4.18 Female Genital Mutilation

Contents

1. Legal status
2. Cultural Underpinnings
3. Types of Female Genital Mutilation
4. Implications of Female Genital Mutilation for a child's health and welfare
5. Identifying a Child who has been Subjected to Female Genital Mutilation or who is at Risk of Being Abused through Female Genital Mutilation
6. Responding to Female Genital Mutilation - Referral to Children, Young People and Families
7. Responding to Female Genital Mutilation - the Role of Health
8. Reducing the Prevalence of Female Genital Mutilation

1.  Legal Status

The World Health Organisation (WHO) defines female genital mutilation (FGM) as: "all procedures (not operations) which involve partial or total removal of the external female genitalia or injury to the female genital organs whether for cultural or other non-therapeutic reasons" (WHO, 1996)

It is illegal in the UK to subject a child to female genital mutilation or to take a child abroad to undergo FGM. In England, Wales and Northern Ireland all forms of FGM are illegal under the Female Genital Mutilation Act 2003 and in Scotland it is illegal under the Prohibition of FGM (Scotland) Act 2005.

A child for whom FGM is planned is at risk of significant harm through physical abuse and emotional abuse, which is categorised by some also as sexual abuse. See Recognition of Significant Harm - Definitions and Signs of Abuse Guidance.

Significant harm is defined as a situation where a child is suffering, or is likely to suffer, a degree of physical, sexual and / or emotional harm (through abuse or neglect) which is so harmful that there needs to be compulsory intervention by child protection agencies into the life of the child and their family.

2.  Cultural Underpinnings

Female genital mutilation (FGM) is a complex issue. Despite the harm it causes, many women from FGM practising communities consider FGM normal to protect their cultural identity.

Although FGM is practiced by secular communities, it is most often claimed to be carried out in accordance with religious beliefs. However, neither the Bible nor the Koran supports the practice of FGM. In addition to giving religious reasons for subjecting their daughters to FGM, parents say they are acting in a child's best interests because it:

• Brings status and respect to the girl;
• Preserves a girl's virginity / chastity;
• Is a rite of passage;
• Gives a girl social acceptance, especially for marriage;
• Upholds the family honour;
• Helps girls and women to be clean and hygienic.

The age at which girls are subjected to female genital mutilation varies greatly, from shortly after birth to any time up to adulthood. The average age is 10 to 12 years

3.  Types of Female Genital Mutilation

Female genital mutilation (FGM) has been classified by the WHO into four types:

• Type 1: Circumcision -  Excision of the prepuce with or without excision of part or all of the clitoris;
• Type 2: Excision (Clitoridectomy) - Excision of the clitoris with partial or total excision of the labia minora. After the healing process has taken place, scar tissue forms to cover the upper part of the vulva region;
• Type 3: Infibulation (also called Pharaonic Circumcision) -This is the most severe form of female genital mutilation. Infibulation often (but not always) involves the complete removal of the clitoris, together with the labia minora and at least the anterior two-thirds and often the whole of the medial part of the labia majora;
• Type 4: Unclassified - This includes all other procedures on the female genitalia, and any other procedure that falls under the definition of female genital mutilation given above.

4. Implications of Female Genital Mutilation for a Child's Health and Welfare

Short-term health implications can range from severe pain and emotional / psychological trauma to, in some cases, death.

The health problems caused by FGM Type 3 are severe - urinary problems, difficulty with menstruation, pain during sex, lack of pleasurable sensation, psychological problems, infertility, vaginal infections, specific problems during pregnancy and childbirth, including flashbacks.

Women with FGM Type 3 require special care during pregnancy and childbirth.

5.  Identifying a Child who has been Subjected to Female Genital Mutilation or who is at Risk of Being Abused Through Female Genital Mutilation

Indications that Female Genital Mutilation (FGM) may be about to take place include:

• The family comes from a community that is known to practise FGM;
• A child may talk about a long holiday to her country of origin or another country where the practice is prevalent, including African countries and the Middle East;
• A child may confide to a professional that she is to have a 'special procedure' or to attend a special occasion;
• A child may request help from a teacher or another adult;
• 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 child who has a sister who has already have undergone FGM must be considered to be at risk, as must other female children in the extended family.

