Female Genital Mutilation Multi-Agency Protocol

The Greater Manchester Female Genital Mutilation Forum Group was established in June 2011. The aim of the forum was to enable statutory and voluntary organisations to work in partnership to raise awareness and reduce incidents of Female Genital Mutilation (FGM) in Greater Manchester.

This protocol covers female children under the age of 18.

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.

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”
WHO Fact sheet No. 241 (February 2014)

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.

1. Clitoridectomy 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.

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 30 African countries and 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 200 million girls and women worldwide have been subjected to female genital mutilation.

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 Bohra Muslims.

Greater Manchester is one of the main areas for FGM in the UK. 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.

FGM has also been documented in communities including:

• Iraq;
• Israel;
• Oman;
• The United Arab Emirates;
• The Occupied Palestinian Territories;
• India;
• Indonesia;
• Malaysia;
• Pakistan.

Table 3: Prevalence of FGM within African Communities in Greater Manchester

(Source Afruca 2015)

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.

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.

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.**

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 gangrene and tetanus. Tetanus is fatal in 50 to 60 percent of all cases;***
• Urological complications including 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.

_{*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)}

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;
• Recurrent urinary, uterine, vaginal and pelvic infections;
• Keloid scarring;
• Vaginal obstruction;
• Infertility;
• Cysts;
• Complications with menstruation;
• Psychological damage; including a number of mental health and psychosexual problems, e.g. depression, anxiety, post-traumatic stress disorder (PTSD), fear of sex* **. Many children exhibit behavioural changes after FGM, but problems may not be evident until adulthood;
• 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)}

Among some of the more common myths are:

See also Forward UK website.

• Maintain family honour and a girl’s virginity;
• Improving a girl's 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.

Indicators that a child / young person is at risk of 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;
• Parents state that they or a relative will take the child out of the country for a prolonged period;
• Parents have poor access to information about FGM and do not know about harmful impact;
• Girl has attended travel clinic for vaccinations;
• Family not engaging with professionals i.e.: health or school;
• A child may talk about a long holiday (usually over 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.

If one indication leads to a potential concern ask more questions with child / parent (see Appendix 1: Guidance for Interviewing Parents/Children/Vulnerable Adults). If you are unsure whether the level of risk requires a referral to children’s social care, discuss with your named designated safeguarding lead.

Information should be shared with the child’s GP and school nurse / health visitor.

Significant or Immediate Risk of FGM

(extracted from DoH FGM risk and safeguarding guidance for professionals 2015)

• If a child/young person under the age of 18 identifies one or more serious or immediate risks from the list below, or other risks that in your judgment appear to be serious, then refer to children’s social care;
• A child or sibling asks for help;
• A parent or family member expresses concern that FGM may be carried out on the child;
• Girl has confided that she is to have a `special procedure; or to attend a ` special occasion’. Girl has talked about going away to ‘become a woman’ or to ‘become like my mum and sister’;
• Girl has a sister or other female child relative who has already undergone FGM;
• Family/child is already known to social services - if known and have identified FGM within a family you must share this information with children social care.

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.

Any information or concern that a female is at immediate risk of FGM, should result in a safeguarding referral to the Local Authority Social Care.

A disclosure from the girl or professional observing a physical sign that an FGM procedure has taken place should be reported to the police via mandatory reporting pathway (see Appendix 5: Female Genital Mutilation Greater Manchester Pathway).

Information should be shared with the relevant school nurse/health visitor and GP.

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.

With effect from 3 May 2015, the Female Genital Mutilation Act 2003 was amended by the Serious Crime Act 2015. The law is extended so that:

• A non-UK national who is ‘habitually resident’ in the UK and commits such an offence abroad can now face a maximum penalty of 14 years imprisonment. It is also an offence to assist a non-UK resident to carry out FGM overseas on a girl who is habitually, rather than only permanently, resident in the UK. This follows a number of cases where victims were unable to get justice as FGM was committed by those not permanently residing in the UK;
• A new offence is created of failing to protect a girl from the risk of FGM. Anyone convicted can face imprisonment for up to seven years and/or an unlimited fine;
• Anonymity for victims of FGM. Anyone identifying a victim can be subject to an unlimited fine.

