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11.1 Female Genital Mutilation Multi-Agency Protocol

Acknowledgements

Wirral Safeguarding Children Board/Safeguarding Adult Partnership Board would like to thank Greater Manchester FGM Forum whose template was used for these guidelines.

NOTE

Any information or concern that a female is at immediate risk of, or has undergone, FGM should result in a Safeguarding Referral to the Local Authority Social Care and the Police Public Protection Investigation Unit.

The Home Office has launched free online training produced by the virtual college. It can be accessed at the Safeguarding Children e-Academy website.

This course is useful for anyone who is interested in gaining an overview of FGM, particularly frontline staff in healthcare, police, border force and children’s social care (added November 2014).

RELATED GUIDANCE

Mandatory Reporting of Female Genital Mutilation – procedural information

FGM: Care for patients and safeguarding children, BMA July 2011 (under review)

FGM Multi-Agency Practice Guidelines: Home Office 2014

FGM Risk & Safeguarding: Guidance for professionals: DOH 2015

FGM Enhanced Dataset Clinical Audit Platform Operational Guidance: Health and Social Care Information Centre 2015

Merseyside Forced Marriage Protocol 2014

NICE guidance – Domestic Violence and Abuse: How Health Services, Social Care and the Organisations They Work with Can Respond Effectively 2014

SCCI 2026 Requirements Specification FGM Enhanced Dataset: Health and Social Care Information Centre 2015

Serious Crime Act 2015

Tackling FGM in the UK – Intercollegiate recommendations for identifying, recording & reporting 2013

RELATED CHAPTER

Responding to Children and Young People who are at Risk from Domestic Violence and Abuse - Policy and Guidance for Professionals

Female Genital Mutilation Procedure

AMENDMENT

This chapter was comprehensively updated in March 2016 to provide a range of links to relevant guidance and a full update on protective legislation (see Section 13, Protective Legislation and Appendix 2: Legislation on Female Genital Mutilation). The procedure on safeguarding has been fully revised (see Section 16, Procedure Within Social Care for Safeguarding Children, and Adults at Risk of or who have Undergone FGM) and Section 19, Procedure for Safeguarding Children and Adults from FGM within the Health Sector). A range of tools are provided in the Appendices. Please ensure the chapter is fully re-read.


Contents

Section A: Background Information

  1. Introduction
  2. What is FGM
  3. Female Genital Mutilation is Classified into Four Major Types
  4. Local Terms for the Procedure
  5. Who Practices It
  6. Religion and FGM
  7. Communities At Risk of FGM in the UK
  8. Health Impact
  9. Long-term Health Implications
  10. The Myths of why Circumcision is Necessary Vary Between Ethnic Groups
  11. Common Justifications for FGM
  12. Risk Factors that Heighten the Girl’s/Woman’s Risk of Being Subjected to FGM
  13. Protective Legislation
  14. National Developments

Section B: Practice Guidance

  1. Safeguarding: Actions to be Taken by Single and Multi-Agency Workforce
  2. Procedure Within Social Care for Safeguarding Children, and Adults at Risk of or who have Undergone FGM
  3. Assessment
  4. Procedure for Safeguarding Children and Adults from FGM within Education / Leisure and Community and Faith Groups
  5. Procedure for Safeguarding Children and Adults from FGM within the Health Sector
  6. Procedures for Police Officers/Police Staff
  7. When an Adult Female has Undergone/is about to Undergo FGM
  8. Links to Forced Marriage and Domestic Violence and Abuse
  9. Support for Girls and Women Affected by FGM

    Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults

    Appendix 2: Legislation on Female Genital Mutilation

    Appendix 3: Useful Contacts

    Appendix 4: Glossary

    Appendix 5: FGM Flowchart for Arrowe Park Staff

    Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff

    Appendix 7: FGM Flowcharts for Mental Health Staff

    Appendix 8: Decision-Making and Action Flowchart for Safeguarding Adults at Risk

    Appendix 9: FGM Safeguarding and Risk Assessment Guidance

    Appendix 10/10a: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care

    Appendix 11: Flowchart for GP Practice Staff


Section A: Background Information


1. Introduction

Wirral Safeguarding Boards recognises that FGM has been carried out for centuries, and it directly causes serious short and long term medical and psychological complications. Consequently it is considered to be a physically abusive act.

This protocol covers female children under the age of 18 and adult females including those who come under the Care Act 2014 definition of a Adult at risk (see Appendix 4: Glossary). These groups of females will have similar needs for support and protection but different legislation and routes to safety will apply.

1.2 Community Engagement

To prevent FGM in the future as agencies we need to work closer with practising communities and foster stronger links so together we are able to break the taboo and silence surrounding the harmful practise of FGM.


2. What is FGM

The World Health Organisation (WHO) states that female genital mutilation (FGM):

Comprises of all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons

FGM is also known as Female Circumcision (FC) and Female Genital Cutting (FGC). The reason for these alternative definitions is that it is better received in the communities that practice it, who do not see themselves as engaging in mutilation.

FGM is included within the revised (2013) government definition of Domestic Violence and Abuse.


3. Female Genital Mutilation is Classified into Four Major Types

  1. 'Clitoridectomy which is the partial or total removal of the clitoris and, in rare cases, the prepuce (the fold of skin surrounding the clitoris);
  2. Excision which is the 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 1 and II account for 75% of all worldwide procedures;
  3. Infibulation which is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris; Type III accounts for 25% of all worldwide procedure and is the most severe form of FGM;
  4. All other types of harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.


4. Local Terms for the Procedure

These include tahara in Egypt; tahur in Sudan; and bolokoli in Mali, which are words synonymous with purification.

Several countries refer to Type 1 FGM as sunna circumcision* (which means usual practise/tradition in Islam). It is also known as kakia, and in Sierra Leone as bundu, after the Bundu secret society.**

Type III FGM (infibulation) is known as "pharaonic circumcision" in Sudan, and as "Sudanese circumcision" in Egypt. ***

* Rahman, A and Toubia, N: Female Genital Mutilation – A Practical Guide to Worldwide Laws and Policies (Zed Books, 2000)

**Kasinga, Fauziya and Bashir, Layli Miller: Do They Hear You When You Cry (1998)

*** Elmusharaf, S.; Elhadi, N; Almroth, L: Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study (2006)


5. Who Practices It

FGM is practised around the world in various forms across all major faiths. Today it has been estimated that currently, about three million girls, most of them under 15 years of age, undergo the procedure every year. The majority of FGM takes place in 29 African and Middle Eastern countries, and also includes other parts of the world; Middle East, Asia, and in industrialised nations through migration which includes; Europe, North America, Australia and New Zealand. Globally the WHO estimates that between 100 and 140 million girls and women worldwide have been subjected to one of the first three types of FGM.

There are substantial populations of people in the UK from countries where FGM is endemic; in London, Liverpool, Birmingham, Sheffield, Cardiff and Manchester (HM Government 2006).

It should be noted that FGM is not purely an African issue, although there is greater prevalence there. In the UK FGM has been found among Kurdish communities; Yeminis, Indonesians and among the Borah Muslims.

It is important to recognise that the migrant populations may not practice FGM to the same level as their country of origin; a migrant’s reason for being in the UK may well be avoidance of FGM and second and third generation migrant populations may have very different attitudes towards FGM than their parents. However that same second or third generation may often be the children or adults at greatest risk of having the procedure carried out.

