Female Genital Mutilation (FGM)

Female Genital Mutilation (FGM)

Introduction

Local Government Association (2014) guidance for councillors states that Female Genital Mutilation (FGM) is a serious form of child abuse and violence against women and girls. It has been illegal in this country since 1985 and councils have a statutory duty to safeguard children and protect and promote the welfare of all women and girls.

 

FGM is defined by the World Health Organisation as "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”. It can leave women and girls traumatised as well as in severe pain, cause difficulties in child birth, and in some rare cases it can lead to death.

 

There are 4 different types of FGM, and by the World Health Organisation classifies these as

  • Type 1 - Clitoridectomy: Partial or total removal of the clitoris and/or the prepuce
  • Type 2 - Excision: Partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora
  • Type 3 - Infibulation: Narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with, or without excision of the clitoris
  • Type 4 - All other harmful procedures to female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterisation.

(*) Type 3 is the most difficult to care for and manage in child birth requiring specialist obstetric and midwifery support.


FGM is performed on women and girls at different ages, depending on the community or ethnic group that carries it out, though it is mostly carried out on girls between the ages of 5 and 8 years old. The procedure is traditionally carried out by women with no medical training. Anaesthetics and antiseptic treatments are not generally used and the practice is usually carried out using knives, scissors, scalpels, pieces of glass or razor blades. 


Intercollegiate guidance published by the Royal College of Midwives (2013) has enabled significant progress to be made in

  • Raising awareness of FGM
  • Training staff in recording FGM across a range of services
  • Agreeing recording and reporting requirements from contracted services
  • Agreeing pathways for the care of women antenatally and in the post partum period
  • Working with partners to improve identification and take action to prosecute if necessary

Women who were born and brought up in countries where FGM is practiced are most at risk, as are UK born children who may be taken back to their mother’s country of origin to undergo FGM. There is also incidence of “cutters” being brought into the UK.


Risk factors identified that may indicate that FGM has taken place are

  • Prolonged school absence with noticeable behaviour change on return
  • Bladder and menstrual problems
  • Reluctance to receive medical attention or participate in sport

Visit the Wokingham Safeguarding Childrens Board website for guidance about Female Genital Mutilation

 

Whilst the intercollegiate guidance noted that FGM was practiced mainly in North African countries, such as Somalia advice from our local hospital indicated that women are appearing from many other countries in Europe.

 

The protocol for managing newly identified cases whether in primary or secondary care is now clearly understood. The gap remains in knowledge about how many children are at risk who currently attend schools in Wokingham.

The national best practice guidance includes

 

The Hackney Best Practice guidance for Children’s Social Care provides an assessment of risk for FGM, which includes

 

  • The family’s belief system in relation to the practice of FGM
  • The family’s contact with community and/or faith groups that support the practice of FGM
  • If the family are likely to be in contact with those who have previously or currently perform FGM
  • If there are other risks including Honour Based Violence, Early Forced Marriage or Child Trafficking
  • Whether there are any plans for female children in the household to visit a country in which FGM is practiced
  • The capacity of the child’s parents/carers to resist community and familial pressure to subject female children to FGM and to protect female children in their care from FGM 
  • The child(s) views, knowledge and understanding of FGM (depending on age and understanding)
  • The child’s experience of family life and family / community belief systems
  • Whether female children in the household are able to access social / educational  and health resources with an age-appropriate degree of autonomy
  • Whether the child has a safe adult(s) she can access if she is worried about her safety or welfare 
  • Whether the child has already experienced or is likely to experience FGM during her minority
  • Whether a professional response is required to meet the child’s needs, reduce risk or provide immediate protection

 

Since July 2016 Berkshire West has had a multi-agency strategy for FGM, with pathways and assessment tools available for practitioners to use. These can be found on the Reading Local Safeguarding Children Board website.


What is this telling us?

 

Despite the progress of awareness raising, increased reporting and legal action, more needs to be done within Education to identify children at risk of travel to countries for the purpose of FGM. This is particularly difficult as country of origin alone is not sufficient to ascertain risk. 

Female Genital Mutilation’s prevalence in the UK is difficult to estimate because of the hidden nature of the crime. A study conducted by City University London (2014) estimated that

  • Approximately 60,000 girls aged 0 to 14 were born in England and Wales to mothers who had undergone FGM
  • Approximately 103,000 women aged 15 to 49 and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM
  • Approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM

  

FGM cases will not be evenly distributed across the UK and will be more prevalent in communities from practicing countries. The City University London study identified higher prevalence rates in London, Cardiff, Manchester, Sheffield, Northampton, Birmingham, Oxford, Crawley, Reading, Slough and Milton Keynes.