On 17 July 2015, Female Genital Mutilation Protection Orders came into force.

Female Genital Mutilation Protection Orders are obtained in the Family Court like Forced Marriage Protection Orders. If you are concerned that someone may be taken abroad for FGM you can apply for a Protection Order. 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.

From October 2015, the new ‘mandatory reporting’ duty for professionals working in the ‘regulated professions’ comes into force. This requires them to notify the police if they discover that an act of FGM appears to have been carried out on a girl who is under 18 (either if they have visually confirmed it or it has been verbally disclosed by an affected girl). ‘Regulated professionals’ will cover healthcare professionals, teachers and social care workers. The only exception to the duty is if the professional knows that another individual from their profession has already made a report - there is no requirement to make a second. 

Government Guidance Mandatory Reporting of Female Genital Mutilation – Procedural Information provides that social workers should not under any circumstances examine a girl for signs of FGM. See Section 20, Medical Examinations.

For the purposes of the duty, the relevant age is the girl’s age at the time of the disclosure or identification of FGM – it does not apply where a woman aged 18 or over discloses, she had FGM when she was under 18.

The duty does not apply where there is merely a suspicion that a girl is at risk of undergoing FGM.

The duty only applies to cases directly disclosed by the victim: it does not apply where a disclosure is made by a third party such as a parent, guardian or sibling. However it will still need a referral into your local Children’s Social Care – see Appendix 5: Female Genital Mutilation Greater Manchester Pathway. The Guidance states that complying with the duty "does not breach any confidentiality requirement or other restriction on disclosure which might otherwise apply."

A failure to report the discovery in the course of their work could result in a referral to the relevant professional body.

FGM is considered to be a form of child 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.

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.

The first successful prosecution for FGM offences in the UK took place in February 2019. The defendant, the mother of the 3-year-old victim, stated to doctors at the hospital that the injuries to her daughter were caused by her daughter falling on sharp metal object after reaching for cookies. The injuries required the victim to undergo emergency surgery, and the doctor found three separate cuts that he determined had been deliberately inflicted with a sharp instrument. This opinion was shared by other specialist doctors. Following the Classification Criteria set by the World Health Organization, the injuries amounted to a type II FGM, which involves the partial or complete removal of the clitoris and labia minora, with or without excision of the labia majora.

When sentencing the defendant, the judge noted that, as there were no specific sentencing guidelines for this offense, he had consulted Guidelines from the Sentencing Council that he deemed had relevance to the case, including the Overarching Guidelines on Domestic Abuse, the Assault Guidelines, and the Child Cruelty Guidelines. Taking into account these Guidelines, and both the aggravating and mitigating factors of the case, the judge sentenced the defendant to 11 years’ imprisonment for one count of FGM.

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. Female Genital Mutilation breaches several of these rights.

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.

Investigation of referrals regarding the risk of FGM requires a sensitive and multi-agency response.

On receipt of referral into Children’s Social Care (CSC), a Strategy Meeting should be called within two working days or sooner as directed by the urgency of the information within the referral – see Strategy Discussions Procedure.

If a referral is received concerning one female in a family, consideration should be given as to whether other females in the family are also at similar risk. There should be consideration of other females from other associated families.

The Strategy Meeting must establish whether parents of the girl have 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.

In addition, the strategy meeting should consider the need for medical assessment and / or therapeutic services for the female. An FGM Strategy Meeting should cover, as a minimum, the following issues:

• Family history and background;
• 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;
• Whether or not 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 from the country;
• Identify key outcomes for the child and their family and consider possible implications and impact on the wider community;
• Whether or not there has been a direct report to the Police (mandatory reporting) – where it is a ‘known’ case of FGM in a child under 18, the strategy discussion should ensure that there has been a formal report to the Police.

See Mandatory Reporting of Female Genital Mutilation – Procedure Information.