5.1 Estimated prevalence of FGM

FGM’s prevalence in the UK is difficult to estimate because of the hidden nature of the crime. However, a report published in July 2014 by Equality Now and City University has estimated that:

  • Approximately 60,000 girls aged 0-14 have been born in England and Wales to mothers who had undergone FGM;
  • Approximately 103,000 women aged 15-49, and approximately 24,000 women aged 50 and over who have migrated to England and Wales, are living with the consequences of FGM. In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM;
  • Combining the figures for the three age groups, an estimated 137,000 women and girls with FGM, born in countries where FGM is practised, were permanently resident in England and Wales in 2011.

Information is now regularly being collected to gain a national picture of the prevalence of FGM by The Health & Social Care Information Centre (HSCIC). The “FGM Prevalence Dataset” (ISB 1610) provides data from acute hospital providers in England.

It is an aggregated return of the incidence of FGM including women who have been previously identified and are currently being treated (for FGM related or non FGM related conditions as at the end of the month) and newly identified women within the reporting period. In October 2014 the first prevalence figures were published:

Key facts

For the month of September 2014:
125 of the 160 eligible acute trusts in England submitted signed off data.
1,279 active cases (i) and 467 newly identified (ii) cases of FGM were reported nationally.

Definitions

Patients identified as having a history of any FGM type prior to the reporting period and still being actively seen/treated for FGM-related conditions or any other non-related condition at the end of the month. Note: does not include those patients within NUMBER OF PATIENTS WITH FGM NEWLY IDENTIFIED IN REPORTING PERIOD (i.e. identified within this reporting period).

Patients first identified during the reporting period as having undergone FGM. This will include those diagnosed/identified within the provider within the month.

Figure 1: The % prevalence rates of FGM in girls and women aged 15-49 years within the top 15 practicing countries.

Rank Country Continent Survey Type Year %

1

Somalia

Africa

MICS*

2006

97.0

2

Egypt

Africa

DHS**

2005

95.8

3

Guinea

Africa

DHS

2005

95.6

4

Sierra Leone

Africa

MICS

2005

94.0

5

Djibouti

Africa

MICS

2006

93.1

6

Sudan

Africa

Local Survey***

2006

89.3

7

Eritrea

Africa

DHS

2002

88.7

8

Mali

Africa

DHS

2006

85.2

9

Gambia

Africa

MICS

2005-6

78.3

10

Ethiopia

Africa

DHS

2005

74.3

11

Burkina Faso

Africa

MICS

2006

72.5

12

Mauritania

Africa

MICS

2007

72.2

13

Guinea-Bissau

Africa

MICS

2006

44.5

14

Ivory Coast

Africa

MICS

2006

36.4

15

Kenya

Africa

DHS

2003

32.2

It important to understand that countries with a lower prevalence rate could have high rates of FGM within the various ethnic groups such as Iraq, and Iran where overall prevalence rates are low but within the Kurdish communities the rate of FGM is high. Equally in India and Pakistan prevalence rates within the Muslim Bohra community is over 90%.

*The Multiple Indicator Cluster Surveys (MICS) are a survey program developed by the United Nations Children's Fund to provide internationally comparable data on the current situation for children and women in developing nations throughout the World

** Demographic and Health Surveys. The 'Measure DHS Project' is a project which measures health and population statistics within developing nations. DHS is ran by Macro International, Inc. and is funded by the United States Agency for International Development (USAID) with contributions from other donors such as UNICEF, UNFPA, WHO, UNAIDS.

***The Sudan data comes from the 'Sudan Household Health Survey'.


6. Religion and FGM

Muslim scholars have condemned the practice and are clear that FGM is an act of violence against women. Furthermore, scholars and clerics have stressed that Islam forbids people from inflicting harm on others and therefore most will teach that the practice of FGM is counter to the teachings of Islam. However, many communities continue to justify FGM on religious grounds. This is evident in the use of religious terms such as “sunnah” that refer to some forms of FGM (usually Type I).

FGM is not practised amongst many Christian groups except for some Coptic Christians of Egypt, Sudan, Eritrea and Ethiopia. The Bible does not support this practice nor is there any suggestion that FGM is a requirement or condoned by Christian teaching and beliefs.

FGM has also been practiced amongst some Bedouin Jews and Falashas (Ethiopian Jews) and again is not supported by Judaic teaching or custom.


7. Communities At Risk of FGM in the UK

UK communities that are most at risk of FGM include Kenyans, Somalis, Sudanese, Sierra Leoneans, Egyptians, Nigerians, Eritreans and Ethiopians. However women from non-African communities that are at risk of FGM include Yemeni, Kurdish (Iraqi, Iranian and Turkish country of origin), Indonesian, Malaysian, Pakistani women and Indian women (Muslim Bohra Community).


8. Health Impact

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.

Many women appear to be unaware of the relationship between FGM and its health consequences; in particular the complications affecting sexual intercourse and childbirth which can occur many years after the mutilation has taken place.

8.1 Health Impact Complications Are Common and Can Lead to Death

The highest maternal and infant mortality rates are in FGM-practicing regions*. The actual number of girls who die as a result of FGM is not known. However, in areas of Sudan where antibiotics are not available, it is estimated that one-third of the girls undergoing FGM will die.**

8.2 Immediate Physical Problems

  • Intense pain and/or haemorrhage that can lead to shock during and after the procedure;
  • Occasionally death;
  • Haemorrhage that can also lead to anaemia;
  • Wound infection, including tetanus. Tetanus is fatal in 50 to 60 percent of all cases;***
  • Urine retention from swelling and/or blockage of the urethra;
  • Injury to adjacent tissues;
  • Fracture or dislocation as a result of restraint;
  • Damage to other organs.

A 1991 survey of 1,222 women in four Kenyan districts indicated that 48.5% of the women experienced haemorrhage, 23.9% infection, and 19.4% urine retention at the time of the FGM operation.****

* Sudan Household Health Survey

**Women's Policy: Female Genital Mutilation - Women's Health Equity Act of 1996: Legislative Summary and Overview (July 12, 1996)

***Institute for Development Training: Health Effects of Female Circumcision: A Training Course in Women's Health, Chapel Hill, NC: Institute for Development Training (1986)

****Maendeleo Ya Wanawake Organization and the Program for Appropriate Technology in Health: Quantitative Research Report on Female Circumcision in Four Districts in Kenya (Nairobi, 1993)


9. Long-term Health Implications

In the UK, girls and women affected by FGM will manifest some of these long term health complications. They may range from mild to severe or chronic.

  • Excessive damage to the reproductive system;
  • Uterine, vaginal and pelvic infections;
  • Infertility;
  • Cysts;
  • Complications with menstruation;
  • Psychological damage; including a number of mental health and psychosexual problems, e.g. depression, anxiety, post traumatic stress, fear of sex* **. Many children exhibit behavioural changes after FGM, but problems may not be evident until adulthood;
  • Abscesses;
  • Sexual dysfunction;
  • Difficulty in passing urine;
  • Increased risk of HIV transmission/Hepatitis B/C – using same instruments on several girls;
  • Increased risk of maternal and child morbidity and mortality due to obstructed labour. Women who have undergone FGM are twice as likely to die during childbirth and are more likely to give birth to a stillborn child than other women.*** Obstructed labour can also cause brain damage to the infant and complications for the mother (including fistula formation, an abnormal opening between the vagina and the bladder or the vagina and the rectum, which can lead to incontinence).

