Key learning points:
– What is female genital mutilation, where it is practised and why?
– The mandatory recording and collecting of data
– The safeguarding risk assessment guidance and new mandatory reporting duty
‘Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.’1 It involves removing and damaging healthy female genital tissue, and hence interferes with the natural function of girls’ and women’s bodies.
Types of FGM
The World Health Organization1 (WHO) has classified FGM into different four types:
Type 1 –Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Type 2 –Excision: 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 3 –Infibulation: narrowing of the vulval opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner or outer labia, with or without removal of the clitoris.
Type 4 –Other: all other harmful procedures to the female genitalia for non-medical purposes, eg pricking, piercing, incising, scraping and cauterising the genital area.
Consequences of FGM
Many men and women from practising communities can be unaware of the relationship between FGM and its harmful physical and mental health consequences. The short-term consequences following FGM can include:
– Severe pain.
– Emotional and psychological shock (exacerbated by having to reconcile being subjected to the trauma by loving parents, extended family and friends).
– Wound infections, such as tetanus and blood borne viruses (eg HIV and hepatitis B and C).
– Urinary retention.
– Injury to adjacent tissues.
– Fracture or dislocation as a result of restraint.
The longer-term implications for women who have had FGM types 1 and 2 are likely to be related to the trauma of the actual procedure, while health problems caused by FGM type 3 are more severe and long-lasting. However, all types of FGM are extremely painful and distressing and damage sexually sensitive skin. The long-term health implications can include:
– Chronic vaginal and pelvic infections.
– Difficulties with menstruation.
– Difficulties in passing urine and chronic urine infections.
– Renal impairment and possible renal failure.
– Damage to the reproductive system, including infertility.
– Infibulation cysts, neuromas and keloid scar formation.
– Complications in pregnancy and delay in the second stage of childbirth (when the woman is fully dilated).
– Pain during sex and lack of pleasurable sensation.
– Psychological damage, including a number of mental health and psychosexual problems such as depression, anxiety, sexual dysfunction, flashbacks, substance misuse and/or self-harm.
– Increased risk of HIV and other sexually transmitted infections.
– Death of mother and/or child during childbirth.
International prevalence of FGM
FGM is practised mainly among specific ethnic populations in Africa and parts of the Middle East and Asia. The WHO1 estimates that more than 125 million girls and women worldwide have experienced FGM and around three million girls undergo some form of the procedure each year in Africa alone. FGM has also been documented in Iraq, Israel, Oman, the United Arab Emirates, the Occupied Palestinian Territories, India, Indonesia, Malaysia and Pakistan.2 It is also found in Europe, Canada, the USA, Russia and Australia because of migrating populations.
Prevalence of FGM in the UK
A recent report3 estimated that 137,000 women and girls affected by FGM – born in countries where FGM is practiced – were permanently residents in England and Wales in 2011. Additionally, the report estimated that there are approximately 60,000 girls aged 0-14 born in England and Wales to mothers who have themselves undergone FGM.3 In addition, approximately 10,000 girls aged less than 15 who have migrated to England and Wales are likely to have undergone FGM. Although there are reported cases where FGM has been carried out in the UK, the majority of women and girls will have experienced FGM before arriving here. The Health and Social Care Information Centre4 recently began collecting data on the numbers of girls and women with FGM accessing acute trusts in England and Wales. From September 2014 – March 2015, 3,963 women (more than 18 years of age) and 60 girls (less than 18 years of age) were identified as having had FGM.
Why it is practised?
FGM is a deeply-rooted practice, with culture and tradition given as the main reasons for its continuation.5 Reasons include:
– Controlling women’s sexuality and ensuring marital fidelity.
– Cultural identity/social cohesion.
– Hygiene and preserving virginity.
– Mistaken belief that it is a religious obligation.
– Girls may want to undergo FGM as a result of social pressure.
– Honour, gender based violence and transition to womanhood.
How is FGM performed?
FGM is usually performed by traditional birth attendants or circumcisers. However, evidence suggests that 18% of all FGM is performed by qualified healthcare providers.1 Anaesthetic is rarely used and the child may be held down by a number of women. Special knives, scissors, razors or pieces of glass, even sharp stones are reported as being used. The wound is often held together with thorns and afterwards the girls’ legs may be bound together until the wound is healed. The age of FGM varies from a few days old to adulthood depending on the geographical area and community, but is most common from five to 14 years of age.1
FGM and the law
FGM is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. FGM has been illegal in the UK since the Prohibition of Female Circumcision Act 1985. The Female Genital Mutilation Act 2003 made it illegal to aid, abet, counsel or procure a non-UK national to carry out FGM on girls (who are British nationals or permanent residents of the UK) abroad, whether or not it is lawful in that country. It also increased the penalty of performing FGM to 14 years’ imprisonment. The Serious Crime Act 2015 extended the offences related to FGM in England and Wales to include: making parents/carers responsible for failing to prevent their child being subjected to FGM, granting life-long anonymity to victims of FGM, introducing a new FGM protection order, and a new mandatory reporting duty.
