Female Genital Mutilation
(FGM)
Policy Title:
Female Genital Mutilation - FGM
Female Genital Mutilation (FGM) constitutes all the procedures that involve
partial or total removal of the external female genitalia or other injury to the
female organs whether cultural or any non-therapeutic reasons. This guideline
provides information for the care of women who have experienced the
procedure or is at risk of having FGM undertaken.
Executive
Summary:
Supersedes:
Female Genital Mutilation Maternity Policy
Description of
Amendment(s):
To include all Trust departments and specialities not only Maternity services
To update in line with Pan Cheshire LSCB Female Genital Mutilation Policy
To update in relation to Mandatory Recording and Reporting duties under the
Serious Crime Act 2015
This policy will impact on: The work of all employees and volunteers working at East Cheshire
Trust
Financial Implications: Non-known
Policy Area:
Version Number:
Issued By:
Author:
1
Performance & Quality
Corporate Business Unit
Heather Millward
Named Midwife for
Safeguarding
Document
Reference:
Effective Date:
Review Date:
Female Genital Mutilation
January 2017
January 2020
Impact
January 2017
Assessment Date:
APPROVAL RECORD
Committees / Group
Date
Maternity Clinical Governance
Committee
September 2017
Integrated Safeguarding
Assurance Group
September 2017
Kath Senior
September 2017
Consultation:
Approved by Director:
2
Table of Contents
1. Introduction
2. Purpose
3. Responsibilities
4. Processes and Procedures
Incidence
Classification of FGM
Health Implications of FGM
Risk factors
FGM and the Law
Professional Response ER
Identification of FGM with in Health Care Sector
hm
Safeguarding Children
Mandatory Reporting for Health Care Professionals
Mandatory Recording for Health Care Professionals
Managing FGM with in Maternity services
Reversal of infibulations (De-infibulation)
Technique use for De-infibulation
Safeguarding Unborn baby girls
Intrapartum Care
Postpartum Care
Emergency departments and walk-in centres
Links with Forced Marriage and Domestic Violence and Abuse
Counselling
5. Monitoring Compliance with the Document
6. References
Page
7. Communication
8.
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Page
Appendix
12
3
Appendix 1 Types of FGM (WHO classification)
Appendix 2 Countries that practice FGM
Appendix 3 Patient Information Resources
Appendix 4 Flowchart following a disclosure of or identification of Female Genital
Mutilation (FGM)
Appendix 5 Female Genital Mutilation (FGM) Recording proforma
1. Introduction
It is illegal to practice FGM in the United Kingdom (UK) and to assist in its practice on UK
nationals or permanent residents abroad. FGM is typically performed on girls between the age
of 4 and 13, although in some cases it is performed on new born babies or young women prior
to marriage or pregnancy. It is considered child abuse and a grave violation of the human rights
of girls and women. In all circumstances where FGM is practised on a child it is a violation of
the child’s right to life, their right to their bodily integrity as well as their right to health. FGM has
been included within the revised (2013) Government definition of Domestic Violence and Abuse.
2. Purpose
This guideline supports the Heath Care practitioner in the care of women who have
undergone Female Genital Mutilation (FGM) which constitutes 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).
FGM is also known as Female Circumcision (FC) and Female Genital Cutting (FGC). These
alternative definitions are better received in the communities that practice it, as they do not see
themselves as engaging in mutilation.
This policy should be read in conjunction with:
Pan Cheshire LSCB Female Genital Mutilation Policy
East Cheshire Trust Safeguarding Children’s Policy
East Cheshire Trust Adults at Risk Policy
East Cheshire Trust Domestic Violence and Abuse Policy
3.0 Responsibilities
4
Chief Executive
Has ultimate responsibility for the implementation and monitoring of the policies in use in the
Trust. This responsibility may be delegated to an appropriate colleague.
Clinical Leads/Head of Midwifery
Where Clinical Leads/Head of Midwifery are asked to ratify this guideline they are responsible
for the review of the guideline and the final ratification prior to the guideline actually being
implemented. This ratification process will take place following the consultation and approval
process.
Trust Committees
As a group are responsible for the consultation and approval process required during the
development of guidelines for the Trust. The committees are responsible for the review of
guidelines submitted to them to ensure that guidelines are appropriate, workable and follow the
principles of best practice.