* British Medical Association - Female Genital Mutilation: caring for patients and safeguarding children (2011)

** Toubia, N. Female Genital Mutilation: A Call for Global Action, Women, Ink (New York,1993)

*** Koso-Thomas, O: The Circumcision of Women: A Strategy for Eradication (Zed Books, London, 1987)


10. The Myths of why Circumcision is Necessary Vary Between Ethnic Groups

Among some of the more common myths are:

Myth

Fact

Circumcision protects the sexual morality of girls before marriage and women within marriages. Women that aren’t circumcised are not in control of their sexual urges and are likely to be sexually promiscuous

FGM makes no difference to a woman’s libido but usually prevents her from enjoying sex. Pre or extra marital sex also occurs in women who have been mutilated.

If the clitoris is not cut it will harm the husband during intercourse

The clitoris gives a woman pleasure and does not cause harm to the husband but can enhance the sexual experience for both of them.

Girls that are not circumcised do not reach puberty, nor do they develop female shapes and are not able to get pregnant.

Girls reach puberty and conceive in communities not practising FGM.  FGM can lead to infertility.

Babies that are in contact with the clitoris during birth will die.

The clitoris causes no harm to the newborn baby.

If the clitoris is not removed, it will continue to grow until it develops into the size of a penis.

The clitoris stops growing after puberty.

If a woman does not undergo FGM her genitals will smell

Infection from any type of FGM can cause a smell.


11. Common Justifications for FGM

See also Forward UK website.

  • Maintain family honour and a girl’s virginity;
  • Improving a girls marriage prospects;
  • Protecting perceived cultural and religious beliefs and traditions.

In some communities the bridal price for an uncircumcised girl is lower or non-existent, bringing an economic reason for keeping the custom. For these reasons alone, many mothers and grandmothers are the advocates of FGM for their young daughters or granddaughters.

Some men are brought up to believe that they have no way of knowing that their bride is a virgin unless she is circumcised. A bride who is not a virgin has little value in many African communities.

In some communities, the uncircumcised are considered unclean and are not permitted to enter a part of a house where worship takes place. They may be excluded from prayer and other religious rites. This can have an emotional impact on uncircumcised adults and children.

FGM is a form of child and adult physical abuse. However, the issue is complex and despite its very severe health consequences, some parents and others who want their daughters to undergo this procedure do not intend it, or regard it, as an act of abuse.

FGM is a social norm and communities are socialised into accepting FGM as essential and those who fail to conform may be ostracised or stigmatised. In general FGM aims to promote acceptance and sense of belonging.


12. Risk Factors that Heighten the Girl’s/Woman’s Risk of Being Subjected to FGM

  • The family comes from a community that is known to practice FGM;
  • 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 who has a relative who has already undergone FGM must be considered to be at risk;
  • The socio-economic position of the family and the level of integration within UK society can increase risk.


13. Protective Legislation

See also Appendix 2: Legislation on Female Genital Mutilation.

FGM has been a criminal offence in the UK since The Prohibition of Female Circumcision Act 1985.

The Act was repealed by The Female Genital Mutilation Act 2003 and closed a loophole which enabled victims to be taken outside of the jurisdiction for the purposes of FGM, without sanction. The Female Genital Mutilation Act 2003 made it unlawful for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where FGM is legal. This legislation was designed to prevent families and carers from taking girls abroad to undergo the procedure. The Act increased the maximum penalty for being found guilty of FGM from 5 to 14 years imprisonment. The Female Genital Mutilation Act 2003 also made it a criminal offence to re-infibulate following an FGM procedure.

There are new legislative measures being brought through the Serious Crime Act 2015 which will strengthen the legislative framework around tackling FGM. The Act created a new duty of Mandatory Reporting of Female Genital Mutilation for regulated professionals in health and social care professions, and teachers in England and Wales which came into force on the 31st October 2015. The changes also include introducing ‘habitual UK resident’ rather than ‘permanent UK resident’, and introducing FGM Protection Orders (similar to Forced Marriage Protection Orders).

FGM is considered to be a form of child abuse (it is categorised under the headings of both Physical Abuse and Emotional Abuse). A local authority may exercise its powers under Section 47 of the Children Act 1989 if it has reason to believe that a child is likely to suffer or has suffered FGM. Under the Children Act 1989, local authorities can apply to the Courts for various Orders to prevent a child being taken abroad for mutilation.

FGM is also an abuse of female adults usually categorized under honour based violence and domestic abuse definitions. Where a female adult is also defined as an Adult at Risk, additional support mechanisms would be available through local social care teams and adult safeguarding processes.

Private law remedies can be used as a form of legal protection. For example a Prohibited Steps Order under Section 8 Children Act 1989 can be used to prevent a child being taken abroad or from having the procedure. A Non Molestation Order under Part IV of the Family Law Act 1996 may also be used as protection for the child or adult. The Domestic Violence Crime and Victims Act 2004 make the breach of a Non Molestation Order a criminal offence.

It may be possible for victims of FGM to claim compensation from the Criminal Injuries Compensation Authority. The injuries must be reported to the police.

The Police have Police Protection powers where there is reasonable cause to believe that a child or young person, under the age of 18 years, is at risk of Significant Harm. A police officer may (with or without the cooperation of social care) remove the child from the parent and use the powers for ‘police protection’ (section 46 of the Children Act 1989) for up to 72 hours. The Local Authority has further powers under Section 44 of the Children Act 1989. Under this section, the Local Authority may apply for an Emergency Protection Order (EPO). The Order authorizes the applicant to remove the girl and keep her in safe accommodation for up to 8 days. This Order is often sought to ensure the short term safety of the child.

An EPO can be followed by an application from the Local Authority for a Care Order, Supervision Order or an Interim Order (sections 31 and 38 of the Children Act 1989). Without such an application, the EPO will lapse and the local authority will no longer have Parental Responsibility for the child.

There will be cases where a Care Order is not appropriate, possibly because of the age of the young person. A Local Authority may ask the Court to exercise its inherent jurisdiction to protect the young person.

Once a young person has left or been removed from the jurisdiction, the options available to police, Local Authority and other services become more limited. In such situations an application may be made to the High Court to make the young person a Ward of Court and have them returned to the UK.

When a British national seeks assistance at a British Embassy or High Commission overseas and wishes to return to the UK, the Foreign and Commonwealth Office (FCO) will do what it can to assist or repatriate the individual.

International legislation

There are two international conventions containing articles which can be applied to FGM. Signatory states, including the UK, have an obligation under these standards to take legal action against FGM.  These include: The UN Convention on the Rights of the Child and The UN Convention on the Elimination of All Forms of Discrimination against Women. FGM breaches several of these rights.


14. National Developments

  • A pocket guide to the UK law on female genital mutilation is available to girls at risk to help them speak out against the practice. The leaflet a Declaration against Female Genital Mutilation (FGM) for Families and Girls is designed to slip in the back of a passport allowing girls to present it as a formal document to friends or family reminding them that FGM is against the law in the UK. It also sets out what the penalties are for offenders, including a maximum fourteen year custodial sentence, as well as advice on help and support;
  • Phone line The NSPCC has launched a 24hour helpline to protect children and young people affected by FGM Anyone who is worried about a child being or has been a victim of FGM can contact 0800 028 3550 for information and support;
  • Revised (2015) statutory guidance Keeping Children Safe in Education includes advice on FGM. The Education Secretary has written to all schools in England to ask them to help protect girls from female genital mutilation (FGM);
  • The government has appointed a consortium of leading anti-FGM campaigners to deliver a global campaign to end FGM. The consortium will work across Africa to bring about a transformation in attitudes towards FGM.