Remember: If a young person under the age of 18 discloses to a professional that they have been subjected to FGM or a professional observes physical signs that FGM has been carried out, then mandatory guidance / pathway must be followed. (see Section 13, Protective Legislation and Appendix 5: Female Genital Mutilation Greater Manchester Pathway).

Experience has shown that often parents themselves can experience pressure to agree to FGM for their children and may view this 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 cutting are unlikely to perceive it to be harmful and on the contrary, believe it to be legitimised by longstanding tradition. Therefore, it is essential that when first approaching a family about issues of FGM a thorough assessment should be undertaken with a particular focus on:

• Parental/carer attitudes and understanding about the practice and where appropriate;
• Child/young person’s understanding and views on the issue.

Every attempt should be made to work with parents/carers on a voluntary basis to prevent FGM, however the child’s best interests are always paramount.

Consideration should be given to where the assessment is undertaken e.g. speaking with children/families outside of the family home to encourage them to talk freely and discuss the impact that FGM would have.

As good practice, wherever possible a female interpreter should be used in all interviews with the family and children where English is not their first language. The interpreter must not be a family relation and should not be known to the family. See Section 23, Interpreters.

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

All interviews should be undertaken in a sensitive manner, taking into account any disability/additional needs and should only be carried out once.

Parental consent and the child’s agreement (where age appropriate) for assessment should be sought; and all attempts should be made to work with parents. Where consent is not given, legal advice should be sought.

The strategy meeting should reconvene to discuss the outcomes/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, the first priority is protection and the Local Authority should consider the need for:

• Proceeding to initial case conference;
• Seeking legal advice/planning;
• Immediate Police intervention.

Following all referrals relating to FGM, regardless of the outcome, consideration should be given to the therapeutic/counselling needs of the female(s) and family.

See also section on Section 20, Medical Examinations.

See also Keeping Children Safe in Education and Making Referrals to Children’s Social Care.

Teachers, other school staff, volunteers and members of community groups may become aware that a female 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;
• Child discloses 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 if they suspect a child may be at risk of FGM. In cases where professionals believe that a child is at immediate risk of FGM, the Police should be called.

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.

Please ensure Children’s Social Care share this information with the child’s GP and the school health lead.

If a young person under the age of 18 discloses to a professional that they have been subjected to FGM or a professional observes physical signs that FGM has been carried out, then mandatory guidance / pathway must be followed. (see Section 13, Protective Legislation and Appendix 5: Female Genital Mutilation Greater Manchester Pathway).

See also Making Referrals to Children’s Social Care Procedure.

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.

GPs, and Practice Nurses should be vigilant to any health issues such as resistance to partake in cervical smear testing, recurrent urinary tract infections or vaginal infections that may indicate FGM has been carried out. Those that do attend for health checks or travel vaccinations from affected communities could be asked about FGM and advised about its health impacts and informed that it is illegal within the UK. They should be offered/referred for additional support. They should document 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 woman - (including de-infibulation);
• Consider if there are any other girls or women in the family at risk of FGM.

Consideration should be given if there are any suspicions that a child is being prepared to be taken abroad for FGM, if the family belongs to a community that practises female genital mutilation, and preparations are being made to take the girl overseas. For example:

• Arranging vaccinations;
• Planning absences from school;
• The child is talking about a “special procedure” taking place.

Document any advice or leaflets provided. Any concerns about a parent’s attitude towards FGM should be taken seriously and appropriate referrals made. Wherever possible, health professionals could assess the attitudes of extended family members towards the practice of FGM and should consult with their child protection adviser and with the relevant Social Work Assessment Team about making a referral to them. (Female Genital Mutilation care for patients and safeguarding children, BMA (July 2011)).

A question about FGM should be asked when a routine new patient history is being taken from girls and women from communities that practise FGM. Information on FGM could be included in a welcome pack which is given to new patients from practising communities.

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 who come from countries that practice FGM or if they are married to or in a relationship with men from FGM practising communities. 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 woman - (including de-infibulation);
• Consider if there are any other girls or women in the family at risk of FGM.

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 available.

All this information should be shared with appropriate health professionals (including the GP, school nurse and the Health Visitor as appropriate). Professionals should consult with their safeguarding leads for guidance and support.

