Female Genital Mutilation (FGM)

Safeguarding Adults and Safeguarding Children partners across Cheshire recognise 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 practice guidance covers female children under the age of 18 and adult females including those who come under the Care Act 2014 definition of an Adult at risk (see Appendix 5: Glossary). These groups of females will have similar needs for support and protection but different legislation and routes to safety will apply.

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

The World Health Organisation (WHO) states that Female Genital Mutilation (FGM):

FGM is also known as Female Circumcision (FC) and Female Genital Cutting (FGC). These alternative definitions are better received in the communities that practise it, who do not see themselves as engaging in mutilation. There are also other terms used to describe these practises in different countries across the world).

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

Additional information about FGM can be found in Multi-Agency Statutory Guidance on Female Genital Mutilation (FGM).

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.

FGM takes place around the world in various forms across all major faiths. It has been estimated that currently, about 3 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, BUT includes other parts of the world; 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). 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).

It is important to recognise that the migrant populations may not practise 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 despite their differing attitude towards FGM, this second or third generation may be the children or adults at greatest risk of having the procedure carried out.

FGM has NO health benefits, and causes harm 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.

• The family comes from a community that is known to practise 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.

See also Appendix 2: Legislation on Female Genital Mutilation (FGM).

FGM has been a criminal offence in the UK since The Prohibition of Female Circumcision Act 1985. The Act was repealed and replaced by The Female Genital Mutilation (FGM) Act 2003.

The Serious Crime Act 2015 strengthened the legislative framework around tackling FGM. The Act introduced '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.

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

• Where a girl / woman is at risk of FGM;
• Where a girl / woman has undergone FGM;
• Where an expectant 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.

Professionals should make a safeguarding referral in accordance with their local procedures. If a professional feels that a child is at risk of immediate significant harm they should not discuss the referral with the parents/carers/family until a Strategy meeting has been convened

The initial referral to Children's Social Care should be treated as a Child Protection referral and an immediate Strategy Discussion should be held to determine immediate safeguards required to protect the child. A multi agency Strategy Meeting must be called within 2 working and chaired by a Senior Social Care representative. The Strategy Meeting must consider the risks of FGM to all children in the household. In situations where the referral relates to an unborn the Pre-Birth assessment must be completed prior to birth and ideally started at 26 weeks. The pre-birth assessment must consider the mother's views on FGM and her partners and extended family members' views on FGM in order to determine the risks presented to the child upon birth.

Each agency involved in the multi-agency strategy meeting must share relevant information that their agency holds, which will contribute to the multi-agency plan and investigation required to safeguard the child/women. During this period agencies should continue to look for appropriate support for the child/women in order to address any emotional/physical harm caused as a consequence of the FGM or prospect of FGM.

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 associated families once concerns are raised about an incident or the perpetrator of FGM.

See Appendix 3: Useful Contacts.

See also Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM.

See also FGM Assessment tool developed by the National FGM Centre.

Where a female has been identified as at risk or has had FGM, it may not be appropriate to take steps to remove the child or Adult at Risk 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 practise and where appropriate;
• Child/young person/Adult at Risk's knowledge, understanding and views on the issue;
• For an Adult at Risk a Capacity assessment will be required to see whether the legislation of the Mental Capacity Act 2005 applies;
• Consideration of whether there are any issues relating to domestic abuse.

Every attempt should be made to work with parents/carers on a voluntary basis to prevent abuse. It is the responsibility of the multi agency partnership 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, and as a result, any indication of increased risk of the procedure taking place should be responded to swiftly.

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, especially 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; where consent is not given, legal advice should be sought. Children of sufficient age and understanding should be given every opportunity to be interviewed alone.

Adults who are vulnerable / At Risk need to be interviewed alone and a Capacity assessment completed. Capacity is a decision and time 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. Adults at Risk 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 initial investigations and assessment. The multi agency group will need to agree next steps for support and level of need. 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:

• Legal action;
• Criminal prosecution;
• An Initial Child Protection Conference/Adult Safeguarding Conference.

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

For Adults, a Safeguarding Plan will be formulated and monitored in accordance with the Safeguarding Adult Procedures (See Appendix 6: 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.

Adults in Immediate Danger

When an adult is in immediate danger, contact the Police. If concerned, irrespective of whether the adult has capacity or not, take legal advice as applications to either the Court of Protection or High Court may be required.

If there is no evidence of risk to the Adult at Risk or Child (ren)

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 them 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.

See also Keeping Children Safe in Education (DfE).

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.

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 children's social care in accordance with their local safeguarding procedures.