All Staff
It is incumbent on relevant staff, when asked, to provide comments and feedback on the content
and practicality of guidelines that are being developed and reviewed. It is the duty of all staff
when asked, to provide assistance during the development and review stages of guideline
formulation.
Stakeholders
Are those people with an interest in a guideline who contribute, comment and agree to the
content of the guideline. They include specific committees, groups or forums, individual
colleagues, whole departments, service users and their families.
4.0
Processes and Procedures
Incidence
UNICEF estimates that worldwide over 125 million women and girls have undergone FGM. It
has been estimated that 137 000 women and girls in England and Wales, born in countries
where FGM is traditionally practiced (Appendix 2), have undergone FGM including 10 000 girls
under 15 years of age. (RCOG 2015)
This estimate is based on combining published data on FGM prevalence in FGM practicing
countries with census and birth registration data in England and Wales.
2.4 Classification of FGM (Appendix 1)
Female Genital Mutilation is classified into four types:
Type 1
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
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Type 2
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia
majora (excision).
Type 3
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the
labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4
Unclassified. This involves pricking, piercing or incising of the clitoris and/or labia; stretching of
the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping
of tissue surrounding the vaginal orifice or cutting of the vagina; introduction of corrosive
substances or herbs into the vagina to cause bleeding or for the purposes of tightening or
narrowing it; and any other procedure that falls under the definition of female genital mutilation
given above.
.
Health Impact
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.
Immediate Physical Problems
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Intense pain and/or haemorrhage that can lead to shock during and after the procedure
Death
Haemorrhage that can lead to Anaemia
Wound infection including Tetanus
Urinary 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
Long Term Health Implications
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Excessive damage to the reproductive system
Uterine, vaginal and pelvic infections
Infertility
Cysts
Complications with menstruation
Psychological damage; including a number of mental health and psychosexual problems
Abscesses
Sexual dysfunction
Difficulty passing urine
Increased risk of HIV, Hep and Hep C
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Health implications related to pregnancy and childbirth
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Increased risk of Maternal and Child Morbidity and Mortality (women who have
undergone FGM are twice as likely to die during childbirth and are more likely to give
birth to a stillborn child)
Fear of childbirth
Difficulty in catheterising the bladder
Increased risk of candidiasis
Reduced vaginal opening which makes vaginal procedures difficult or impossible and
painful.
Difficulty in performing fetal bloods sampling or applying a fetal scalp electrode
Increased risk of uterine rupture
Increased risk of severe vaginal lacerations. (including fistula formation)
Increased risk of episiotomy
Increased risk of caesarean section
Increased risk of postpartum haemorrhage
Increased risk of fetal asphyxia or death
Extended hospital stay
Risk Factors for being subjected to FGM
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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
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 i.e. poor levels of integration can increase level of risk.
FGM and the Law
FGM has been illegal in the UK since 1985 (Female Circumcision Act) this was revised in 2003
and became the Female Genital Mutilation Act. More recently in 2015 the Serious Crime Act
was introduced and strengthened the legislative framework around tackling FGM.
All health care professionals must be able to explain the UK Law. The FGM Act 2003 states:
FGM is illegal unless it is a surgical operation on a girl or woman irrespective of her age which
a) is necessary for her physical or mental health or b) she is in any stage of labour, or has just
given birth, for purposes connected with the labour or birth.
It is illegal to arrange, or assist in arranging, for a UK national or UK resident to be taken
overseas for the purpose of FGM
It is an offence for those with parental responsibility to fail to protect a girl from the risk of FGM
If FGM is confirmed in a girl under 18 years of age reporting to the police and Children’s
Social Care is mandatory (Serious Crime Act 2015)
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FGM is considered to be a form of child abuse (Physical and Emotional abuse) it is also an
abuse of female adults categorised under Honour Based Violence and Domestic Abuse
definitions.
Professional Response
There are three circumstances relating to FGM which require identification, assessment
and possible intervention.
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Where a child is at risk of FGM;
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Where a child has been abused through FGM;
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Where a (prospective) mother has undergone FGM.
Professionals and volunteers in most agencies have little or no experience of dealing with
female genital mutilation. Coming across FGM for the first time they can feel shocked, upset,
helpless and unsure of how to respond appropriately to ensure that a child, and/or a mother, is
protected from harm or further harm.