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 Domestic Abuse Procedure.

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 (and that of their extended family members) 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, including the GP, are aware of the FGM incident and any concerns for female children.

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, and any other signs of FGM, 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 parents’ and extended family members’ 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.

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. Information should be shared via existing information sharing systems with relevant health professionals, including the GP, health visitor and school nurse if appropriate. See Section 11, Risk Factors that Heighten the Girl’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. Consideration should be given to other females within the family who may be at risk of FGM. All this information should be shared with appropriate health professionals (GP, Health Visitor, school nurse etc). Professionals should consult with their safeguarding lead about making a referral to social care.

Remember: If a young person under the age of 18 discloses to a professional that they have been subjected to FGM or a professional observes physical signs that FGM has been carried out, then mandatory guidance / pathway must be followed. (see Section 13, Protective Legislation and Appendix 5: Female Genital Mutilation Greater Manchester Pathway).

From 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 woman - (de-infibulation).

From September 2014, all acute hospitals must report this data centrally to the Department of Health on a monthly basis. This is the first stage of a wider ranging programme of work in development to improve the way in which the NHS will respond to the health needs of girls and women who have suffered FGM and actively support prevention. And with effect from April 1, 2015, The Female Genital Mutilation Enhanced Dataset began collecting data. The FGM Enhanced Information Standard (SCCI2026) instructs all clinicians to record into clinical notes when a patient with FGM is identified and what type it is.

Data should be submitted every time the woman or girl has treatment related to her FGM or gives birth to a baby girl, and every time FGM is identified (by a clinician or self-reported), not just the first time.

The FGM Enhanced Dataset is being undertaken under Directions for the Department of Health (DH). This provides the legal basis for collecting patient identifiable data without explicit patient consent. No patient identifiable data will be published.

If a patient raises an objection within the care delivery setting (i.e. within the GP surgery or the hospital), the local organisation must consider this objection within their own processes, and ensure they record within the healthcare record the outcome of this decision (i.e. whether or not to disclose information to HSCIC).

If the objection is not raised at this point, and the patient's information is submitted, they can still choose to contact HSCIC at a later date to raise an objection at the following email address: enquiries@hscic.gov.uk.

All cases of FGM will be dealt with by the relevant Public Protection Investigation Unit based on the appropriate territorial division.

Operational Communications Branch - Call Handlers

The first point of contact by a victim may be via telephone to the Force Operations Room. As a call taker, supervisor or radio operator you must recognise the importance of the call and the impact on the victim having made the decision to make a call to the police.

You should be sympathetic, reassuring and calming. You must seek to establish the full circumstances taking cognisance of the domestic abuse, so-called honour-based violence and Safeguarding Children policies.

Call takers should assess immediate risk where FGM is reported and where intervention is required without delay, make telephone contact with the relevant PPIU.

Investigating Officer/Public Protection Investigating Officer

If you are dealing with a case of or suspected case of FGM you must seek advice from a Public Protection Investigation Detective Inspector, Detective Sergeant or in their absence an Inspector at the earliest opportunity.

You must give the individual the opportunity to talk to you in private and you must obtain as much information from them at that time.

Where the victim is a child of FGM or potential FGM

• All cases must be referred to Children’s services where it is a child;
• As a Section 47 Children’s Act investigation, EVERY referral with regard to FGM must generate a strategy meeting with Police, Children’s Social Care and the referrer (e.g. school) as soon as practicable (and in any case within 48 hours). Consider, also, attendance by a representative from Health;
• It is the police’s responsibility to assess risk and manage it;
• Utilise powers of PPO or EPO where appropriate;
• Must refer to Case Conference where required;
• Consider if it is a critical incident;
• The welfare of other children within the family in particular female siblings should be reviewed;
• Any investigation should be the subject of regular on-going multi-agency reviews to discuss the outcome and any further protective steps that need to be taken with regard to that child and any other siblings.

If FGM is believed to be taking place in the future

The first consideration should be informing the parents of the law and the dangers of FGM. This can be done by representatives from schools, children’s social care, health professionals and/or police. It is the duty of all professionals to look at every possible way that parental co-operation can be achieved, including the use of community organisations to facilitate the work with the parents/family.