The mandatory reporting duty
A new mandatory reporting duty for professionals to report cases of FGM in females less than 18 years of age came into force 31 October 2015. On the 20 October 2015 the Home Office published procedural guidance6 and this states clearly that the duty:
– Only applies to cases where a girl or young woman less than 18 years of age has been identified as having had FGM.
– Applies to all regulated healthcare and social care professionals and teachers.
– Require reports to be made to the police via the non-emergency number, 101, by the end of the next working day (although under exceptional circumstances this may be within one month of initial disclosure/identification – depending on the circumstances of the case).
– Is a personal duty placed upon the individual professional who identifies FGM. If you do not comply your professional regulator may consider the circumstances under the existing Fitness to Practise proceedings.
The reporting and recording of FGM data
Information standards were introduced in April 2014 to ensure that healthcare professionals record and collect information when they care for women and girls with FGM. The current standard is called the Enhanced Dataset and since 1 October 2015 applies to acute trusts, GP surgeries and mental health trusts in England and Wales. The standard requires professionals to record information about FGM and to send aggregate data to the Health and Social Care Information Centre. The data will be used to support commissioning of appropriate NHS services and to provide a clearer understanding of the extent of FGM across the NHS. Education and training resources are available for healthcare professionals (see Resources section).
Making a difference
Nurses are at the frontline engaging with families from FGM practising communities. They may become specialists who become involved in setting up or leading FGM clinics/services or they may refer women and girls to specialist support services (such as uro-gynae clinics, counselling services or FGM clinics). They provide support across the life course for children from 0-18. For example, midwives should ask all pregnant women routinely at antenatal booking whether they have had FGM. The health visitor should carry out a risk assessment at the new birth visit and share this information with her colleagues. The school nurse can liaise with teachers to identify when a child may be discussing going on a family holiday where a coming of age ceremony may be taking place. The practice nurse may identify FGM when carrying out a smear test or may notice – when giving travel immunisations – that the family comes from an FGM practising community. Family planning nurses or paediatric nurses may be the first to visually identify a young woman/girl with FGM and need to be vigilant when observing genitalia that appears different/distorted.
It is imperative that nurses know the signs to look out for when a child might be at risk of, or may have had, FGM.
Health Education England FGM training programme –
FGM safeguarding risk assessment document – gov.uk/government/publications/safeguarding-women-and-girls-at-risk-of-fgm
Commissioning services to support women and girls with FGM –
NHS Choices FGM webpage for professionals – nhs.uk/fgmguidelines
FGM multi-agency guidelines – gov.uk/government/publications/female-genital-mutilation-guidelines
Statement opposing FGM known as ‘health passport’ – gov.uk/government/publications/statement-opposing-female-genital-mutilation
NSPCC’s FGM helpline for all frontline professionals – 0800 028 2550
HSCIC Care, FGM monthly statistics – hscic.gov.uk/fgm
Home Office, e-learning toolkit, free online training –
1. World Health Organization. Female Genital Mutilation Factsheet No 241, 2014. tinyurl.com/yrtjlx (accessed 13 May 2015).
2. UNICEF. Female Genital Mutilation/Cutting: a statistical overview and exploration of the dynamics of change, 2013. childinfo.org/files/FGCM_Lo_res.pdf (accessed 22 October 2015).
3. Macfarlane A, Dorkenoo E. Female Genital Mutilation in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk. Interim report on provisional estimates. London: City University London and Equality Now; 2014.
4. Health & Social Care Information Centre. Female Genital Mutilation (FGM) March 2015, experimental statistics. hscic.gov.uk/catalogue/PUB17463/fgm-mar-2015-exp-rep.pdf (accessed 9 October 2015).
5. Momoh C. Female genital mutilation. In: Squire C, ed. The Social Context of Birth. Radcliffe Medical Press, Abingdon: 2003;121-35
6. Home Office. Mandatory reporting of female genital mutilation: procedural information. gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare (accessed 3 November 2015).