriate and sensitive language. If professionals do not give a girl the opportunity to talk about FGM, it can be very difficult for her to bring this up herself.

3. FGM Mandatory Reporting Duty

Regulated health and social care professionals and teachers in England and Wales have a 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 should be made as soon as possible after a case is discovered, and best practice is for reports to be made by the close of the next working day. A longer timeframe than the next working day may be appropriate in exceptional cases where, for example, a professional has concerns that a report to the police is likely to result in an immediate safeguarding risk to the child (or another child, e.g. a sibling) and considers that consultation with colleagues or other agencies is necessary prior to the report being made.

Cases of failure to comply with the duty will be dealt with in accordance with the existing performance procedures in place for each profession.

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

4. 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 Safeguarding Practitioners. 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 (for example the use of an FGM Protection Order).

The level of safeguarding intervention needed will depend on how imminent the risk of harm is. An appropriate course of action should be decided on a case-by-case basis, following a risk assessment, with expert input from all relevant agencies. A victim centred approach should be taken, based on a clear understanding of the needs and views of the child.

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 will be held and this should include relevant health professionals and, if the child is of school age, a school representative.

It may not always be appropriate to remove the child from an otherwise loving family environment. Parents and carers may genuinely believe that it is in the girl’s best interest to conform to their prevailing custom. Professionals should work in a sensitive 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 illegal in the UK. 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.

If the only risk indicator is that a girl’s mother has undergone FGM, Referral to Children’s Social Care may not be appropriate, but other local multi- agency arrangements may be relevant. In such cases, monitoring is important to ensure that agencies respond appropriately if circumstances change and other risk factors arise. Where there is a specific risk, the case should be referred to Children’s Social Care.

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 Assessing Need and Providing Help).

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 will 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. Criminal investigations into the perpetrators can also be commenced (see Section 6, Law in England and Wales).

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.

5. Issues

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.

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 could include the following:

• An overview of FGM (what it is, when and where it is performed);
• The UK law on FGM and child protection;
• The potential 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 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.

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.

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.

Justifications for FGM

FGM is a complex issue, and individuals and families who support it give a variety of justifications and motivations for this. However, FGM is a crime, a form of child abuse, and no explanation or motive can justify it. The justifications given may be based on a belief that, 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.

See the Health Passport - Statement Opposing FGM for an overview of the law on FGM in England in Wales. Copies can be downloaded in a range of different languages.

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. Sensitive language should be used and the girl's wishes, culture and values are recognised and respected;

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.

6. Law in England and Wales

In England and Wales, 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 or to order the surrender of passports;
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.

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

7. NHS Data Sharing

Female Genital Mutilation Information Sharing (FGM- IS) is a national IT system that supports the early intervention and ongoing safeguarding of girls, under the age of 18, who have a family history of Female Genital Mutilation (FGM).

FGM-IS is a service that supports the sharing of FGM information, and allows authorised healthcare professionals and administrative staff throughout England to view information about girls with a family history of FGM, regardless of care setting.

A national alert instigated by NHS Digital enables health professionals to add a ‘standard’ alert to a child’s summary care record (SCR) if it is highlighted they are at risk of FGM. The FGM-IS tab sits alongside the CP-IS (child protection information sharing) tab on the patient information page of their summary care record.

There are FGM risk assessments for safeguarding pregnant women/a woman who has recently had a baby and children to help support decision making.

8. 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.

Further Information

Legislation, Statutory Guidance and Government Non-Statutory Guidance

Multi-Agency Statutory Guidance on Female Genital Mutilation (GOV.UK)

Female Genital Mutilation Resource Pack (Home Office) - including links to local organisations.

FGM Protection Orders: Factsheet

Mandatory Reporting of Female Genital Mutilation – procedural information

Safeguarding Women and Girls at Risk of FGM – Guidance for Professionals (DHSC) – includes Pathway and Risk Assessment tools

Female Genital Mutilation CPS Guidelines

Virginity Testing and Hymenoplasty: Multi-agency Guidance (DHSC)

National Support Agencies

Good Practice Guidance

FGM Assessment Tool for Social Workers (National FGM Centre). It has two elements; Best Practice Guidance and an Online FGM Assessment Tool to help guide the assessment of cases where FGM is a concern.

NSPCC FGM helpline: 0800 028 3550

Female Genital Mutilation and its Management: Royal College of Obstetricians and Gynaecologists 2015

Useful Websites

National FGM Centre - provides a range of guidance for all agencies including schools, health and social care.

AFRUCA (Child Protection of African Children)

Forward (Foundation for Women's Health Research and Development)

NHS - FGM (including information on where to get support)

Appendix 1: Pan Bedfordshire FGM Pathways

Click here to view Appendix 1: Pan Bedfordshire FGM Pathways