If there is any suggestion that the family still intend to subject that child to FGM, the first priority is the protection of the child and the least intrusive legal action should be taken to ensure the child’s safety. Officers should consider the use of Police Protection powers under S.46 Children Act 1989 and removing her to a place of safety. In addition, Children’s Social Care should consider the use of a Prohibitive Steps Order or Emergency Protection Order.

Child where FGM has taken place

If made aware that a child has already undergone FGM an immediate referral should be made to Children Social Care and to Public Protection Investigation Unit (PPIU) Officers should carry out the following actions:

• Complete appropriate checks;
• Update PPI OPUS using investigation type female genital mutilation;
• Risk assessment/Risk management plan;
• Refer to Children’s Social Care unless they were the referrer;
• Crime Report using the flag “PG”;
• All Officers must inform their supervisor, who must be at least the rank of Inspector;
• PPIU Officers should ensure the duty Superintendent is made aware of the referral.

All Officers and staff must consider whether this could be a Critical Incident and deal with the matter accordingly.

Remember: If a young person under the age of 18 discloses to a professional that they have been subjected to FGM or a professional observes physical signs that FGM has been carried out, then mandatory guidance / pathway must be followed. (see Section 13, Protective Legislation and Appendix 5: Female Genital Mutilation Greater Manchester Pathway).

Early Consultation with CPS

Early consultation between police and CPS (alongside our other statutory child protection partners) will be key in bringing FGM cases to the criminal courts swiftly.

Delay in the investigation and review stage can be damaging to the individual and increases the risk of her being pressurised by family and her community.

You should refer to the CPS and GMP FGM Service level Agreement.

A second strategy meeting should take place within 10 working days of the initial referral.

The Investigative Strategy should consider identifying established excisors (people who carry out FGM for payment or otherwise) and investigating these with a view to identifying further victims.

Except in extreme circumstances Medical examinations should only be undertaken after a strategy discussion/meeting has taken place and once consent from the child (if age appropriate) and person with parental responsibility has been given. If consent is not given legal advice should be sought and Children’s Social Care may need to apply for an Emergency Protection Order or Interim Care Order.

Medical examinations should be arranged as per local arrangements for Section 47 / Child Protection medicals and should be carried out by a consultant paediatrician or Forensic Physician who has experience of dealing with cases of FGM. Across Greater Manchester St Mary’s SARC has the most expertise in recognising FGM in children. See their Referral Form.

The medical needs of a girl or young person who has already undergone FGM should be considered. St Mary’s SARC can advise.

The need for psychological and therapeutic support should also be considered. Please see Appendix 3: Useful Contacts.

Given the need to potentially safeguard over a significant proportion of a girl’s childhood, it is appropriate to recognise here that there are a number of different responses to safeguard against FGM, and appropriate course of action should be decided on a case by case basis, with the expert input from all agencies involved.

If you are made aware that an adult female has undergone FGM, a consideration should be given on whether to convene a multi-agency meeting. This meeting should discuss any potential risk to any girls within the family (and extended family) and consider initial and core assessments of those girls. It should also consider providing supportive services for the woman, including counselling and medical assistance.

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 where deemed necessary.

If the adult female is a Vulnerable Adult, then a referral should be made to the local Adult safeguarding team who will determine the necessary course of action.

Care must be taken to ensure that an interpreter is available. The interpreter should be an authorised accredited interpreter and should not be a family member, not be known to the individual, and not be an individual with influence in the individual’s community.

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 above).

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 de-infibulation will affect them. Parents, husbands, boyfriends, partners can also be offered counselling.

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 childbirth 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.

Ask

• Ask children 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 GMP’s Public Protection and Investigation Unit, Children’s Social Care or Health/Voluntary sector for medical follow up or support services.

