4.12 Female Genital Mutilation (FGM)

1. What is Female Genital Mutilation ?

Female Genital Mutilation (FGM) is a procedure where the female genital organs are deliberately cut, injured or changed and there is no medical reason for this. It is often a very traumatic and violent act and can cause harm in many ways. FGM can cause immediate as well as long-term health consequences, including pain and infection, mental health problems, difficulties in childbirth and/or death (see Section 2, Consequences of Female Genital Mutilation).

The age at which FGM is carried out varies according to the community. The procedure may be carried out on new-born infants, during childhood or adolescence or just before marriage or during a woman’s first pregnancy. There is no religious reason, in the Bible or Koran for example, for FGM and religious leaders from all faiths have spoken out against the practice. The exact number of girls and women alive today who have undergone FGM is unknown; however, UNICEF estimates that over 200 million girls and women worldwide have had FGM procedures.

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

• type 1 – clitoridectomy: part or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);
• type 2 – excision: removal of part or all of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina);
• type 3 – infibulation: narrowing the vaginal opening by creating a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and
• type 4 – other: all other harmful procedures to the female genitals for non-medical reasons, for example pricking, piercing, incising, scraping and cauterising (burning) the genital area.

Under the Female Genital Mutilation Act 2003, FGM is a criminal offence and a form of violence against women and girls.

 2. Consequences of Female Genital Mutilation

There are no health benefits to FGM. Removing and damaging healthy female genital tissue interferes with the natural functions of women’s bodies.

2.1 Immediate effects

• severe pain;
• shock;
• bleeding / haemorrhage;
• wound infections;
• difficulty urinating;
• injury to adjacent tissue;
• genital swelling;
• in some cases, death.

2.2 Long term consequences

• genital scarring;
• genital cysts and keloid (a thick) scar formation;
• re-occurring urinary tract infections and difficulties in passing urine;
• possible increased risk of blood infections such as hepatitis B and HIV;
• pain during sex, lack of pleasurable sensation and impaired sexual function;
• psychological concerns such as anxiety, flashbacks and post traumatic stress disorder;
• difficulties with menstruation (periods);
• complications in pregnancy or childbirth (including long labour, bleeding or tears during childbirth, increased risk of having a caesarean section); and
• increased risk of stillbirth and death of child during or just after birth.

Personal accounts from survivors show that FGM is an extremely traumatic experience for girls and women, the effects of which remain with them throughout their life. Young women may feel betrayed by their parents, when they are involved in the decision to have the procedure, as well as feeling regret and anger.

 3. Law in England, Wales and Northern Ireland

In England (as well as Wales and Northern Ireland),  under the Female Genital Mutilation Act 2003 (‘the 2003 Act’) it:

• is illegal to carry out FGM in the UK;
• is illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM, whether or not it is lawful in that country;
• is illegal to aid, assist, guide or arrange the carrying out of FGM abroad;
• has a penalty of up to 14 years in prison and / or, a fine.

Regardless of individual status in the UK ie. Permanent or otherwise, the same safeguarding response will be afforded to all.

3.1 Female Genital Mutilation Protection Orders (FGMPO)

A FGMPO is a civil order which can be made to protect a girl against FGM offences or protect a girl against whom a FGM offence has taken place. Breaching an order carries a penalty of up to five years in prison.

The terms of the order can be flexible, and the court can include whatever terms it thinks are necessary and appropriate to protect the girl, including to protect her from being taken abroad or to order giving up her passport so she cannot leave the country. See also: Making an Application for an FGM Protection Order (FGMPO) – Flowchart.

 4. Risk Factors

The most significant factor to consider when assessing if a girl may be at risk of FGM is whether her family has a history of practising FGM. In addition, it is important to consider whether FGM is known to be practised in her community or country of origin.

As FGM is illegal and therefore not discussed openly, women who have undergone FGM may not fully understand what FGM is, what the consequences are, or that they themselves have had FGM. Discussions about FGM should therefore always be undertaken with care and sensitivity.

There are a number of other factors which could indicate a girl is at risk of being subjected to FGM.

• a girl / family believe FGM is essential in their culture or religion;
• the family mainly associates with other people from their own culture and has not mixed much with the wider UK community;
• parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
• a family is not engaging with professionals (health, education or other professionals).