The appropriate response to FGM is to follow usual child protection procedures to ensure:
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Immediate protection and support for the child/ren; and
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That the practice is not perpetuated.
An appropriate response to a child suspected of having undergone FGM as well as a child at
risk of undergoing FGM could include:
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Arranging for a professional interpreter if this is necessary and appropriate;
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Creating an opportunity for the child to disclose, seeing the child on their own;
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Using simple language and asking straightforward questions;
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Using terminology that the child will understand e.g. the child is unlikely to view the
procedure as abusive;
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Being sensitive to the fact that the child will be loyal to their parents;
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Giving the child time to talk;
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Getting accurate information about the urgency of the situation, if the child is at risk of
being subjected to the procedure;
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Giving the message that the child can come back to you again.
An appropriate response by professionals who encounter a girl or woman who has undergone
FGM includes:
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Arranging for a professional interpreter and not agreeing to friends/family members
interpreting on their behalf;
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Being sensitive to the intimate nature of the subject;
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Making no assumptions;
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Asking straightforward questions;
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Being willing to listen;
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Being non-judgemental (condemning the practice, but not blaming the girl/woman);
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Understanding how she may feel in terms of language barriers, culture shock, that she,
her partner, her family are being judged;
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Giving a clear explanation that FGM is illegal and that the law can be used to help the
family avoid FGM if/when they have daughters
Identifying FGM with in the Health Care sector
Health professionals working with in GP surgeries, sexual health clinics, gynaecology, A&E and
maternity services are the most likely to encounter a girl or woman who has been subjected to
FGM.
Health Care professionals should deal with FGM in a sensitive and professional manor, 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. Health Care professionals should
remember that some females may be traumatised from their experience and as a consequence
be suffering from a range of Mental Health issues including Post Traumatic Stress Disorder.
All girls and women who have undergone FGM should be given information about the legal and
health implications of practising FGM. The ‘More Information about FGM leaflet’ is available to
download and print out – please see Appendix 3
Please see Appendix 4 ‘Flowchart following a disclosure or identification of FGM.
Safeguarding Children
Health professionals, particularly GPs, Midwives, School Nurses, Sexual Health Staff and
Gynaecologists, are in a key position to identify female children in a family where women or girls
have already undergone FGM.
Health staff particularly school nurses and nurses working in vaccination clinics are in a key
position to identify girls who may be visiting overseas and may be at risk of FGM.
FGM is considered child abuse in the UK and a grave violation of the human rights of girls and
women. In all circumstances where FGM is practised on a child it is a violation of the child’s
right to life, their right to their bodily integrity, as well as their right to health. The UK
Government has signed a number of international human rights laws against FGM, including the
Convention on the Rights of the Child.
Female Genital Mutilation is illegal in the UK under the Female Genital Mutilation Act 2003. The
Act also makes it an offence for UK nationals and those with permanent UK residence to be
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taken overseas for the purpose of female circumcision, to aid and abet, counsel, or procure the
carrying out of Female Genital Mutilation.
Practice points:
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‘aiding, abetting and counselling applies to those who assist or persuade a girl to
perform FGM on herself even though it is not itself an offence for that child to carry it out
on herself.
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‘Girl includes woman’ (Female Genital Mutilation Act, 2003) although not an offence for
a girl or young woman to perform FGM on herself, consideration should be given to
whether such self-harm is a safeguarding issue where the action may be the result of
adult pressure
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Midwives need to note that it is illegal to re-infibulate a woman following the birth of her
baby.
Midwives and Obstetricians may become aware that FGM has taken place when treating a
pregnant woman. This should trigger concern for any female child of the family and should be
reported to the Safeguarding Children Team.
All incidents of FGM must be recorded on the patients records and notified via the Datix system
What to do if you suspect a child may be at risk of undergoing FGM
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Be aware that FGM is child abuse and that you must take action
Discuss your concerns with the Safeguarding Team
Follow Cheshire East LSCB (Local Safeguarding Children Board) procedures
Refer to Children’s Social care/Police
(This Guidance should be read in conjunction with the Safeguarding Adult Policy, Safeguarding
Children’s Policy & the LSCB Pan Cheshire FGM Policy)
Mandatory REPORTING for Healthcare providers
Regulated professionals i.e. teachers, social workers and healthcare professionals have a
mandatory duty under the Serious Crime Act 2015 to report all cases of FGM identified in a
female less than 18 years of age to the police via the 101 number and to children’s social care.