Section B: Practice Guidance


15. Safeguarding: Actions to be Taken by Single and Multi-Agency Workforce

There are three circumstances relating to FGM which require identification and intervention:

  • Where someone is at risk of FGM;
  • Where someone has undergone FGM;
  • Where a prospective mother has undergone FGM.

Professionals and volunteers in most agencies have little or no experience of dealing with female genital mutilation. Encountering FGM for the first time can cause people to feel shocked, upset, helpless and unsure of how to respond appropriately to ensure that a child, and/or a mother/any female adult, is protected from harm or further harm. The following agency specific guidance may help support the professional.

15.1 When someone is at risk of FGM

Indicators that FGM may soon take place:

  • 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 (usually within the school summer holiday) to her country of origin or another country where the practice is prevalent;
  • 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;

15.2 Where someone has undergone FGM

Signs that FGM has taken place:

  • Prolonged absence from school with noticeable behaviour changes on the girl's return;
  • Longer/frequent visits to the toilet particularly after a holiday abroad, or at any time;
  • Some girls may find it difficult to sit still and appear uncomfortable or may complain of pain between their legs;
  • Some girls may speak about ‘something somebody did to them, that they are not allowed to talk about';
  • A professional overhears a conversation amongst children about a `special procedure’ that took place when on holiday;
  • Young girls refusing to participate in P.E regularly without a medical note;
  • Recurrent Urinary Tract Infections (UTI) or complaints of abdominal pain.

If you identify a female under 18 has had FGM contact the police via 101 (see Appendix 10/10a: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care).

Any information or concern that a female is at immediate risk of, or has undergone, FGM should result in a safeguarding referral to the Local Authority Social Care and the Public Protection Investigation Unit. Immediate danger dial 999.


16. Procedure Within Social Care for Safeguarding Children, and Adults at Risk of or who have Undergone FGM

When information is received by Social Care, the Referral must be discussed with the IFD/MASH Manager who will subsequently inform the appropriate team in line with local policies and procedures. In all cases, professionals should not discuss the referral with the parents/carers/family until a multi-agency action plan has been agreed.

On receipt of referral, a Strategy Meeting must be called within two working days or sooner as directed by the duty care Manager – see Strategy Discussions/Meetings and Section 47 Enquiries as Part of Social Work Assessment of Needs and Strengths Procedure.

If a referral is received concerning one female in a family, consideration must be given to whether other females in that family are also at similar risk. There should be consideration of other females from other associated families once concerns are raised about an incident or the perpetrator of FGM.

In response to the initial referral, a senior social care representative will convene and chair a Strategy Meeting. It will be the senior social care representative’s responsibility to access relevant information on the practice, and identify specialist help within Merseyside and nationally (Nestac) to assist in the sensitive planning of enquiries. Sourcing specialists should not stop or delay any initial intervention from taking place.

See also Appendix 3: Useful Contacts.

See Appendix 10/10a: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care.

The Strategy Meeting should include:

  • A senior social care representative, to chair and co-ordinate the meeting;
  • The allocated social worker;
  • A senior member of the Family Crime Investigation Unit (D/Sgt);
  • A legal representative should be available for consultation;
  • Appropriate health representation:
    • Designated/Named Dr for Safeguarding Children;
    • FGM consultant (Obstetrics & Gynaecology).
  • A specialist in FGM from the statutory or voluntary sector; (Specialist Midwife Arrowe Park Hospital);
  • For children, the lead health professional;
  • Any other professional deemed appropriate by the social care manager.

The Strategy Meeting must establish whether parents or the girl/woman has had access to information about the harmful aspects of FGM and the law in the UK. If not this information should be made available to them.

The Strategy Meeting should consider the need for medical assessment and / or therapeutic services for the female.

An FGM Strategy Meeting should cover, at a minimum, the following issues:

  • Family history and background information;
  • Scope of the investigation, what needs to be addressed and who is best placed to do this;
  • Roles and responsibilities of individuals and organisations within the investigation, with particular reference to the role of the police;
  • If FGM has already taken place, the police should log this as a crime (if this has not already been done) and allocate a crime number which then needs to be fed back to the referrer (This is a new requirement of the Serious Crime Act 2015);
  • As to whether a medical examination/treatment is required and if so who will carry out what actions, by when and for what purpose;
  • What action may be required if attempts are made to remove the child / adult from the country;
  • Identify key outcomes for the child/adult and their family and implications and impact on the wider community.


17. Assessment

See also Single Assessment Policy and Guidance (This links directly to the Wirral Children's Services Procedures Manual).

Where a female has been identified as at risk or has been mutilated, it may not be appropriate to take steps to remove the child or a Vulnerable Adult from an otherwise loving family environment. Experience has shown that often the parents themselves can experience pressure to agree to FGM and see it as the best thing they can do for their daughter’s marriageable status. It is also important to recognise that those seeking to arrange the mutilation are unlikely to perceive it to be harmful and, on the contrary, believe it to be legitimised by longstanding traditions. Therefore it is essential that when first approaching a family about the issue of FGM a thorough assessment should be undertaken, with particular focus on:

  • Parental/carer attitudes and understanding about the practice and where appropriate;
  • Child/young person/Vulnerable Adult’s knowledge, understanding and views on the issue. For Vulnerable Adults a Capacity assessment will be required to see whether the legislation of the Mental Capacity Act 2005 applies.

Every attempt should be made to work with parents/carers on a voluntary basis to prevent abuse. It is the duty of social care to look at every possible way that parental/family co-operation can be achieved.  However, the child’s/adult’s best interest is always paramount.

Some thought and consideration should be given to where the assessment is undertaken. For example it may be beneficial to talk to the family/affected female outside the home environment to encourage them to talk freely and acknowledge the impact FGM would have.

An interpreter must be used in all interviews with the family, and more importantly the affected female, if their first language is not English. The interpreter must not be a family relation and must not be known by the family. The interpreter should be female.

In cases where an interpreter is not used, and English is not the female's first language, the reasons for not using an interpreter must be recorded, as part of the assessment.

Appropriate communication aids must be offered for affected females who have difficulties communicating due to disability/illness and this should be documented within the record.

All interviews should be undertaken in a sensitive manner, and should only be carried out once.

With regards to children - parental consent and the child's agreement should be sought before interviews take place. All attempts must be made to work in partnership with parents, and to endeavour for parents to retain full parental rights in these circumstances; where consent is not given, legal advice should be sought.

Adults who are vulnerable need to be interviewed alone and a Capacity assessment completed. Capacity is decision-specific – the decisions to be assessed may include whether they can consent to travel abroad when there is a risk of their family arranging for them to undergo FGM. If they are not able to make a decision or safeguard themselves, then a Best Interests decision should be made. When an adult lacks Capacity and needs to be safeguarded the Local Authority can apply to the Court of Protection to give them powers to protect an individual. Vulnerable Adults who are assessed as having Capacity but are at risk of coming to harm can be protected using the powers contained within the inherent jurisdiction of the high court. Other adults may be protected for example through non molestation orders.

The Strategy Meeting should reconvene as agreed to discuss the outcomes and recommendations from the assessment and continue to plan the protection of the female.  At all times the primary focus is to prevent the female undergoing any form of FGM by working in partnership with parents, carers and the wider community to address risk factors. However where the assessment identifies a continuing risk of FGM then, the first priority is protection and the local authority should consider the need for:

If a Child Protection Case Conference is deemed necessary and a Child Protection Plan is to be formulated, the Category of Abuse or Neglect should be Physical Abuse.