FGM has been a specific criminal offence in the UK when the Prohibition of Female Circumcision Act 1985 was passed. The Female Genital Mutilation Act 2003 replaced the 1985 Act in England, Wales and Northern Ireland. It modernised the offence of FGM and the offence of assisting a girl to carry out FGM on herself while also creating extra-territorial offences to deter people from taking girls abroad for mutilation. To reflect the serious harm caused, the 2003 Act increased the maximum penalty for any of the FGM offences from five to 14 years imprisonment.

Current Law

Under the 2003 Act it is an offence for any person in England, Wales or Northern Ireland (regardless of their nationality or residence status) to perform FGM (Section 1); or to assist a girl to carry out FGM on herself (Section 2). It is also an offence to assist (from England, Wales or Northern Ireland) a non-UK national or resident to carry out FGM outside the UK on a UK national or permanent UK resident (Section 3).

Section 4 extends sections 1 to 3 to extra-territorial acts so that it is also an offence for a UK national or permanent UK resident to: perform FGM abroad; assist a girl to perform FGM on herself outside the UK; and assist (from outside the UK) a non-UK national or resident to carry out FGM outside the UK on a UK national or permanent UK resident.

The intention was for the extra-territorial provisions to catch offences involving those with a substantial connection to the UK but not those who were here temporarily. However, the Director of Public Prosecutions has highlighted a small number of cases where the CPS could not prosecute for FGM committed abroad because those involved were not, at the material time, permanent UK residents as defined by the 2003 Act.

Extension of extra-territorial jurisdiction

Against that background, Section 70(1) of the Serious Crime Act 2015 amends Section 4 of the 2003 Act so that the extra-territorial jurisdiction extends to prohibited acts done outside the UK by a UK national or a person who is resident in the UK. Consistent with that change, Section 70(1) also amends Section 3 of the 2003 Act (offence of assisting a non-UK person to mutilate overseas a girl’s genitalia) so it extends to acts of FGM done to a UK national or a person who is resident in the UK.

“UK resident” is defined as an individual who is habitually resident in the UK. The term habitually resident covers a person's ordinary residence, as opposed to a short, temporary stay in a country.

These changes will mean that the 2003 Act can capture offences of FGM committed abroad by or against those who are at the time are habitually resident in the UK irrespective of whether they are subject to immigration restrictions. It will be for the courts to determine on the facts of individual cases whether or not those involved are habitually resident in the UK and thus covered by the 2003 Act.

Anonymity of victims of FGM

Reluctance to be identified as a victim of FGM is believed to be one of the reasons for the low incidence of reporting of this offence. It is anticipated that providing for the anonymity of victims of alleged offences of FGM will encourage more victims to come forward.

Section 71 of the 2015 Act amends the 2003 Act to prohibit the publication of any information that would be likely to lead to the identification of a person against whom an FGM offence is alleged to have been committed. This is similar, although not identical, to the anonymity given to alleged victims of sexual offences by the Sexual Offences (Amendment) Act 1992.

Anonymity will commence once an allegation has been made and will last for the duration of the victim’s lifetime.

There are two limited circumstances where the court may disapply the restrictions on publication. The first is where a person being tried for an FGM offence, could have their defence substantially prejudiced if the restriction to prevent identification of the person against whom the allegation of FGM was committed is not lifted. The second circumstance is where preventing identification of the person against whom the allegation of FGM was committed, could be seen as a substantial and unreasonable restriction on the reporting of the proceedings and it is considered in the public interest to remove the restriction.

Offence of failing to protect a girl from risk of FGM

Section 72 of the 2015 Act inserts new Section 3A into the 2003 Act; this creates a new offence of failing to protect a girl from FGM. This will mean that if an offence of FGM is committed against a girl under the age of 16, each person who is responsible for the girl at the time of FGM occurred will be liable under this new offence. The maximum penalty for the new offence is seven years’ imprisonment or a fine or both.

To be “responsible” for a girl, the person will either have parental responsibility for the girl (such as mothers, fathers married to the mothers at the time of birth and guardians) and have frequent contact with her, or where the person is aged 18 or over they will have assumed responsibility for caring for the girl “in the manner of a parent”, for example family members to whom parents might send their child during the summer holidays.