Girls identified as at risk of having FGM should be referred to Children’s Social Care following
the Trusts safeguarding Children’s policy.
Mandatory RECORDING of FGM information
It is mandatory for health care professionals to record the presence of FGM in a patient’s
healthcare records whenever it is identified through the delivery of NHS healthcare. The
patients’ health record should always be updated with whatever discussions or actions have
been taken. If FGM has been identified then this should be included in any discharge
documentation so that the patients GP is made aware of the patients FGM status. If a girl has
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been identified as at risk of FGM this information must be shared with the GP, Health Visitor or
School Nurse (dependant on the child’s age) as part of Child Safeguarding actions.
Since April 2014 it has been mandatory for NHS hospitals to record the following:
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If a patient has undergone FGM
What type of FGM
If there is a family history of FGM
If an FGM-related procedure has been carried out on the woman i.e. deinfibulation
If FGM has been disclosed or identified then it is the responsibility of all health care staff to
complete the FGM recording Proforma (Appendix 5) once completed this proforma needs to be
filed in the woman’s health care records and copied to the Safeguarding Team.
All women accessing Maternity services will be routinely asked about FGM at their booking in
appointment with the Midwife. For women who do not disclosed that they have had FGM at the
booking appointment but it is identified in labour or at delivery midwives are able to document
this as part of their electronic delivery documentation.
.
If FGM has been identified then a Datix incident form should be completed. This enables the
Trust to accurately collect FGM data that needs to be reported to the Health and Social Care
Information Centre (HSCIC) as part of the Trusts mandatory reporting duties.
Managing FGM within Maternity Services
Midwives and Obstetricians need to be aware of how to care for women and girls who have
undergone FGM during the antenatal, intrapartum and postnatal periods
All women accessing Maternity services will be routinely asked about FGM at their initial
booking in appointment with the Midwife. They should document if the woman has:
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Undergone FGM
When the FGM was undertaken
What type of FGM – this may necessitate a clinical examination as the women herself
may not be aware which type of FGM she has had.
If there is a family history of FGM
If an FGM-related procedure has been carried out on the woman i.e. deinfibulation
All women identified as having had FGM should be referred for Consultant review and a plan for
delivery discussed and clearly documented. Women who have had Type 1 or 2 who have had
successful vaginal deliveries in the past may be eligible for midwifery lead care but only after an
initial review by a consultant obstetrician.
Clinical examination by an experienced obstetrician or Midwife should be offered to the woman
and only undertaken with her consent. The assessment should include inspection of the vulva to
determine the type of FGM and whether deinfibulation is indicated. If the introits is sufficiently
open to permit vaginal examination and if the urethral meatus is visible, then de-infibulation is
unlikely to be necessary. If the FGM is more extensive then elective deinfibulation should be
considered to enable to women to achieve a vaginal delivery. Deinfibulation will also reduce
some of the long-term health implications of FGM and enable the women to partake in the
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cervical screening programme. Deinfibulation however should not be seen as reversal of FGM
as there is no way of replacing the healthy tissue that was removed by the original procedure.
Deinfibulation does not restore psychical or emotional normality.
The consultation should also include a psychological assessment and referral to a psychologist
should be discussed with the woman.
Reversal of infibulations (Deinfibulation)
De-infibulation is a small procedure to open the scar carried out in a clinical setting usually
under local anaesthetic
Women should be recommended to undergo de-infibulation before conception, especially if
difficult surgery is anticipated.
 Urine should be screened for bacteriuria before surgery
 Blood should be taken for group and save due to the risk of haemorrhage
 De-infibulation may be carried out in a suitable outpatient room equipped for minor surgery
or in an operating department
 Ideally the surgeon should have experience of de-infibulation. It may be appropriate to
consult with a tertiary centre that has developed expertise in the assessment and
management of affected women.
Technique use for Deinfibulation
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Before De-infibulation, identification of the urethra should be attempted and a catheter
passed
Incision should be made along the vulval excision scar
Cutting diathermy reduces the amount of bleeding
The use of fine absorbable suture material such as Vicryl Rapide is recommended
Prophylactic antibiotic therapy should be considered
Adequate pain relief is essential to limit the risk of psychological harm. The needs of the
individual woman should be considered
Re-infibulation following childbirth is illegal. This should be discussed with the woman prior
to undertaking de-infibulation.