For Adults, a Safeguarding Plan will be formulated and monitored in accordance with the WSAPB Safeguarding Procedures (See Appendix 8: Decision-Making and Action Flowchart for Safeguarding Adults at Risk).

Following all enquiries into FGM, regardless of the outcome, consideration must be given to the therapeutic/counselling needs of the female and the family.

Medical examination, if necessary must only be undertaken with the child's and the parents' consent or the consent of the adult female. If the adult lacks the Capacity to consent to the examination; then a Best Interests decision can be made for them. Where parents do not consent, legal advice should be sought.

In the majority of cases there should only be one medical examination of the child or woman. In cases where subsequent medicals are required, clear reasons for this decision should be recorded as part of the assessment.

If a medical/surgical procedure is required, and parents refuse consent, legal advice must be sought immediately.

Children in Immediate Danger

Where the child appears to be in immediate danger of FGM and parents cannot satisfactorily guarantee that they will not proceed with it, and then an Emergency Protection Order should be sought

When the immediate danger to the child/young person has been addressed, a Strategy Meeting should be convened.

Adults in Immediate Danger

Adults in immediate danger – When an adult is in immediate danger, contact the police. Protection can also be obtained by an emergency order by the Court of Protection where an adult lacks Capacity under the Mental Capacity Act 2005. Where an adult who lacks Capacity is being put under duress to comply with a situation, seek immediate legal advice; in some instances it will be necessary to approach the High Court for an emergency interim order.

If there is no evidence of risk

If the safeguarding enquiry concludes that there is no clear evidence of risk to the female then Social Care will:

  • Consult the female's GP and a child’s Health Visitor or School Nurse about this conclusion and invite her/him to notify Social Care if any further information challenges it;
  • Notify appropriate professionals involved with the family of the enquiry and the stage at which it was concluded;
  • Inform the family and the referrer that the enquiry has been concluded;
  • Consider whether any child may be a Child in Need or if the adult requires a community care assessment and, if so, offer appropriate services and offer the family/carers any appropriate support services.

If it appears that no other females are at risk

  • Social Care will take no further action other than to liaise with health services to review any health concerns for the female who has undergone the procedure;
  • If the FGM seems to have been performed in the UK, the police will seek information for the possible prosecution of the perpetrator;
  • Social Care will notify the female's GP and a child’s Health Visitors/School Nurse and invites her/him to notify them if any changes in the situation give rise to further concerns, e.g. the mother giving birth to further girls;
  • If there are concerns about younger girls in the family, Children’s Services must convene a Strategy Meeting as soon as possible to discuss whether any protective action can be taken.


18. Procedure for Safeguarding Children and Adults from FGM within Education / Leisure and Community and Faith Groups

See also Keeping Children Safe in Education.

Teachers, other school staff, volunteers and members of community groups may become aware that a female is at risk of FGM (see Section 15.1, When someone 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 or adult in the family has already undergone FGM.

A professional, volunteer or community group member who has information or suspicions that a female is at risk of FGM should consult with their agency or group’s designated safeguarding adviser (if they have one) and should make an immediate Referral to LA Social Care and Family Crime Investigation Unit.

The Referral should not be delayed in order to consult with the designated safeguarding adviser, a manager or group leader, as multi-agency safeguarding intervention needs to happen quickly.

Once concerns are raised about FGM there should also be consideration of possible risk to other females in the practicing community.


19. Procedure for Safeguarding Children and Adults from FGM within the Health Sector

Health professionals in GP surgeries, sexual health clinics, Women’s Health, A&E 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 practicing FGM. Health Professionals should remember that some females may be traumatised from their experience and have already resolved never allow their daughters to undergo this procedure.

Health Professionals should deal with FGM in a sensitive and professional manner, and not exhibit signs of shock when treating patients affected by FGM. They should ensure that the mental health needs of a patient are taken into account.

Guidance on Recording FGM Information

When a patient is treated by an acute hospital, and FGM is identified, this should always be recorded in the patient clinical record, as part of the full clinical history. This is in accordance with the multi-agency guidelines.

In Wirral it has been agreed that in certain departments, it is routine to enquire whether a woman has FGM, namely maternity, family planning clinics, sexual health services, obstetrics and gynaecology departments, and urology although this list is not exhaustive.

The suggested “Trigger question” is: “Have you had any female circumcision/cutting or piercing, or any surgery to your genital area?” (Use appropriate language depending on the client’s needs). If there is a positive response to this question further clarification should be sought see Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults.

FGM may be identified in many other clinical settings, with those of note being Accident & Emergency, mental health services. However, in all circumstances staff must act upon warning signs such as a history of repeat Urinary Tract Infections, a planned holiday to countries / areas of high prevalence for a girl to undergo a special ceremony, or a family history of FGM.

The many warning signs which should be acted upon are to be found in the multi-agency guidance, Intercollegiate Report and other Royal College publications which may lead to identifying FGM.

Mandatory recording and reporting for Healthcare providers

From the 31st October 2015, regulated professionals in health and social care professions and teachers in England and Wales have a duty to report ‘known’ cases of FGM in under 18s which they identify in the course of their professional work to the police.

‘Known’ cases are those where either a girl informs the person that an act of FGM – however described – has been carried out on her, or where the person observes physical signs on a girl appearing to show that an act of FGM has been carried out and the person has no reason to believe that the act was, or was part of, a surgical operation within section 1(2)(a) or (b) of the FGM Act 2003.

A failure to report the discovery in the course of their work could result in a referral to their professional body. The Home office has produced guidance Mandatory Reporting of Female Genital Mutilation – procedural information to support this duty.

It is mandatory for health professionals to record the presence of FGM in a patient’s healthcare record whenever it is identified through the delivery of NHS healthcare.

The patient’s health record should always be updated with whatever discussions or actions have been taken. If the patient has had FGM, referral to a specialist FGM clinic should always be considered. In addition to any referral to social services and/or police, and this being recorded in the medical record appropriately, if a patient is identified as being at risk of FGM, this information must be shared with the GP and health visitor, as part of child safeguarding actions.

Each health organisation will need to introduce methods of collection and issue clear instructions on how and where to record FGM within their own systems with immediate effect, and consider how best to support teams, through either additional professional training and/ or guidance.

Health care providers are encouraged to consider an implementation plan across their organisation, which considers what steps, can be taken to monitor reporting compliance.

It will need to be determined locally how the collection of information to support the FGM Prevalence Dataset will be managed locally, (including any data capture mechanisms), the main impact on staff and the organisation will be; communicating to all staff about the mechanisms that will be used to capture the relevant data and how this will be undertaken locally. This will include where the tools are located and how these will be accessed.

Since April 2014, it is be a mandatory requirement for NHS hospitals to record:

  • If a patient has had FGM;
  • If there is a family history of FGM;
  • If an FGM-related procedure has been carried out on a women - (deinfibulation).

Since September 2014, all acute hospitals must report this data centrally to the Department of Health on a monthly basis. By the end of 2015 this same duty will extend to Mental Health Trusts and GP practices. This is part of a wide ranging programme of work in development to improve the way in which the NHS will respond to the health needs of girls.

GPs, and Practice Nurses: A question about FGM could be asked when a routine new patient history is being taken from girls and women. Information on FGM could be included in a welcome pack which is given to new patients. In addition those that attend for health checks or travel vaccinations from affected communities could be asked about FGM and advised about its health impacts.

