Safeguarding Children at Risk of Abuse Through Female Genital Mutilation (FGM)

The government has made it illegal to carry out, offer or aid and abet virginity testing or hymenoplasty in any part of the UK, as part of the Health and Care Act 2022.

It is also illegal for UK nationals and residents to do these things outside the UK

The law defines ‘virginity testing’ as “the examination of female genitalia, with or without consent, for the purpose (or purported purpose) of determining virginity.”

The law defines ‘hymenoplasty’ as “the reconstruction of the hymen (with or without consent).”

Virginity testing and hymenoplasty are illegal and therefore women and girls are not able to consent to the procedures. Women and girls may request the procedures, but due to the harm they cause and them being precursors to other forms of so called ‘honour-based’ abuse, the procedures have been banned. As such, there are no circumstances under which a woman or girl should be subjected to a virginity test or hymenoplasty.

Virginity testing and hymenoplasty are forms of violence against women and girls and are part of the cycle of so called ‘honour-based’ abuse.

The most significant factor to consider when deciding whether a female child or woman may be at risk of FGM is whether her family has a history of practising FGM. In addition it is important to consider whether FGM is known to be practised in her community or county of origin; see Appendix 4: International Prevalence of FGM (Documents Library, Other Useful Information). Women may also marry into practising communities and then have to go through FGM. Alongside a female child or woman's community or country of origin there are a range of other factors that could indicate a risk that she will be subjected to FGM. These include:

• A female child is born to a woman who has undergone FGM;
• A female child has an older sibling or cousin who has undergone FGM;
• A female child's father comes from a community known to practise FGM;
• The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
• A woman/family believe FGM is integral to cultural or religious identity;
• A female child/family has limited levels of integration within UK community;
• Parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
• A family is not engaging with professionals (health, education or other);
• A family is already known to Social Care in relation to other safeguarding issues;
• Any female child from a practising community withdrawn from Sex and Relationships Education or its equivalent as a result of her parents wishing to keep her uninformed about her body and rights;
• Parents seeking to withdraw their children from learning about FGM;
• Sections are missing from a female child's health red book (parent held record).

Consider factors above and specifically the points below:

• If a family elder is present, particularly if she is visiting from a country of origin, and taking a more active/influential role in the family;
• If there are references to FGM in conversation, e.g. a female child may tell other children about it or confide that she is about to have a 'special procedure' or to attend a special occasion to 'become a woman. See Appendix 5: Names and Terms Used for FGM (Documents Library, Other Useful Information);
• Parents state that they or a relative will take the female child out of the country for a prolonged period. This may be discussed within the school environment or travel clinics when asking for vaccinations in preparation for travel;
• A female child may talk about a long holiday to her country of origin or another country where the practice is prevalent. See Appendix 4: International Prevalence of FGM (Documents Library, Other Useful Information);
• A female child may request help from a teacher or another adult if she is aware or suspects she is at risk;
• A female child is unexpectedly absent from school;
• A parent or family member expresses concerns that FGM may be carried out on the female child.

The above is not an exhaustive list of risk factors. There may be additional risk factors to specific communities e.g. in certain communities FGM is closely associated to when a female child reaches a particular age.

There are a number of indications that a female child or woman has already been subjected to FGM. This includes a female child or woman:

• Asking for help;
• Experiencing difficulty walking, sitting or standing and may appear to be uncomfortable;
• Finding it hard to sit still for longer periods of time, and this was not a problem previously;
• Having frequent urinary, menstrual or stomach problems;
• Avoids physical exercise or requires to be excused from physical education (PE) without a GP's letter;
• Spending long periods of time away from the classroom during the day with bladder or menstrual problems;
• Having prolonged or repeated absences from school or college;
• Spending longer than normal in the toilet due to difficulties urinating;
• Increased emotional or psychological needs e.g. withdrawal or depression or significant change in behaviour;
• Talks about a pain or discomfort between her legs;
• Asking for help, but may not be explicit about the problem; and/or
• Being reluctant to undergo any medical examinations.

A parent / other adult, a child or other children may also disclose that the child has been subjected to FGM.

