Female Genital Mutilation (FGM) Mary Flynn, Named GP Safeguarding Children, B&H CCG

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1 Female Genital Mutilation (FGM) Mary Flynn, Named GP Safeguarding Children, B&H CCG

2 Learning Outcomes Definition Types of FGM How and why is FGM performed Global and UK Data Guidance/Legislation Duty to report

3 Definition Female genital mutilation comprises all procedures involving partial or total removal of the external genitalia or other injury to the female genital organs for non-medical reasons. It has no health benefits and harms girls and women in many ways WHO 2015

4 Four Main Types It can be classified into four main types: Type 1: Clitoridectomy - Partial or total removal of the clitoris. Type 2: Excision - Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora. Type 3: Infibulation (the most widely practiced) - Narrowing of the vaginal opening through the creation of a covering seal, which is formed by cutting and repositioning the inner or outer labia with or without the removal of the clitoris. Nothing remains, but the walls of flesh from the pubis down to the anus, except for a small opening to allow urine and menstrual flow to pass through; this is known as pharonic circumcision. Type 4: Pricking, piercing, incising, scraping and cauterizing the genital area.

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6 Types of FGM Type i Clitoridectomy Partial or total removal of the clitoris and sometimes the prepuce (the fold of skin surrounding the clitoris). This practice is extremely painful and distressing, damages sexually sensitive skin & is an infection risk.

7 Types of FGM Type 2 Excision 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).

8 Types of FGM Type 3 Infibulation Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner and sometimes outer labia, with or without removal of the clitoris.

9 Types of FGM Type 4: Other All other harmful procedures to the female genitalia for nonmedical purposes. Such as: pricking, piercing, incising, and cauterization, packing with herbs, etc. Pulling and stretching the labia and clitoris. Damage during sexual violence or abuse?

10 It is commonly performed between the ages of 4 and 8 but can take place from infancy to adolescence. It is often performed by people who have no medical training and who use no anaesthetic or proper medical instruments. The procedure can lead to death through shock of excessive bleeding. Failure to use sterile medical instruments can lead to infections. It is commonly performed between the ages of 4 and 8 but can take place from infancy to adolescence.

11 Short term complications Haemorrhage Severe pain and shock Urine Retention Injury to adjacent tissue Tetanus Fracture or dislocation limbs as a result of being restrained The procedure can result in death through severe bleeding leading to haemorrhagic shock, neurogenic shock as a result of pain and trauma, and overwhelming infection and septicaemia

12 Long term complications Difficulty passing urine and chronic urinary tract infection. Possible renal failure. Difficulties with menstruation and painful periods. Possible hysterectomy. Sexual dysfunction & lack of sexual pleasure Acute and chronic pelvic infections which can lead to Infertility HIV, Hep C/B

13 Obstetric complications May not be identified antenatally Difficulty with vaginal examination Scarring & stricture of vaginal canal Possible obstructed labour Psychological Trauma, Flash backs Increased risk of C/S, PPH, foetal asphyxia/anoxia Perineal trauma/tears

14 Psychological and Mental Health FGM is extremely traumatic & can have lifelong consequences for mental health. Young women report feelings of betrayal by parents, incompleteness, regret and anger. Can cause mental health problems, drug and alcohol dependency. Research in African communities show women who have had FGM have the same level of PTSD as adults who were subjected to other forms of abuse in childhood. The fact that FGM is embedded in culture does not protect from developing PTSD

15 NSPCC Ending FGM

16 Some countries where female circumcision is practiced: Sudan (91%, Types 1, 2 and 3) Somalia (95%, Types 1 and 3) Sierra Leone (90%, Type 2) Kenya (50%, Types 1, 2 and 3) Guinea (98.6%, Types 1, 2 and 3) Gambia (80-90%, Types 1, 2 and 3) Ethiopia ( %, Types 1, 2 and 3) Egypt (78-97%, Types 1, 2 and 3) Djibouti (90-98%, Types 2 and 3)