GP’s and Practice Nurses should be vigilant to any health issues such as resistance to partake in cervical smear testing. When a female attends the practice presenting with symptoms related to urology/gynaecology/sexual health problems the FGM trigger question must be asked and the pathway in Appendix 11: Flowchart for GP Practice Staff followed.

In accordance with the new mandatory reporting requirements; The GP/Nurse should document in the patients record if a female patient has:

  • Undergone FGM;
  • What type of FGM;
  • If there is a family history of FGM;
  • If any FGM-related procedure has been carried out on a women - (including deinfibulation).

Further clarification questions (see Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults) should be asked to determine if there are any safeguarding issues. The risk assessment (Appendix 9: FGM Safeguarding and Risk Assessment Guidance) will help to determine the most appropriate referral pathway. They should be offered/referred for additional support. Document any advice or leaflets provided. Professionals should consult with their child protection adviser and with the IFD/MASH about making a referral to them.

In all cases of FGM identified (whether there are safeguarding issues identified or not), the information should be submitted via the Datix incident reporting system this will enable the practice to receive support if required, it will also enable the anonymised data to be uploaded to the HSCIC dataset (New legal duty 2015).

Where a prospective mother has undergone FGM

Midwives and nurses should be aware of how to care for women and girls who have undergone FGM during the antenatal, intrapartum and postnatal periods. They should discuss FGM at the initial booking visit to all women. They should document if the woman has:

  • Undergone FGM;
  • What type;
  • If there is a family history of FGM;
  • If any FGM-related procedure has been carried out on a women - (including deinfibulation).

They must also document what plan is in place for delivery. Document that the woman has been told about the health risks and the law and given a leaflet in an appropriate language (if available) that explains the health risks of FGM, the law and local support services. All this information should be shared with appropriate health professionals (including the GP and the Health Visitor). Professionals should consult with their safeguarding leads for guidance and support (see Appendix 5: FGM Flowchart for Arrowe Park Staff).

If a girl or woman who has been de-infibulated requests re-infibulation/re-suturing after the birth of a child, and/or the child is female or there are daughters in the family, health professionals should consult with their safeguarding leads and with LA Children’s Social Care about making a referral to them. Re-infibulation is illegal in the UK.

Whilst the request for re-infibulation is not in itself a safeguarding issue, the fact that the girl or woman is apparently not wanting/able to comply with UK law due to family pressure and / or does not consider that the procedure is harmful raises concerns in relation to female children she may already have or may have in the future.

Some women may be pressured to ask for re-infibulation by their partner. This would come under the category of Domestic Violence and Abuse and local protocols must be followed – see Responding to Children and Young People who are at Risk from Domestic Violence and Abuse - Policy and Guidance for Professionals.

Health visitors are in a good position to reinforce information about the health consequences and the law relating to FGM. Health visitors should discuss the risks of FGM and document the parent’s response and the advice and any leaflets given to explain the law relating to FGM. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made. Professionals should consult with their safeguarding leads about making a referral to social care and inform the family’s GP of the referral.

Midwives and Health visitors should seek to record this information to ensure that all relevant health professionals are aware of the FGM incident and any concerns for female children. (See Appendix 5: FGM Flowchart for Arrowe Park Staff and Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff).

School Nurses are in a good position to reinforce information about the health consequences and the law relating to FGM. The school nurse should work closely with the child’s school supporting them with any concerns. The school nurse should be vigilant to any health issues such as recurrent urinary tract infection that may indicate FGM has been undertaken. If the school nurse has contact with any family that originates from a country where FGM is practised, they should discuss the risks of FGM and document the parent’s response along with any advice and leaflets provided to explain the law relating to FGM. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made. (See Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff).

Mental Health Practitioners need to be aware of the risks associated with FGM if girls/women from FGM practising countries attend, particularly with Post Traumatic Stress Disorder for example. If a disclosure is made regarding FGM, this should be documented and professionals should consult with their child or adult safeguarding lead about the appropriate course of action. (See Appendix 7: FGM Flowcharts for Mental Health Staff).

Emergency Departments and Walk-in Centres need to be aware of the risks associated with FGM if girls/women from FGM practising countries attend, particularly with urinary tract infections (UTIs), menstrual pain, abdominal pain, or altered gait for example. Their assessment should include assessing the risks associated with FGM. This should be documented and professionals should consult with their child or adult safeguarding lead about making a referral to social care. (Appendix 5: FGM Flowchart for Arrowe Park Staff and Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff).

See Section 12, Risk Factors that Heighten the Girl’s/Woman’s Risk of Being Subjected to FGM.

Health Services for Asylum Seekers & Refugees: Where initial health assessments for asylum seekers and refugees are undertaken, the health professional can introduce a discussion about FGM. They should document if the female has undergone FGM and what type. They must also document that the woman has been told about the law and given a leaflet in an appropriate language (if possible) that explains the risks of FGM, the law and local support services. All this information should be shared with appropriate health professionals (GP, Health Visitor etc). Professionals should consult with their safeguarding lead about making a referral to Social Care.


20. Procedures for Police Officers/Police Staff

There is a risk that the fear of prosecution of family members may prevent those concerned from seeking help and support from relevant agencies and in particular medical help as a result of long term complications caused by FGM.

In many communities where the practice of FGM is prevalent, children who may have undergone/be due to undergo FGM may accept it as part of their religious/cultural upbringing due to a lack of understanding of the potential criminal offence being committed and future health complications that may prevail.

Police should work with other agencies to obtain relevant support and guidance for the victim. Where relevant they can work with other professionals to prevent FGM by educating parents/carers about the legislation relating to FGM and possible consequences.

Police staff working with Children - If a girl is at risk of undergoing or has already undergone FGM, the duty inspector must be made aware and support should be sought from the Public Protection Investigation Unit where the victim resides or in their absence the CID. Relevant safeguards should be put in place immediately in order to prevent any risk of harm to the child.

  • Risk to any other children should be considered and acted upon immediately;
  • The investigation should be dealt with as a child safeguarding issue taking cognisance of any honour-based violence issues.

If any officer believes that the girl could be at immediate risk of Significant Harm, they should consider the use of Police Protection powers under section 46 of the Children Act 1989.

The Public Protection Investigation Unit should commence Strategy Meetings with Children’s Services and relevant agencies.

If it is believed or known that a girl has undergone FGM, a Strategy Meeting must be held as soon as practicable (and in any case within two working days) to discuss the implications for the child and the coordination of the criminal investigation.

A second Strategy Meeting should take place within ten working days of the initial Referral.

Children and young people should be interviewed under the relevant procedure/guidelines (e.g. Achieving Best Evidence) to obtain the best possible evidence for use in any prosecution.

A medical examination should be conducted by a qualified doctor trained in identifying FGM (Dr Fiona Reid) at St Marys Hospital, Manchester have in house specialists. Consideration should be given as to the effective use of a specialist FGM nurse. In all cases involving children, an experienced paediatrician should be involved in setting up the medical examination (Dr Gail Busby at St Mary’s Hospital). This is to ensure that a holistic assessment which explores any other medical, support and safeguarding needs of the girl or young woman is offered and that appropriate referrals are made as necessary.


21. When an Adult Female has Undergone/is about to Undergo FGM

These incidents should be dealt with by the Public Protection Investigation Unit as a form of Domestic Violence and Abuse/Honour Based Violence incident. Relevant risk assessments (such as the domestic abuse risk indicator checklist) and safeguards should be put in place and referrals to partner agencies made as appropriate in order to ensure the victim receives all relevant support.