Safeguarding Unborn baby girls
If a girl or women who has been de-infibulated requests re-infibulation/re-suturing after the birth
of a child, and/or the child born is female or there are daughters in the family health
professionals should consult with the Trusts Safeguarding team and Children’s Social Care
about making a referral to them.
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 have or may have in the future. Some women will be pressurised to ask for re-infibulation
by their partners. This would come under the category of Domestic Abuse and trust policy
should be followed.
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Intrapartum Care
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Women should be strongly advise to deliver in an obstetric unit where emergency services
are available
Women who have undergone successful de-infibulation and an uncomplicated vaginal birth
(and no repeat procedure) can be considered for a midwifery led unit
Genital mutilation is not an absolute indication for caesarean section unless the woman has
such an extreme form of mutilation with anatomical distortion that makes de-infibulation
impossible
Decisions about delivery must take into account the psychological needs of the woman
Episiotomy should be recommended if inelastic scar tissue appears to preventing progress
but careful placement is essential to avoid severe trauma to surrounding tissues, including
bowel.
Intravenous access and group and save serum should be strongly recommended
Epidural is recommended for those women who find difficulty in tolerating vaginal
examination
Epidural should be recommended if anterior episiotomy is needed in labour
Postpartum Care
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Care of the perineum must be observed and advised
Discuss with the woman and family the potential of female genital mutilation for the female
child and the legal consequences should this be considered.
Information leaflets for support groups can be obtained from such organisations as BWHFS
(Black Women’s Health & family support groups). A list of useful contacts is enclosed within
this Guideline.
Emergency departments and walk-in centres
Health care professionals working within Emergency departments or 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, 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 the Safeguarding Team about
making a referral to social care if the child is under the age of 18 years or is an adult and
assessed as being vulnerable.
Links with Forced Marriage and Domestic Violence and Abuse
There can be links between FGM and Forced Marriage particularly in adults/teenagers when the
woman may be mutated shortly before the marriage. A woman/girl who has been subjected to
FGM may have numerous gynaecological problems and this may make consummation of her
marriage or sexual activity with her partner uncomfortable/painful/impossible. Women and girls
may be raped within their relationship and suffer pain and re-traumatisation every time a partner
demands sex. Some men may understand and the couple may seek support.
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
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undergone FGM should be offered counselling to discuss how de-infibulation will affect them.
Parents, husbands and boyfriends and partners can also be offered counselling. The Mental
Health service for Cheshire area (CWP) has an identified consultant psychiatrist to lead on
FGM.
5.0 Monitoring Compliance with the Document
Measuring Performance and Audit
The Trust will measure performance of this guideline via the Datix reporting system.
Review
This guideline will be reviewed every three years or sooner following findings from audit,
changes to national guidance, or in response to clinical practice. The responsibility for the
review of guidelines lies with the author.
6.0
References
DOH (2009) Government Equalities Office Fact Sheet. Putting equality at the heart government
DOH (2007) Statistical Study to Estimate the Prevalence of Female Genital Mutilation in
England and Wales.
DOH (2015) Mandatory reporting resources for healthcare professionals
www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare
DOH (2013) Domestic violence and abuse - professional guidance
FORWARD (1999) A report on the conference on Female Genital Mutilation (Moving Forward).
London. Foundation for Women’s Health Research and Development (FORWARD).
Home Office (2015) Mandatory reporting procedural information
www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilationprocedural-information
Home Office (2016) Fact sheet on mandatory reporting of female genital
mutilationwww.gov.uk/government/publications/fact-sheet-on-mandatory-reporting-of-femalegenital-mutilation
Home Office (April 2016) Multi-agency statutory guidance on female genital mutilation.
HSCIC, NHS England FGM data
www.hscic.gov.uk/searchcatalogue?q=%22female+genital+mutilation%22&area=&size=10&sort
=Relevance
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Macfarlane A, Dorkenoo E. (2015) Prevalence of Female Genital Mutilation in England and
Wales: National and local estimates. London: City University London and Equality Now
http://openaccess.city.ac.uk/12382/
Newman, M (1996) ‘Midwifery Care for Genitally Mutilated Women’. Modern Midwife. Vol.6.
No.6. June. pp 20-22.