If a woman who has been de-infibulated (surgical procedure to open up the closed vagina of FGM type 3) requests re-infibulation (when the raw edges of the FGM wound are sutured again to recreate a small vaginal opening similar to the original FGM Type 3 appearance) after the birth of a baby this should be treated as a child protection concern. Evidence that the woman has been previously re-infibulated following the births of older children should also be treated as a child protection concern.

FGM is a complex and sensitive issue which requires practitioners to approach the subject carefully; see Multi Agency Statutory Guidance on Female Genital Mutilation (HM Government, 2020) Annex C: talking about FGM. Practitioners should be sufficiently prepared to deal with FGM in a professional and sensitive manner, using simple language, asking straightforward questions and terminology that the female child or woman will understand. FGM is known by a number of names, and females are likely to use their own terms to describe what may happen or what has already happened. Practitioners should sensitively explore the language used to ensure that they understand what is being said. See Appendix 5: Names and Terms Used for FGM (Document Library, Other Useful Information). Practitioners should also be mindful that some female children and women may not be aware they have been subject to FGM as the procedure may have occurred during very early childhood.

Where an interpreter is required practitioners should always use an accredited female interpreter. Practitioners must not ask family members, individuals known to the family or an individual with influence in the community to act as an interpreter.

All practitioners have a responsibility to ensure that families know that FGM is illegal, and that the authorities are actively tackling the issue. This knowledge alone may deter families from having FGM performed on their children and save female children and women from harm.

The Health Passport - Statement Opposing FGM can be useful to share with families as it outlines what FGM is, the legislation and penalties involved and the help and support available. It is available in a range of languages.

Practitioners should be aware that alerting the female child's or woman's family to the fact that she is disclosing information about FGM may place her at risk of harm.

There have been reports of cases where individuals have been subjected to both FGM and forced marriage. If you are concerned that a child may be subject to a forced marriage a referral to Children's Social Care should be made; see Forced Marriage Procedure.

Where practitioners believe that an individual has undergone FGM, they also must consider the risks to other female children and women who may be related to, or living with her and/or her family. As FGM is an inter-generational practice, their female children and young women may be likely to suffer significant harm.

There is evidence that women and girls from the age of 13 to 30 are most at risk of undergoing a virginity test and/or hymenoplasty, but girls as young as 8 can be affected. Any woman or girl, of any age, ethnicity, race, sexual orientation, religion, disability or socioeconomic status could be subjected to a virginity test or hymenoplasty. Women and girls may take years to discuss their experiences due to the shame associated with these practices, the level of trauma that could be experienced and the fear of further so called ‘honour-based’ abuse.

Practitioners may encounter at-risk women and girls in a face-to-face situation, virtually or over the phone, or via a third party such as a concerned friend or a referral from another organisation. These are forms of so called ‘honour-based’ abuse and as such physical signs of the woman or girl having undergone the procedure may be absent. However, the stress, anxiety and other psychological or behavioural signs may be present.

There are several indicators that a woman or girl is at risk of or has been subjected to a virginity test and/or hymenoplasty: (this is not an exhaustive list)

• The woman or girl requests either procedure or asks for help;
• Family members ask for the procedures or disclose that the woman or girl has already undergone the practices;
• There could be pain and discomfort after the procedures, which, for example, could result in the woman or girl having difficulty in walking or sitting for a long period of time which was not a problem previously;
• Concern from family members that a woman or girl has a boyfriend, or plans for the woman or girl to be married;
• A close female relative has been threatened with either procedure or has already been subjected to one;
• The woman or girl has already experienced or is at risk of other forms of so called ‘honour-based’ abuse;
• The woman or girl is already known to social services in relation to other safeguarding issues;
• The woman or girl may disclose other concerns that could be an indication of abuse. For example, they may state that they do not feel safe at home, that family members will not let them out the house and/or that family members are controlling;
• The woman or girl may have suffered trauma from being coerced and having to undergo the procedures. This could result in an increase in emotional and psychological needs, for example withdrawal, anxiety or depression, or significant change in behaviour. The trauma could also have long-term implications for the woman or girl and may not manifest for many years after the event
• The woman or girl may appear fearful of their family or a particular family member;
• Unexplained absence from school, potentially to go abroad;
• Changes in behaviour – becoming withdrawn, anxious, or depressed; a deterioration in schoolwork, attendance, or attainment.