 

Since September 2014, all acute hospital providers in England are required to return monthly aggregated data about the incidence of FGM identified. The NHS began collecting an enhanced dataset in April 2015. The FGM Enhanced Dataset contains more data items than previously, including some patient identifiable demographic data, and is extending the collection to include mental health trusts and GP practices. 


For 2015 to 2016 it was found that

  • There were 5,702 newly recorded cases of FGM reported, and 8,656 total attendances where FGM was identified or a procedure for FGM was undertaken
  • More than half of all cases relate to women and girls from London NHS Commissioning Region
  • Self-report was the most frequent method of FGM identification, accounting for 73 per cent of cases where the FGM identification method was known
  • 106 girls under 18 at the time of their first attendance were reported, comprising 2 per cent of all newly recorded cases
  • 87 percent of women with a known pregnancy status were pregnant at the point of attendance
  • 90 percent of women and girls with a known country of birth were born in an Eastern, Northern or Western African country, and 6 percent were born in Asia
  • Somalia in Eastern Africa accounts for more than one third of all newly recorded women and girls with a known country of birth (37 percent). Other countries with a large volume of cases include Eritrea in Eastern Africa, the Sudan in Northern Africa and Nigeria and the Gambia in Western Africa
  • 43 newly recorded cases of FGM involved women and girls reported to have been born in the United Kingdom. Of those with a known FGM type, more than 40 per cent were reported with FGM Type 4 – Piercing
  • Where the FGM Type is known, Types 1 and 2 have the highest incidence (35 and 31 percent respectively)
  • The most frequent age range at which the FGM was carried out was between 5 and 9 years old, involving 43 percent of cases where the age was known
  • In 18 newly recorded cases, the FGM was reported to have been undertaken in the United Kingdom, including 11 women and girls who were also reported to have been born in the UK. Where the nature of the UK procedures was known, around 10 were reported with FGM Type 4 – Piercing
  • 145 de-infibulation procedures were reported, occurring at 4 percent of attendances where de-infibulation status was recorded

  

Figure 1 shows this detail at a Trust level for those geographically located Wokingham Borough.

 

Figure 1: Number of newly identified cases of FGM at a Trust level (April 2015 to March 2016)

NHS Trust

Number of newly identified cases of FGM

Royal Berkshire NHS Foundation Trust

50

Frimley Health NHS Foundation Trust

55

Oxford University Hospitals NHS Trust

0

 Source: NHS Digital (2016)

 

FGM incidence data is published at a Local Authority and CCG levels, however analysis is difficult due to the small numbers reported and also the mechanisms in place to capture this data.

The incidence of FGM is higher for

  • Women born in countries in which FGM is practiced as part of particular faith beliefs
  • Female children of women who have undergone the practice
Other factors that might heighten a girl’s risk of FGM include her family’s level of integration within UK society and also being withdrawn from Personal, Social and Health Education (PSHE) as a result of her parents wishing to keep her uninformed about her body and rights. Read the  Multi-Agency Practice Guidelines: Female Genital Mutilation for more details. 


The practice of FGM is associated with high levels of post traumatic stress disorder and psychological distress in women and girls. ( Royal College of Midwives, 2013).

A multi-agency response is required to reach out to particular communities, The communities themselves need to support this and challenge the practice of FGM.


There is clear guidance within the Berkshire Child Protection procedures in relation to FGM. However, the process of reporting FGM that has occurred overseas to social care is identified as needing to be reviewed, as well as the response pathway.


The other gap in Wokingham Borough is obtaining robust estimates of need within the education system in order to safeguard children at risk from travelling to countries where FGM is practiced. The central education system (which is fed by and updated from school records) does not currently contain fields for country of birth – either for the child or the parents. Individual school systems may or may not be configurable to hold this information – and it would be a local matter for each school to decide upon. Data about a child’s ethnicity, country of birth, religion and primary language could potentially be used to identify those at higher risk of FGM, based on assumptions of prevalence amongst different cultural groups.


Recommendations for consideration by other key organisations

 

Guidance sets out the expectations required of all partner organisations for identifying risk of FGM, the care and management of women with FGM and reporting or taking legal action.