Royal College of Obstetricians and Gynaecologists Green top Guideline No 53 Female Genital
Mutilation and its Management 2015
WHO (1996) Female Genital Mutilation Information Pack. World Health Organisation (WHO).
August http://www.who.int/frh-whd/FGM/infopack/English/fgm-infopack.htm
Newman, M (1996) ‘Midwifery Care for Genitally Mutilated Women’. Modern Midwife. Vol.6.
No.6. June. pp 20-22.
UNICEF FGM international data http://data.unicef.org/child-protection/fgmc.html
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Appendix 1
Appendix 1: Types
of FGM [WHO classification]
Normal anatomy
Type 1: Partial or total removal of the
clitoris and/or the prepuce
(clitoroidectomy)
TYPE 2: Partial or total removal of the
clitoris and the labia minora, with or
without excision of the labia majora
(excision)
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TYPE 3: Narrowing of the vaginal orifice
with creation of a covering seal by cutting
and appositioning the labia minora and/or
the labia majora, with or without excision
of the clitoris (infibulation)
TYPE 4: All other harmful procedures to
the female genitalia for non-medical
purposes, e.g. pricking, piercing, incising,
scraping and cauterising.
(Images courtesy of Blatant World, Ireland https://www.flickr.com/people/blatantworld/)
Appendix 2 Health and Safety Process Flow Chart
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Appendix 2
Countries that practice FGM
FGM is concentrated in a swathe of countries from the Atlantic coast to the Horn of Africa
FGM has also been documented in communities including:
Iraq
Israel
Oman
the United Arab Emirates
the Occupied Palestinian Territories
India
Indonesia
Malaysia
Pakistan
Percentage of girls and women aged 15 to 49 years who have undergone FGM/C
Note: In Liberia, girls and women who have heard of the Sande society were asked whether they were
members; this provides indirect information on FGM/C since it is performed during initiation into the
society.
Source: UNICEF global databases, 2014, based on DHS, MICS and other nationally representative
surveys, 2004-2013. http://www.data.unicef.org/child-protection/fgm
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Appendix 3
Patient Information Resources
Department of Health: More information about FGM
For patient information leaflet please follow link below.
http://www.nhs.uk/NHSEngland/AboutNHSservices/sexual-healthservices/Documents/2903740%20DH%20FGM%20Leaflet%20Acessible%20-%20English.pdf
NHS: More information about FGM
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/482799/6_1587_HO_MT_
Updates_to_the_FGM_The_Facts_WEB.pdf
Useful Contacts

Third Sector Agencies Working with FGM

Foundation for Women’s Research and Development (FORWARD)
Tel: 0208 960 4000
Email: [email protected]

The NSPCC 24 hour helpline to protect children and young people affected by FGM
Tel: 0800 028 3550
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NESTAC – Drop in groups across the Northwest for girls and women affected by
FGM
Tel: 01706 868993
Mobile: 07862 279289
Email: [email protected]
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ChildLine
24 hour helpline for children
Tel: 0800 1111

National 24 hour Domestic Violence helpline
24 hour Helpline
Tel: 0808 2000 247

Agent for Culture and Change Management UK (ACCM UK)
[email protected]
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Appendix 4
Flowchart following a disclosure of or identification of Female Genital Mutilation
(FGM)
Mandatory Recording
Patient discloses FGM or FGM
has been Identified
Complete FGM mandatory recording proforma
See appendix ---Trust FGM Policy
File in patient records
Give the Woman the Department of Health Leaflet “More
Information about FGM”
See appendix --- Trust FGM Policy
Consider any health consequences including psychological
of the impact of FGM and refer appropriately
Complete Datix
Share information with the woman’s GP
Mandatory Reporting
If the woman is under 18yrs of age
The Police must be contacted on 101.