Indications that FGM may have already taken place include:

• A child may spend long periods of time away from the classroom during the day with bladder or menstrual problems if she has undergone Type 3 FGM;
• A prolonged absence from school with noticeable behaviour changes on the girl's return could be an indication that a girl has recently undergone FGM;
• Professionals also need to be vigilant to the emotional and psychological needs of children who may/are suffering the adverse consequence of the practice (e.g. withdrawal, depression etc.);
• A child requiring to be excused from physical exercise lessons without the support of her GP;
• A child may ask for help

6.  Responding to Female Genital Mutilation - Referral to Children, Young People and Families

Any information or concern that a child is at immediate risk of, or has undergone, female genital mutilation (FGM) should result in a child protection referral to Children, Young people and Families in line with the Referrals (including Referrals Pathway) Procedure. See also Safeguarding Children at Risk of Abuse through Female Genital Mutilation (London 2007) (which is accessible elsewhere on the website).

Where a child is thought to be at risk of FGM, practitioners should be alert to the need to act quickly - before the child is abused through the FGM procedure in the UK or taken abroad to undergo the procedure.

On receipt of a referral, a Strategy Discussion/Meeting must be convened within two working days, and should involve representatives from the police, Children, Young People and Families, education, health and voluntary services.  Health providers or voluntary organisations with specific expertise (e.g. FGM, domestic violence and/or sexual abuse) must be invited, and consideration may also be given to inviting a legal adviser.

Every attempt should be made to work with parents on a voluntary basis to prevent the abuse.  It is the duty of the investigating team to look at every possible way that parental cooperation can be achieved, including the use of community organisations and/or community leaders to facilitate the work with parents/family. However, the child's interest is always paramount.

If no agreement is reached, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child's safety.

If the Strategy Discussion/Meeting decides that the child is in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, then an Emergency Protection Order should be sought.

If the child has already undergone FGM, the Strategy Discussion/Meeting will need to consider carefully whether to continue enquiries or whether to assess the need for support services. If any legal action is being considered, legal advice must be sought.

A child protection conference should only be considered necessary if there are unresolved child protection issues once the initial investigation and assessment have been completed.

Where FGM has been practised, the police child abuse investigation team (CAIT) will take a lead role in the investigation of this serious crime, working to common joint investigative practices and in line with strategy agreements.

7.  Responding to Female Genital Mutilation - the Role of Health

Health professionals in GP surgeries, sexual health clinics and maternity services are the most likely to encounter a girl or woman who has been subjected to Female Genital Mutilation (FGM).

Health professionals encountering a girl or woman who has undergone FGM should be alert to the risk of FGM in relation to her:

• Younger siblings;
• Daughters or daughters she may have in the future;
• Extended family members.

All girls/women who have undergone FGM (and their boyfriends / partners or husbands) must be told that re-infibulation is against the law and will not be done under any circumstances. Each woman should be offered counselling to address how things will be different for her afterwards.

After childbirth, a girl / woman who has been de-infibulated may request and continue to request re-infibulation. This should be treated as a child protection concern, as the girl / woman's apparent reluctance to comply with UK law and/or consider that the process is harmful raises concerns in relation to female child/ren she may already have or may have in the future. Professionals should consult with their agency's nominated safeguarding children adviser and with Children, Young People and Families about making a referral to them. See also the BMA guidance: FGM: Caring for patients and child protection

8.  Reducing the Prevalence of Female Genital Mutilation

Local Safeguarding Children Boards should promote awareness in the local area, particularly amongst local communities which practice FGM, that female genital mutilation is abusive to children and not legal in the UK.

See the Local Authority Social Services Letter LASSL (2004)4 for details of organisations able to advise on this form of community outreach work.

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