The requirement for “frequent contact” is intended to ensure that a person who in law has parental responsibility for a girl, but whom in practice has little or no contact with her, would not be liable. Similarly, the requirement that the person should be caring for the girl “in the manner of a parent” is intended to ensure that a person who is looking after a girl for a very short period – such as a baby sitter – would not be liable.

Defence

It would be a defence for a defendant to show that at the relevant time they did not think that there was a significant risk of FGM being committed, and could not reasonably have been expected to be aware that there was any such risk; or they took such steps as he or she could reasonably have been expected to take to protect the girl from being the victim of FGM. The onus would then be on the prosecution to prove the contrary.

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.

Female Genital Mutilation Protection Order (FGMPO)

Section 73 of the 2015 Act provides for FGMPOs for the purposes of protecting a girl against the commission of a genital mutilation offence or protecting a girl against whom such an offence has been committed. Breach of an FGMPO would be a criminal offence with a maximum penalty of five years’ imprisonment, or as a civil breach punishable by up to two years’ imprisonment.

The court may make a FGMPO on application by the girl who is to be protected or a third party. The court must consider all the circumstances including the need to secure the health, safety, and well-being of the girl.

Under the new provisions an FGMPO might contain such prohibitions, restrictions or other requirements for the purposes of protecting a victim or potential victim of FGM. This could include, for example, provisions to surrender a person’s passport or any other travel document; and not to enter into any arrangements, in the UK or abroad, for FGM to be performed on the person to be protected.

Third Sector Agencies Working With FGM

Emotional Health & Wellbeing Service for Young People affected by FGM
AFRUCA Centre for African Children and Families:
Phoenix Mill
20 Piercy Street
Ancoats
Manchester 
M4 7HY
Tel: 0161 205 9274
Fax: 0161 205 2156

Opening Times
Monday - Friday: 10am - 5pm

See information leaflet Emotional Wellbeing for FGM Survivors in Greater Manchester.

AFRUCA – Africans Unite Against Child Abuse
Tel: 0161 953 4711/4712
www.afruca.org
info@afruca.org

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

Saheli Asian Women’s Refuge
Tel: 0161 945 4187
Email: saheliltd@btconnect.com
www.saheli.org.uk

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

Women’s DV Helpline – Gt Manchester
Tel: 0161 636 7525
Directory of local services see www.endthefear.co.uk

NESTAC - Drop-in groups across Greater Manchester for girls and women affected by FGM
Provision of emotional support to young people (The Guardian Project) and to adults (SOS Project)
Tel: 01706 868993
Mob: 07862 279289
Email: peggy@nestac.org

Bolton FGM Project – Drop in groups for girls and women living in Bolton
Tel: 01204 399239
Email: bolsomcom@hotmail.com

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

Local Authority referral points for children across Greater Manchester

Public Protection and Investigation Units across Greater Manchester:

ppiu.area@gmp.pnn.police.uk / ppiu.salford@gmp.pnn.police.uk

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

For referral to St Mary’s SARC, Children’s Clinic for Examination in relation to Female Genital Mutilation see their Referral Form for details.

St Mary's Hospital – Gynaecology & Midwifery Departments
Consultant Urologist
The Warrell Unit
St Mary's Hospital
Manchester

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

Princess of Wales Women’s Unit Labour Ward
Birmingham Heartlands Hospital
Bordesley Green East
Birmingham,
B9 5SS
Tel: 0121 424 3909 or 0121 424 0730
Mob: 0781 753 4274
Open: Thursday and Friday
Contact: Alison Hughes alison.hughes@heartofengland.nhs.uk.

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 re-infibulation 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.

Vulnerable Adult: ‘Someone who is using or in need of Community Care Services because of learning or physical disability, older age, drug or alcohol dependency or physical or mental illness or unable to take care of themselves or protect themselves from harm or exploitation’ (No Secrets 2000).

Click here to view the Female Genital Mutilation Greater Manchester Pathway.

• Salford;
• Rochdale;
• Stockport;
• Tameside.

Click here to view the Referral to St Mary’s Centre, Children’s Clinic for Examination in relation to Female Genital Mutilation.