Good communication is essential when talking to individuals who have undergone or are at risk of virginity testing and/or hymenoplasty, or when talking to friends or family members who might be requesting these procedures for others.

The topic may arise in a variety of settings, including a GP’s surgery or sexual health clinic as part of a medical consultation, or at school. It could take place face to face, virtually or over the phone. Some broad principles on how to approach these conversations are outlined below.

Acknowledge the disclosure, bearing in mind this is a sensitive topic. Women and girls may feel uncomfortable talking about their sexual experiences or sexual assault fearful of judgement and may be fearful of speaking out against their family and/or community and of an escalation in so called ‘honour-based’ abuse.

Explain to the individual:

• The limits of confidentiality;
• What information may have to be shared, with whom and for what purpose.

Where there is reasonable cause to suspect that a child is suffering, or likely to suffer, Significant Harm Children's Social Care will hold a Strategy Discussion / Meeting involving Police, Health and other agencies as appropriate (including those with specialist experience of working with families who have experienced FGM). A strategy discussion / meeting must be held if:

• There is suspicion that a female child or young woman, under the age of 18, is at risk of FGM, virginity testing or hymenoplasty;
• It is believed that a female child or young woman is at risk of being sent abroad for that purpose; or
• There are indications that a female child or young woman has undergone FGM, virginity testing or hymenoplasty.

If emergency action is needed this will usually take place following an immediate strategy discussion.

The strategy discussion / meeting will consider relevant matters including:

• Agreeing what further information is required about the child and family and how it should be obtained and recorded;
• Agreeing who should be interviewed, by whom, for what purpose, and when;
• Agreeing, in particular, how the child's wishes and feelings will be ascertained so that they can be taken into account when making decisions;
• Plan any intervention, including any medical examinations, with consideration of the cultural factors such as the significance it has in terms of cultural identity, please refer to Appendix 1: Multi-Agency FGM Decision Making and Action Flowchart and Appendix 1a: Clinical Pathway for FGM medicals;
• Consider taking legal advice as to the options for protection available, including obtaining a FGM Protection Order. The primary focus is to prevent the female child undergoing any form of FGM, removal from home should be considered only as a last resort;
• If the strategy discussion / meeting decides that the female child is in immediate danger of FGM and/or practitioners consider that her parents will allow or facilitate FGM in the near future then a FGM Protection Order and/or an Emergency Protection Order or Interim Care Order should be sought;
• Consider carefully whether to continue enquiries or whether to assess the need for support services for a female child who has already suffered FGM and how any criminal investigation will be conducted;
• Plan appropriate action which recognises that FGM is a one-off event of physical abuse. (Whilst in no way minimising the grave permanent sexual, physical, and emotional consequences for a female child who experiences FGM);
• Consider the need for enquiries to be made about the risks to other female children in the family i.e. sisters, cousins or the community;
• Establish whether an accredited female interpreter will be required, to be used in all interviews with the family.

The strategy discussion / meeting must establish if either parents or the female child has had access to information about the harmful aspects of FGM, virginity testing and hymenoplasty and the law in the UK. If not, the parents/child should be given appropriate information regarding the law and harmful consequences of FGM.

Where FGM, virginity testing or hymenoplasty has been carried out, the Police Child Abuse Investigation Unit will have the lead role for the criminal investigation however this should be co-ordinated with Children's Social Care to ensure the investigation and Section 47 Enquiry is undertaken in the best interests of the child. This would include the planning and timing of a medical examination.

The following additional issues should help inform the analysis and decision making:

• What are the views of the woman about the importance of FGM, virginity testing or hymenoplasty to her and what has her experience been?
• Does she consider FGM, virginity testing or hymenoplasty to have been harmful to her, or to others who have undergone any of these procedures?
• What is her view about whether her daughters should be subject of FGM, virginity testing or hymenoplasty?
• What is her view of the importance of FGM, virginity testing or hymenoplasty to her partner / husband and extended family?
• Have other female children or women in her extended family experienced FGM, virginity testing or hymenoplasty?
• Is she being forced against her will or does she feel under pressure from a partner / husband for her female children to be subject of FGM, virginity testing or hymenoplasty?
• Is she being forced against her will or is there pressure from extended family members and friends for her female children to be subject of FGM, virginity testing or hymenoplasty?
• How isolated or dependent is the woman within her community, will she or her daughters face rejection if they are not subject of FGM, or virginity testing?
• Is the woman particularly isolated as a refugee and what impact does this have on the decisions she makes about the acceptance within her community of FGM or virginity testing being carried out on her daughters?
• Consideration of risks identified in the assessment tool for FGM.