A referral to children’s Social Care must be made as per
the Trust’s Safeguarding Children Policy
The Children’s Safeguarding team must be informed
Is the woman pregnant or does
she have female children
Has the woman any female
relatives who are under the age of
18 years who reside in the UK or
are UK nationals who could be at
risk of FGM
Has the woman any other
vulnerabilities or an Adult at Risk
If yes a consultation with Children’s Social Care must
take place as per the Trust’s Safeguarding Children
Policy
The Children’s Safeguarding team must be informed
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Follow Trust Safeguarding Adults at Risk Policy and
refer to Adult social Care and Police as appropriate
Inform Adult Safeguarding Team
Appendix 5
Female Genital Mutilation (FGM) Recording proforma
This proforma should only be completed following a disclosure of or an identification of FGM
The Department of Health Leaflet ‘More Information about FGM’ must be given & explained to the patient (See Appendix 3)
Woman’s/Girl’s Name
DOB
If the person is under 18 yrs the Police must be
contacted on 101 see Trust FGM Policy
NHS Number
GP
Country of family origin
Country of Birth
First Language spoken
Consider whether interpreter required
How was FGM identified
What is the type of FGM
See classification below if type 4 please specify
Age at which FGM was undertaken
1
2
3
4
Unknown
Country that FGM was undertaken
Has de-infibulation taken place
Opening up/reversal
Is the woman pregnant/ or just delivered a female
child
If yes to the above
a) what is the country of birth of the baby’s
father
b) what is the country of origin of the baby’s
father
Number of daughters under 18 years
Is there any family history of FGM
Have you informed the woman on the health
implications of FGM
Have you advised the woman on the illegalities of
FGM
Classification of Type
1 = removal of clitoris 2 = removal of clitoris and labia 3 = removal of all external genitalia with partial closing of vagina
4 = piercing, pricking, scraping, incising or cauterisation of genitalia
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Equality Analysis (Impact assessment)
1. What is being assessed?
East Cheshire NHS Trust: Female Genital Mutilation Policy.
Details of person responsible for completing the assessment:
 Name: Heather Millward

Position: Named Midwife for Safeguarding Children

Team/service: Safeguarding Team
State main purpose or aim of the policy, procedure, proposal, strategy or service:
(usually the first paragraph of what you are writing. Also include details of legislation,
guidance, regulations etc which have shaped or informed the document)
 To raise awareness of the issue of female genital mutilation (FGM) and its illegality with frontline professionals;
 To provide front-line professionals with an understanding of:

the complex issues around FGM,

the signs that a girl or woman may be at risk of FGM,

the signs that a girl or woman has been affected by FGM;
 To equip front-line professionals with the knowledge and confidence to undertake appropriate
responses to (potential) cases of FGM in line with existing statutory guidance;
 To encourage front-line professionals to challenge the issue of FGM and support efforts with
practising communities to abandon the practice;
 In the long term, the guidelines aim to support efforts to:

ensure more girls and women are protected from the severe consequences of FGM,

provide support to the girls and women living with the physical and mental
consequences of FGM,
 Reduce the prevalence of FGM in the UK.
2. Assessment of Impact
RACE:
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, racial groups differently?
Yes x No 
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Explain your response:
FGM is a deeply rooted tradition, widely practised mainly amongst specific ethnic populations in
Africa and parts of the Middle East and Asia.
The 28 African countries where FGM is most prevalent are Somalia, Guinea, Djibouti, Sierra
Leone, Egypt, Sudan, Eritrea, Mali, The Gambia, Ethiopia, Burkina Faso, Mauritania, Liberia,
Chad, Guinea-Bissau, Côte d’Ivoire, Nigeria, Senegal, Kenya, Central African Republic,
Tanzania, Benin, Toto, Ghana, Niger, Cameroon, Zambia, Uganda.
FGM has also been documented in communities in Iraq, Israel, Oman, the United Arab
Emirates, the Occupied Palestinian Territories, Yemen, India, Indonesia, Malaysia and
Pakistan.
The only currently available data source for FGM in the UK, the 2007 FORWARD study,
extrapolates prevalence rates from countries where FGM is more common and where UNICEF,
and other organisations, have conducted robust research.
The study highlights 29 nationalities disproportionately affected by FGM. For example, with
45,390 women of Kenyan origin in the UK in 2001 and a FGM prevalence rate of 32.2% in
Kenya, this suggests that there are 18,515 girls and women of Kenyan origin living with the
physical and mental consequences of FGM.
Immigration since 2001 may mean that these communities, and therefore the number of girls
and women at risk of FGM in the UK, are now significantly larger.
However, UNICEF reports have demonstrated that prevalence rates have fallen significantly in
many practising communities in Africa, the Middle East and Asia.