Part of the investigation should entail identification of any persons who seek to aide, abet or procure someone to commit FGM. Contrary to Section 1 and 2 of the Act and with a view to identifying other victims.

Early Crown Prosecution investigative advice will be sought by the Police under the FGM Protocol between Merseyside Police and CPS Mersey-Cheshire Dec 2013.

If the adult female is an Adult at risk, the adult safeguarding process should be initiated and an urgent Strategy Meeting arranged. Note however if the adult has Capacity and does not give consent the safeguarding process would not be taken forward unless there was a wider ‘public interest’ element to the case. Immediate protection may be secured through the Court of Protection or the High Court.


22. Links to Forced Marriage and Domestic Violence and Abuse

There can be a link between FGM and Forced Marriage, particularly in adults/teenagers when the woman may be mutilated shortly before the marriage. Professionals should be alert to this and consider a joint response to the Forced Marriage through local protocols alongside protection from FGM – see Wirral Honour Based Violence and Forced Marriage Protocol.

A woman/girl who has been subjected to FGM may have numerous gynaecological problems and this may make consummation of her marriage or sexual activity with her partner very uncomfortable/painful/impossible. In some communities it is expected that the man will ‘open’ the woman/girl before the wedding following type III FGM. This may be with a sharp instrument. The female may be frightened, not consent to this, suffer re traumatisation and fear/be ostracised from her community as her husband may not stay with her if she does not consent to this.

Women and girls may be raped within their relationship and suffer pain and re-traumatisation every time a partner demands sex. Some men may be more understanding and the couple may seek support. It is important to consider the wider support needs a woman may have including immigration, housing, debt, childcare and counselling support through community groups and domestic abuse specialist support. She may need to be referred to her local Multi Agency Risk Assessment Conference if the risk of forced marriage, serious injury or death is high.

See the WSCB/WSAPB procedures for Responding to Children and Young People who are at Risk from Domestic Violence and Abuse - Policy and Guidance for Professionals and Wirral Honour Based Violence and Forced Marriage Protocol.


23. Support for Girls and Women Affected by FGM

There are two main areas of support that should be offered to all women and girls affected by FGM - Counselling, and de-infibulation for type III (see Section 3, Types of FGM).

Counselling

Girls and women suffering from anxiety, depression or who are traumatised as a result of FGM should be offered counselling and other forms of therapy. All girls and women who have been undergone FGM should be offered counselling to discuss how deinfibulation will affect them. Parents, husbands boyfriends, partners can also be offered counselling. The Mental Health Service for Wirral (Cheshire & Wirral Partnership NHS Trust) has an identified consultant psychiatrist to lead on FGM.

De-Infibulation/Reversal

This is a small procedure to open the scar carried out in a specialist clinic usually under local anaesthetic. The skin will be stitched at either side of the scar to keep it from healing together again and will usually heal very quickly. This should enable normal intercourse and child birth and reduce the number of infections a girl/woman may suffer. It does not replace tissue that has been removed and more scar tissue may form but it can improve a female’s quality of life.


Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults

Ask

Ask children/Vulnerable Adult to tell you about their holiday. Sensitively and informally ask the family about their planned extended holiday ask questions like;
Who is going on the holiday with the child/adult?
How long they plan to go for and is there a special celebration planned?
Where are they going?
Are they aware that the school cannot keep their child on roll if they are away for a long period?
Are they aware that FGM including Sunna is illegal in the U.K even if performed abroad? Use term that may be familiar with as FGM may not always be understood.
If you suspect that a child / adult is a victim of FGM you may ask them;
Your family is originally from a country where girls or women are circumcised – Do you think you have gone through this or at risk of this practice?
Has anything been done to you down there or on your bottom?
Would you like support in contacting other agencies for support, help or advice?
Inform them that you have to share information confidentially with relevant agencies if you are concerned that they or someone else is at risk of being harmed.

These questions and advice are guidance and each case should be dealt with sensitively and considered individually and independently.

Record

All interventions should be accurately recorded by the persons involved in speaking with the child or adult. All recording should be dated and signed and give the full name and role of the person making the recording.

Refer

To Public Protection and Investigation Unit, Social Care or Health/Voluntary sector for medical follow up or support services.


Appendix 2: Legislation on Female Genital Mutilation

Prohibition of Female Circumcision Act 1985

Female Genital Mutilation (FGM) has been a specific criminal offence since 1985, with the introduction of the Prohibition of Female Circumcision Act 1985. However a 'loophole' was identified in the legislation, in that taking girls who were settled in the UK abroad for FGM was not a criminal offence. It is this 'loophole' that the Female Genital Mutilation Act 2003 ('the Act') intended to close.

Female Genital Mutilation Act 2003

The Act was brought into force on 3 March 2004 by the Female Genital Mutilation Act 2003 (Commencement) Order 2004. The provisions of the Act only apply to offences committed on or after the date of commencement. For offences committed before 3 March 2004 the Prohibition of Female Circumcision 1985, as re-enacted in the Female Genital Mutilation Act 2003, continues to apply.

The Act affirmed that it is illegal for FGM to be performed, and that it is also an offence for UK nationals or permanent UK residents to carry out, or aid, abet, counsel or procure the carrying out of FGM abroad on a UK national or permanent UK resident, even in countries where the practice is legal.

Offence of Female Genital Mutilation

Section 1 of the Act makes it a criminal offence to excise, infibulate, or otherwise mutilate the whole or any part of a girl's labia majora, labia minora or clitoris. Although the Act refers to "girls", it also applies to women.

Defence

No offence is committed by a registered medical practitioner who performs a surgical operation necessary for a girl's physical or mental health. Nor is an offence committed by a registered midwife or a person undergoing a course of training with a view to becoming a registered medical practitioner or registered midwife, but only if the operation is on a girl who is in any stage of labour, or has just given birth, and is for purposes connected with the labour or birth (see section 1 of the Act).

This applies if the surgical operation is carried out:

  • In the UK: or
  • Outside the UK, by persons exercising functions corresponding to those of a UK approved person.

Section 1(5) makes it clear that in assessing a girl's mental health, no account is taken of any belief that the operation is needed as a matter of custom or ritual. An FGM operation, therefore, could not legally occur on the ground that a girl's mental health would suffer if she did not conform to the prevailing custom of her community.

There is no fixed procedure for determining whether a person carrying out an FGM operation outside the UK is an overseas equivalent of a medical practitioner etc for the purpose of subsection (4). If a prosecution is brought, this will be a matter for the courts (in the UK) to determine on the facts of the case.

Assisting a girl to mutilate her own genitalia

It is not an offence for a girl to carry out an FGM operation on herself. However, a person is guilty of an offence if he aids, abets, counsels or procures a girl to excise, infibulate or otherwise mutilate the whole or any part of her own labia majora, labia minora or clitoris (see section 2 of the Act).

Assisting a non-UK person to mutilate overseas a girl’s genitalia

Section 3 of the Act makes it an offence for a person to aid, abet, counsel or procure the performance outside the UK of a relevant FGM operation (as defined by subsection (2)) that is carried out on a UK national or habitual UK resident by a person who is not a UK national or permanent UK resident (as defined by section 6).

So the person who, for example, arranges by telephone from his/her home in England for his/her daughter who is a UK national/habitually resident/permanently resident in the UK, to have an FGM operation carried out abroad by a foreign national (who does not live permanently in the UK) is guilty of an offence.