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 practising community.

Regulated professionals i.e. teachers, social workers and healthcare professionals have a duty under the Serious Crime Act (2015) to report any cases of FGM identified in a female under 18 years of age to the Police via the non-emergency number: 101.

Health professionals in GP surgeries, sexual health clinics, Women's Health, hospital Emergency Departments 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 practising FGM. Health Professionals should remember that some females may be traumatised from their experience and have already resolved to never allow their daughters to undergo this procedure.

Mandatory recording and reporting for Healthcare providers

Healthcare professionals have a duty under the Serious Crime Act (2015) to report any cases of FGM identified in a female under 18 years of age to the Police via the non-emergency number: 101.

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 care and / Police.

In maternity departments it should be part of routine enquiry to ask women whether they have undergone FGM. However FGM may be identified in many other clinical settings, including family planning clinics, sexual health services, obstetrics & gynaecology, General Practice, Hospital Emergency Department, mental health services. 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.

If a patient is identified as being at risk of FGM this information must be shared with the GP and Health Visitor or School Nurse (dependent on the child's age), as part of child safeguarding actions.

NHS hospitals, GP practices and Mental Health Trusts must record:

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

GPs, and Practice Nurses

GPs 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 you must specifically ask about FGM and the pathway in Appendix 9: Flowchart for General Practice Staff followed. In addition consider asking those that attend for health checks or travel vaccinations from affected communities about FGM and advising on the health impacts.

In accordance with the mandatory reporting requirements; the GP/Nurse should document in the patients record:

• If a 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/Adults at Risk) should be asked to determine if there are any safeguarding issues. The FGM Risk Assessment Guidance found in the Female Genital Mutilation (FGM) Safeguarding and Risk Assessment Quick Guide for Health Professionals (Department of Health and Social Care), will help to determine the most appropriate referral pathway. They should be offered/referred for additional support. Document in the record any advice or leaflets that are provided. Contact the Named and Designated professionals for advice if required and make a referral to Children's Social Care where there are safeguarding concerns.

In all cases of FGM identified (irrespective of age or whether there are safeguarding issues identified or not), the information should be submitted via the FGM template (distributed to GP practices), to the Named GP for Safeguarding Children who will ensure the practice receive support if required and will upload the data to the FGM Enhanced Dataset

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

They must also document what plan is in place for delivery. It should be documented 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

Re-infibulation is illegal in the UK. 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 Children's Social Care to ensure a referral has been made.

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 Abuse and local protocols must be followed.

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.

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, and 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.

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.

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 consideration of 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.

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.

See also Referrals Procedure.

From 31st October 2015 it is a legal requirement that any case of FGM in those under 18 years old is reported to the Police via the 101 non-emergency number.

This may mean that the Police are the first point of contact and they should follow the agreed local pathway for referral to Children's Social Care (see Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM and Appendix 8: Decision-Making and Action Flowchart for Safeguarding Children – Actual FGM).

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 practise 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.

Risks 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.If it is believed or known that a girl has undergone FGM, a Strategy Meeting must be held as soon as practicable, and dependent upon urgency, to discuss the implications for the child and the coordination of the criminal investigation.

A second Strategy Meeting (if required) should take place within the timeframe agreed at the initial Strategy Meeting.

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.

Where a medical examination is deemed necessary it should be conducted by a doctor trained in identifying FGM. If it has been decided at the strategy meeting that a safeguarding medical is required an identified professional must contact St Mary's SARC for further advice and guidance. 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.

If an adult female is at risk of undergoing or had already undergone FGM, these incidents should be dealt with by the Public Protection Investigation Unit as a form of Domestic Abuse/Honour Based Violence incident. Relevant risk assessments (such as the DASH domestic abuse and stalking risk indicator checklist - see SafeLives website) 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.

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.

Part of the investigation should entail identification of any persons who seek to aide, abet or procure someone to commit FGM and with a view to identifying other victims. Early Crown Prosecution investigative advice will be sought by the Police under the FGM Protocol between Cheshire Constabulary and CPS Mersey-Cheshire Dec 2013.

Appendix 1: Guidance for Interviewing Parents/Children/Adults at Risk

Appendix 2: Legislation on Female Genital Mutilation (FGM)

Appendix 3: Useful Contacts

Appendix 4: Related Guidance

Appendix 5: Glossary

Appendix 6: Decision-Making and Action Flowchart for Safeguarding Adults at Risk

Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM

Appendix 8: Decision-Making and Action Flowchart for Safeguarding Children - Actual FGM

Appendix 9: Flowchart for General Practice Staff