The prevalence rates of FGM in diaspora communities in the UK compared to those in countries
of origin is not known. However, a study of immigrant groups in the Netherlands (TNO,
‘Retrospective study into the prevalence of female circumcision or FGM in midwifery practice in
2008’) has suggested that prevalence rates may be significantly lower in diaspora communities
in West European countries
GENDER (INCLUDING TRANSGENDER):
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, different gender groups differently?
Yes X No 
Explain your response:
Due to its nature, all potential and actual victims of FGM will be female.
DISABILITY
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, disabled people differently?
Yes  No x
Explain your response:
No data is available breaking down the prevalence of FGM in the UK for girls or women with a
disability.
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AGE:
From the evidence available does the policy, procedure, proposal, strategy or service,
affect, or have the potential to affect, age groups differently?
Yes x No 
Explain your response:
Anecdotal evidence suggests that girls between the ages of five and eight are at highest risk of
FGM, although it can be performed on girls at birth, during childhood or adolescence at
marriage, or during the first pregnancy.
For those girls under 18, the guidelines draw on existing statutory guidance (‘Working Together
to Safeguard Children: a guide to inter-agency working to safeguard and promote the welfare of
children (2010)’, and ‘Safeguarding Children: working together to safeguard children under the
Children Act 2004 (2004)).
LESBIAN, GAY, BISEXUAL:
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, lesbian, gay or bisexual groups differently?
Yes  No x
Explain your response:
No data is available breaking down the prevalence of FGM in the UK for transgender or
transsexual individuals. No data is available breaking down the prevalence of FGM in the UK for
gay or bisexual girls or women.
RELIGION/BELIEF:
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, religious belief groups differently?
Yes x No 
Explain your response:
No data is available breaking down the prevalence of FGM in the UK among particular religious
groups.
However, while FGM is not a requirement of any religious group, the African, Middle Eastern
and Asian countries and communities where the practice is particularly prevalent have
significant Muslim, Christian and animalistic populations. It is likely therefore that those
communities practising FGM in the UK are disproportionally likely to also have these religious
beliefs.
CARERS:
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect, carers differently?
Yes  No x
Explain your response: This policy does not affect carers differently however it should
be considered that the patient’s carer(s) could be the perpetrator of the FGM
OTHER:
EG Pregnant women, people in civil partnerships, human rights issues.
From the evidence available does the policy, procedure, proposal, strategy or service affect,
or have the potential to affect any other groups differently?
Yes X No
Explain your response:
Anecdotal evidence suggests that those families that are less integrated into British society are
more likely to practise FGM.
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Language can be a barrier to the effective prevention and tackling of potential cases of FGM.
Therefore the guidelines recommend that a trained and professional interpreter should be made
available when professionals are speaking to girls and women who may not be able to discuss
their problems or fears in English.
FGM is a clear and severe form of violence against women, and, when it affects girls, child
abuse_______________________________________________________________________
3. Safeguarding Assessment - CHILDREN
a. Is there a direct or indirect impact upon children?
Yes x
No 
b. If yes please describe the nature and level of the impact (consideration to be given to all
children; children in a specific group or area, or individual children. As well as
consideration of impact now or in the future; competing / conflicting impact between
different groups of children and young people: The purpose of this policy to help support staff
to identify when FGM had been undertaken or when a female child is at risk of having FGM
undertaken. To give guidance to staff on how to effectively record and report identified cases or
female children who are at risk and to improve the service for female children and young people
who have presented to East Cheshire NHS Trust with FGM or at risk of having FGM undertaken .
This policy could therefore be said to have a positive impact.
c. If no please describe why there is considered to be no impact / significant impact on
children
4. Relevant consultation
Having identified key groups, how have you consulted with them to find out their views and that
the made sure that the policy, procedure, proposal, strategy or service will affect them in the
way that you intend? Have you spoken to staff groups, charities, national organisations etc?
All relevant staff groups have been consulted. This policy supports the Pan Cheshire LSCB FGM
policy and incorporates new legislation outlined in the Serious Crime Act (2015) regarding the
mandatory reporting of identified FGM cases presenting at Acute NHS trusts.
5. Date completed: 25/01/2017 Review Date: 25/01/2020
6. Any actions identified:
Have you identified any work which you will need to do in
the future to ensure that the document has no adverse impact?
Action
Lead
Date to be Achieved
7. Approval
Diversity
– At this point, you should forward the template to the Trust Equality and
Lead [email protected]
Approved by Trust Equality and Diversity Lead:
Date: 8.1.17
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