The exception for necessary surgical operations that applies for the purposes of section 1 of the Act also applies to section 3.

Extra-territorial acts

The effect of the extension (see section 4) on section 1 is that it will be an offence for a UK national or permanent UK resident to carry out an FGM operation outside the UK. By virtue of section 8 of the Accessories and Abettors Act 1861, it will also be an offence for a person in the UK (or a UK national or permanent UK resident outside the UK) to aid, abet, etc a UK national or permanent UK resident to carry out an FGM operation outside the UK. For example, if a person in the UK advises his UK national brother over the telephone how to carry out an FGM operation abroad, he would commit an offence.

The effect of the extension of section 2 is that it will be an offence for a UK national or permanent UK resident outside the UK to aid, abet etc. a person of any nationality to carry out an FGM operation on herself wherever it is carried out.

The effect of the extension of section 3 is that it will be an offence for a UK national or permanent UK resident outside the UK to aid, abet etc. a foreign national (who is not a permanent UK resident) to carry out an FGM operation outside the UK on a UK national or permanent UK resident. For example, a permanent UK resident who takes his permanent UK resident daughter to the doctor's surgery in another country so that an FGM operation can be carried out will commit an offence.

Penalties for offences

A person guilty of an offence under this Act is liable:

  • On conviction on indictment, to imprisonment for a term not exceeding 14 years or a fine (or both);
  • On summary conviction, to imprisonment for a term not exceeding six months or a fine not exceeding the statutory maximum (or both).

See Section 5 of the Act.

Definitions of Girl and UK National

The term ‘girl’ includes ‘woman’.

A United Kingdom national is an individual who is:

  1. A British citizen, a British overseas territories citizen, a British National (Overseas) or a British Overseas citizen;
  2. A person who under the British Nationality Act 1981 is a British subject; or
  3. A British protected person within the meaning of that Act.

A permanent United Kingdom resident is an individual who is settled in the United Kingdom (within the meaning of the Immigration Act 1971).

For more information please see CPS Female Genital Mutilation Legal Guidance.

There are new legislative measures being brought through the Serious Crime Act 2015 which will strengthen the legislative framework around tackling FGM.

The changes include:

  • Creating a new duty of Mandatory Reporting of Female Genital Mutilation for regulated professionals in health and social care professionals and teachers in England and Wales which came into force on the 31st October 2015;
  • Introducing ‘habitual UK resident’ rather than ‘permanent UK resident’;
  • Introducing FGM Protection Orders (similar to Forced Marriage Protection Orders);
  • Duty on individuals to report to the police for cases were FGM is identified in under 18’s;
  • New offence of failing to protect a girl from FGM.


Appendix 3: Useful Contacts

Third Sector Agencies Working With FGM

Foundation for Women’s Research and Development (FORWARD)
Tel: 0208 960 4000
Email: forward@forwarduk.org.uk

The NSPCC 24hour helpline to protect children and young people affected by FGM
Tel: 0800 028 3550

NESTAC - Drop in groups across Merseyside for girls and women affected by FGM
Tel: 01706 868993
Mob: 07862 279289
Email: peggy@nestac.org

Childline
24 hour helpline for children: 0800 1111

National 24 hour Domestic Violence Helpline
24-hour Helpline: 0808 2000 247
The Forum has developed an e-learning package which can be assessed through the End the Fear website.

Statutory Agencies Working with FGM

Merseyside Police
Family Crime Investigation Unit at Wirral BCU FGM Clinics.

FGM Clinics

There are several specialist FGM clinics in many large UK cities. Some are linked to an antenatal clinic; others may be within a community clinic or GP surgery. All of these clinics are NHS clinics and therefore free of charge. Most clinics are run by specially trained doctors, nurses, or midwives.

A point to note is that some victims may not want to use local clinics due to fear of being recognised by local community.

How to access an FGM clinic

If you wish to go to refer to any of the clinics, you should check if a GP referral, is required as most clinics do not do not take self-referrals. If the woman is pregnant, a midwife may be able to refer.

Multi-Cultural Antenatal Clinic – Liverpool Women's Hospital
Crown Street
Liverpool L8 7SS
Tel: 0151 708 9988
Mobile: 07717 516134
Open: Monday-Friday 8.30am-4.30pm
Contact: Ronnie Gilbertson or Joanne Topping
Link Clinic held on a Monday between 9am and 1.30pm
Liverpool Women's NHS Foundation Trust website.

St Mary's Hospital – Gynaecology & Midwifery Departments
Dr Fiona Reid MD MRCOG
Consultant Urologist
The Warrell Unit
St Mary's Hospital
Manchester

St Mary’s Hospital Consultant Paediatric Gynaecologist
Dr Gail Busby
Tel 44 (0) 161 276 1234
Email: Gail.busby@cmft.nhs.uk

Black Association of Women Step Out (BAWSO)
Wrexham Office
33 Grosvenor Road
Wrexham
LL11 1BT
Tel: 01978 355 818
Fax: 01978 355 707
BAWSO website


Appendix 4: Glossary

Angurya cuts: A form of FGM type 4 that involves the scraping of tissue around the vaginal opening.

The term “closed” refers to type 3 FGM where there is a long scar covering the vaginal opening. This term is particularly understood by the Somali and Sudanese communities

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.

Re-infibulation (sometimes known as or referred to as reinfibulation or re-suturing): The re-stitching of FGM type 3 to re-close the vagina again after childbirth (illegal in the UK as it constitutes FGM).

Sunna: the traditional name for a form of FGM that involves the removal of the prepuce of the clitoris only. The word 'sunna' refers to the 'ways or customs' of the prophet Muhammad considered to be religious obligations (wrongly in the case of FGM). Studies show, however, that the term 'sunna' is often used in FGM practicing communities to refer to all forms of FGM, not just FGM that involves only the removal of the hood of the clitoris.

Adult at Risk: The safeguarding Guidance within the Care Act 2014 (Chapter 14) replaces the ‘No Secrets’ Guidance (2000) regarding an adult at risk.

Under the Care Act 2014 safeguarding duties apply to an adult who:

  • Has need for care and support (whether or not the local authority is meeting any of those needs); and
  • Is experiencing, or at risk of, abuse or neglect; and
  • As a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.


Appendix 5: FGM Flowchart for Arrowe Park Staff

Click here to view Appendix 5: FGM Flowchart for Arrowe Park Staff.


Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff

Click here to view Appendix 6: FGM Flowcharts for Wirral Community NHS Trust Staff.


Appendix 7: FGM Flowcharts for Mental Health Staff

Click here to view Appendix 7: FGM Flowcharts for Mental Health Staff.


Appendix 8: Decision-Making and Action Flowchart for Safeguarding Adults at Risk

Click here to view Appendix 8: Decision-Making and Action Flowchart for Safeguarding Adults at Risk.


Appendix 9: FGM Safeguarding and Risk Assessment Guidance

Click here to view Appendix 9: FGM Safeguarding and Risk Assessment Guidance.


Appendix 10/10a: Decision-making and Action Flowchart for Professionals in LA Children’s Social Care

Appendix 10: Decision-Making and Action Flowchart for Safeguarding Children - Risk of FGM.

Appendix 10a: Decision-Making and Action Flowchart for Safeguarding Children - Actual FGM.


Appendix 11: Flowchart for GP Practice Staff

Click here to view Appendix 11: Flowchart for GP Practice Staff.

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