17 Global Data UNICEF estimates 200 million girls and women have experienced FGM in 29 countries in Africa Asia and the Middle East 30 million girls are at risk in the next decade Most girls are cut before the age of 15 with the majority being between 4 and 14 years old 500,000 women and girls living in Europe have undergone FGM and 180,000 girls at risk FGM practiced at all educational levels and in all social classes and is closely associated with ethnicity rather than religion (UNICEF 2013, European Institute For Gender Equality) 2013

18 UK Data 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM Approximately 103,000 women aged and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM (City University & Equality Now, 2007 revised 2014)

19 Guidance/Legislation Intercollegiate document: Tackling FGM in the UK 2013 Dept of Health: Female Genital Mutilation Risk and Safeguarding March 2015 Home Office: Mandatory Reporting of Female Genital Mutilation - procedural information Multi-agency statutory guidance on female genital mutilation HM Govt April 2016

20 FGM Act 2003 The FGM Act 2003 makes it illegal to: Perform FGM in the UK. 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 Aid, abet, counsel or procure a girl to carry out FGM on herself

21 Serious Crime Act 2015 Extra-territorial jurisdiction over offences of FGM committed abroad by UK nationals and those habitually resident in the UK Introducing a new offence of failing to protect a girl from FGM Provides lifelong anonymity for victims FGM protection order - might include surrendering a person s passport

22 Multi agency statutory guidance on FGM Mandatory reporting to the police for cases where FGM is identified in under 18. Personal duty that cannot be transferred Duty is on the individual teachers, social workers, & NHS healthcare professionals Statutory guidance ploads/attachment_data/file/512906/multi_agency _Statutory_Guidance_on_FGM -_FINAL.pdf

23 Dept of Health FGM Risk and Safeguarding Practice guidance Provides FGM risk assessment frameworks Links with local safeguarding procedures Health passport em/uploads/attachment_data/file/378132/fg MstatementNov14.pdf

24 FGM Risk Factors Parents come from a country/ethnic group that practice FGM Come from a country with high prevalence Frequent visits to country of origin Family history of FGM Parents indicate taking the child away for a prolonged period often before end of term Level of family integration within the wider community language, contacts

25 Examples of questions to help you decide if a child is at risk of FGM Parents or child are discussing going abroad for a prolonged period Family not engaging with health services Girl not allowed to attend PHSE lessons Girl confides that she is to have a special coming-of-age party/ceremony A sister or other female relative is found to have had FGM Family already known to social care

26 Examples of questions to help you decide if a child has had FGM Girl is reluctant to undergo any medical exam Girl has difficulty walking, sitting or standing Girl presents to GP or A & E with frequent urine, menstrual or stomach problems Girl appears withdrawn, depressed, or has had significant change in behaviour Girl avoids P.E./spends long time in bathroom/toilet away from classroom Child talks about pain or discomfort between her legs

27 Examples of risk assessment questions for women who have had FGM Does husband or other family elder support practice Do family have knowledge of the law and health consequences of FGM Have other children in family had FGM Is woman attending appointments / engaging with professionals Is she requesting re infibulation after birth Is she a vulnerable adult

28 FGM professional response Pan Sussex Procedures LSCB website section 8.16 Has FGM taken place? Duty to report to Police if under 18yrs. Also consider reporting to MASH. Concerns that FGM might take place? Refer to MASH.

29 Safeguarding Challenges Often families display no other safeguarding concerns Some communities view FGM as being in the best interests of the child Identifying girls at risk is difficult FGM continues to be viewed as a problem for refugees and immigrants

30 Case Study M is a 7 year old girl who attends the surgery for vaccinations as she is going on holiday with her family to back to Sudan. You are aware from the records that the mother has had FGM. The practice nurse is concerned as she knows that Sudan is a high risk area for FGM

31 Case Study P is a pregnant woman who has had FGM in her home country of Gambia as a child. She has a 3 year old daughter and is expecting a girl. She is a single parent and her mother is coming over from Gambia to look after the 3 yr. old and support P

32 Case Study D is a 17 year old girl from Egypt who attends the GP surgery complaining of flashbacks and symptoms consistent with PTSD. She discloses she was cleansed in her home country a few years ago and wants help