It will be important to assess how willing or reluctant the woman is to discuss these issues. If an interpreter has been used, how successful has the communication been? Is further discussion needed to clarify information?

Practitioners should discuss with the woman any concerns she may have about FGM being discussed with her partner / husband. Where ever possible the assessment should include the views of the partner / husband. If concerns exist about the practicalities of obtaining information from them, in individual cases, the absence of this information should be weighed up alongside what is known and a judgement made as to whether this is significant. There may be conflicting views within the family and the practitioner should consider if this is likely to increase the risk to the female child.

Women who have been de-infibulated and request re-infibulation after the birth of a baby or where there is evidence that the woman has been previously re-infibulated following the births of older children should be seen as a risk. This is because the woman is apparently not wanting to comply with UK law and/or does not consider the process to be harmful, and this raises concerns in relation any female children she may already have or may have in the future.

In all cases if there is a concern about one child, the child's sisters, and other female children in the extended family should be considered to be at risk.

Every attempt should be made to work with the parents on a voluntary basis to prevent the abuse. Practitioners must be aware that most decisions about FGM are made by multiple family members, including mothers, father, grandparents and aunts. Often the prime motivating factor for the continuation of FGM is inter-generational peer convention and peer pressure amongst women. Factual aspects such as health risks as well as fear of legal sanctions can motivate the abandonment of FGM. Agencies should look at every possible way that parental co-operation can be achieved, including the use of community organisations and /or community leaders to facilitate the work with the family. It is important that the views of these organisations or leaders are known and approved.

A written agreement should be undertaken with the parents not to arrange FGM to be performed on the female child; this should highlight that FGM is illegal, the harmful aspects of FGM and the actions that will be taken should future concerns arise. The child's interest is always paramount and any agreement must be carefully monitored and enforced.

To facilitate appropriate awareness of the risk and ensure effective monitoring, it is important for key practitioners (particularly those in health and education) to be made aware of the potential risk to a female child and the written agreement with the parents. Where concerns arise that a female child is at increased risk of FGM or that she has been subject to FGM, an immediate re-referral to Children's Social Care should be made. Please also refer to Appendix 1: Multi-Agency FGM Decision Making and Action Flowchart and Appendix 1a: Clinical Pathway for FGM medicals.

If no agreement is reached with parents, the first priority is protection of the female child and the least intrusive legal action should be taken to ensure her safety. The primary focus is to prevent the female child undergoing any form of FGM, rather than removal of the child from the family.

Where the female child is believed to be overseas, Children's Social Care will liaise with the Foreign and Commonwealth Office / Border Agency.

A female child judged to be suffering or likely to suffer Significant Harm as a consequence of anticipated FGM should be made the subject of a child protection plan, under the category of risk of physical abuse, at the Initial Child Protection Conference. 

A female child who has already undergone FGM should not normally be subject to a Child Protection Conference or require a Child Protection Plan unless additional child protection concerns exist. However, she should be offered counselling and medical help.

All female children and women who have undergone FGM should be given information about the legal and health implications of FGM and support services available to them including mental health support. Those who have undergone Type 3 FGM should also be informed that de-infibulation is an option and the benefits of this. Where appropriate boyfriends / partners and husbands should also be offered counselling, they can be supportive when the harmful aspects of FGM and the law is explained to them.

National FGM Support Clinics have been established to offer a range of support services for women over 18 who have undergone FGM. Support for girls under 18 us available from a specialist paediatric service at University College London Hospitals (UCLH). UCLH can be contacted by e-mail at UCLH.paediatricsafeguarding@nhs.net.

Women over the age of 18 years should be reviewed under the safeguarding adults at risk process but any adult assessment must address any potential risk of FGM to any other women or female children living in the family as well as the extended family network.

For details of safeguarding adults processes please see:

• Derby Safeguarding Adults Board website; or
• Derbyshire Safeguarding Adults website.