Signs that FGM may have taken place include:

• a girl asks for help or confides in a professional that FGM has taken place;
• a girl has difficulty walking, sitting or standing or looks uncomfortable;
• a girl spends longer than normal in the bathroom or toilet due to difficulties passing urine;
• a girl has frequent urine, period or stomach problems;
• a girl does not want to have any medical examinations.

If you have concerns, do not be afraid to ask a girl or woman about FGM, using appropriate and sensitive language. Women and girls sometimes say that professionals have avoided asking questions about FGM, and this can then lead to a breakdown in trust. If a professional does not give a girl / woman the opportunity to talk about FGM, it can be very difficult for her to bring this up herself.

There are screening tools that can be used to support the conversations, e.g. Guidance – FGM: Mandatory Reporting in Healthcare (Department of Health and Social Care) 

 5. Action in Suspected Cases

FGM is illegal in England and Wales, and practitioners should act to safeguard girls who may be at risk of FGM or have been affected by it.

5.1 When a Girl is at Risk of FGM

The girl may be at imminent risk, in which case immediate protection should be taken to protect her such as a Female Genital Mutilation Protection Order or other action such as an Emergency Protection Order or the exercise by the police of their powers of protection (see Immediate Protection chapter).

Practitioners should consult with their safeguarding lead and information should be shared with relevant agencies as appropriate to ensure a multi-agency response as necessary. A referral should be made to Children’s Social Care (see Referrals chapter).

Discussions with family members should be conducted sensitively and with use of accredited interpreters (not known to the family) as required.  However, it is important to remember that the child may be at risk of harm from family members who may believe that FGM is in the girl’s best interests and may not understand the legal situation and implications.  The primary consideration at all stages should be the safety and welfare of the girl.

Action should include:

• making enquiries about other female family members who may need to be safeguarded from harm. This includes considering the needs of any unborn child if a  woman is pregnant (see Section 6, Safeguarding Other Family Members); and / or
• considering criminal investigations into the perpetrators, including those who carry out the procedure, to prosecute those who have broken the law and to protect others from harm.

5.2 When a Girl has had FGM

Practitioners should inform their safeguarding lead and make a referral to Children’s Social Care so that further safeguarding enquiries can be made.

Regulated health and social care professionals and teachers in England and Wales have a mandatory duty to make a report to the police if they become aware of a girl having had FGM. See Section 8, FGM Mandatory Reporting Duty.

Action should include:

• making enquiries about other female family members who may need to be safeguarded from harm. This includes considering the needs of any unborn child if a  woman is pregnant (see Section 6, Safeguarding Other Family Members); and / or
• considering criminal investigations into the perpetrators, including those who carry out the procedure, to prosecute those who have broken the law and to protect others from harm;
• arranging for appropriate medical assessment / treatment for the girl to address any medical needs resulting from the FGM.

 6. Safeguarding Other Family Members

Whenever a girl is identified as having had, or being at risk of, FGM professionals must consider whether she is at risk of further harm, and whether there are other girls or women in her family or wider social network who may be at risk of FGM.

 7. NHS FGM Data Collection

NHS England collects the following data from NHS acute trusts, mental health trusts and GP practices:

• if a patient has had Female Genital Mutilation;
• if there is a family history of Female Genital Mutilation;
• if a Female Genital Mutilation-related procedure has been carried out on a patient.

For more information please see Female Genital Mutilation (FGM, NHS)

8. FGM Mandatory Reporting Duty

Where a regulated health and social care professional or a teacher in England and Wales becomes aware of a case of FGM on a girl under the age of 18, they must report this to the police as soon as possible, preferably by the end of the next working day.  They may become aware of the FGM because the girl has disclosed it to them or because they observe physical signs.

Please note:  This is in addition to the safeguarding process.  If a practitioner is concerned that a child has had FGM, they should also consult their safeguarding lead and make a referral to Children’s Social Care (see Referrals chapter).

See also:

Guidance – Mandatory Reporting of Female Genital Mutilation: Procedural Information (gov.uk)

Guidance – FGM: Mandatory Reporting in Healthcare (Department of Health and Social Care)