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Part 2A: Identification of abuse and neglect

Female genital mutilation (FGM)

Female genital mutilation (FGM) is a procedure where the female genitals are deliberately cut, injured or changed, but there's no medical reason for this to be done. It includes procedures where the genitalia are altered without skin removal including labial elongation, and scarification. It's also known as female circumcision or cutting, and by other terms, such as Sunna, gudniin, halalays, tahur, megrez and khitan, among others.

FGM is usually carried out on young girls between infancy and the age of 15, most commonly before puberty starts.

FGM has no health benefits for girls and women and can cause severe bleeding and problems urinating, menstrual difficulties and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.

The practice of FGM is recognised internationally as a violation of the human rights of girls and women. It is illegal in the UK and is child abuse.

It's very painful and can seriously harm the health of women and girls. There are no health benefits from FGM but many documented harms.

It can also cause long-term problems with sex, childbirth and mental health.

Types of FGM

There are four main types of FGM:

  • Type 1 (clitoridectomy) – removing part or all of the clitoris.
  • Type 2 (excision) – removing part or all of the clitoris and the labia minora, with or without removal of the labia majora.
  • Type 3 (infibulation) – narrowing the vaginal opening by creating a seal, formed by cutting and repositioning the labia.
  • Other harmful procedures to the female genitals, including pricking, piercing, cutting, scraping or burning the area and labial elongation.

FGM is often performed by traditional circumcisers or cutters who do not have any medical training. But in some countries, it may be done by a medical professional. The National FGM Centre has an interactive map which contains prevalence rates and research in different countries as well as school holidays and term times in various countries.

Anaesthetics and antiseptics are not generally used, and FGM can be carried out using knives, scissors, scalpels, pieces of glass or razor blades.

FGM often happens against a girl's will without her consent, and girls may have to be forcibly restrained.

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and it interferes with the natural functions of girls' and women's bodies. Although all forms of FGM are associated with increased risk of health complications, the risk is greater with more severe forms of FGM.

Immediate complications of FGM can include:

  • severe pain
  • excessive bleeding (haemorrhage)
  • genital tissue swelling
  • fever
  • infections e.g., tetanus
  • urinary problems
  • wound healing problems
  • injury to surrounding genital tissue
  • shock
  • death.

Long-term complications can include:

  • urinary problems (painful urination, urinary tract infections)
  • vaginal problems (discharge, itching, bacterial vaginosis and other infections)
  • menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.)
  • scar tissue and keloid
  • sexual problems (pain during intercourse, decreased satisfaction)
  • increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby) and newborn deaths
  • need for later surgeries, for example, the sealing or narrowing of the vaginal opening (type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks
  • psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem).
Why is FGM performed?

The reasons vary from one region to another as well as over time and include a mixture of sociocultural factors within families and communities. Some of the reasons include:

  • Where FGM is a social convention (social norm), the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community, are strong motivations to perpetuate the practice.
  • FGM is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage. This can include controlling her sexuality to promote premarital virginity and marital fidelity.
  • Some people believe that the practice has religious support, although no religious scripts prescribe the practice. Religious leaders take varying positions with regard to FGM, with some contributing to its abandonment.
What does the law say about FGM?

FGM is illegal in the UK. It is illegal to carry out FGM in the UK. It is also a criminal offence for UK nationals or permanent UK residents to perform FGM overseas or take their child abroad to have FGM carried out. The maximum penalty for FGM is 14 years imprisonment. There is also an offence of failing to protect a child from FGM.

Possible signs that a girl could be at risk of FGM

These are only possible indicators and by no means indicate that a girl will definitely go on to have FGM or that there is any intention for a girl to have FGM. Practitioners should be culturally aware and approach conversations about FGM sensitively and in a non-judgemental manner. Attitudes around the world are changing towards FGM with the United Nations reporting that two-thirds of people in FGM practising countries in Africa and the Middle East are opposed to FGM, for example.

These possible indicators can be an opportunity for conversation and discussion with families.

  • A girl is born to a woman who has undergone FGM.
  • Mother has requested re-infibulation following childbirth.
  • A girl has an older sibling or cousin who has undergone FGM.
  • One or both parents or elder family members consider FGM integral to their cultural or religious identity.
  • The family indicate that there are strong levels of influence held by pro-FGM elders who are involved in bringing up female children.
  • A girl/family has limited level of integration within UK community.
  • If a girl from a practising community is withdrawn from PSHE and/or sex and relationship education or its equivalent, she may be at risk as a result of her parents wishing to keep her uninformed about her body, FGM and her rights.
  • If there are references to FGM in conversation, for example a girl may tell other children about it.
  • A girl may confide that she is to have a ‘special procedure’ or to attend a special occasion to ‘become a woman’.
  • A girl may request help from a teacher or another adult if she is aware or suspects that she is at immediate risk.
  • Parents state that they or a relative will take the child out of the country for a prolonged period and are evasive about why.
  • A girl is taken abroad to a country with high prevalence of FGM, especially during the summer holidays which is known as the ‘cutting season’.
Possible signs that a girl may have had FGM

As with the possible signs above, the signs below are only possible indicators of FGM but are not proof. These signs can also be indicative of other health needs or other types of abuse such as child sexual abuse for example. Their presence provides an opportunity for conversation and discussion with families.

  • Prolonged absence from schools.
  • Frequent need to go to the toilet.
  • Long break to urinate.
  • Urinary tract infections.
  • Noticeable behaviour change.
  • Talk of something somebody did to them that they are not allowed to talk about.
  • Change of dress from tight to loose-fitting clothing.
  • Menstrual problems.
  • Difficulty in sitting down comfortably.
  • Complain about pain between their legs.
Mandatory reporting of FGM

In England and Wales, regulated health and social care professionals and teachers have a mandatory duty to make a report to the police if:

  • they are informed directly by a child under the age of 18 that they have undergone FGM
  • they observe physical signs that an act of FGM may have been carried out on a child under the age of 18.

Mandatory reporting is only one part of safeguarding children and young people against FGM and other abuse – other safeguarding procedures still need to be followed and all their clinical needs should be met.

It is important to note that you do not need to examine a child to confirm FGM if you are told. This type of examination is highly specialist and there is significant normal variability of genital anatomy. There is also the potential for re-traumatisation.

If a parent/guardian discloses that the child has had FGM, or you consider the girl to be at risk of FGM, follow local safeguarding procedures.

If the patient is over 18:

  • The duty does not apply in this case. You should signpost the woman to services offering support and advice. You may also need to carry out a safeguarding risk assessment considering children who may be at risk or have had FGM.

In Wales, there is The All Wales Female Genital Mutilation Clinical Pathway which should be completed every time a new case of FGM is identified or suspected.

Talking about FGM

Talking about FGM - GPs leaflet provides tips for better, safe, and more effective woman centred conversations about FGM in general practice. It was developed for GPs with input and advice from people with lived experience. There is also an easy read leaflet on FGM.

References
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