Female Genital Mutilation (FGM)
Policy Title: Female Genital Mutilation - FGM Executive Summary: 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. Supersedes: Description of Amendment(s): Female Genital Mutilation Maternity Policy 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: Document Reference: Female Genital Mutilation Version Number: 1 Effective Date: January 2017 Issued By: Performance & Quality Corporate Business Unit Review Date: January 2020 Author: Heather Millward Impact Named Midwife for Assessment Date: Safeguarding January 2017 APPROVAL RECORD Consultation: Committees / Group Maternity Clinical Governance Committee Integrated Safeguarding Assurance Group Date September 2017 September 2017 Approved by Director: Kath Senior September 2017 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 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 hm 5. Monitoring Compliance with the Document 6. References 7. Communication 8. Appendix Page 11 Page 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). 5
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 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 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 6
Health implications related to pregnancy and childbirth 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 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) 7
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. Where a child is at risk of FGM; Where a child has been abused through FGM; 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: Immediate protection and support for the child/ren; and 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: Arranging for a professional interpreter if this is necessary and appropriate; Creating an opportunity for the child to disclose, seeing the child on their own; Using simple language and asking straightforward questions; Using terminology that the child will understand e.g. the child is unlikely to view the procedure as abusive; Being sensitive to the fact that the child will be loyal to their parents; Giving the child time to talk; Getting accurate information about the urgency of the situation, if the child is at risk of being subjected to the procedure; 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: Arranging for a professional interpreter and not agreeing to friends/family members interpreting on their behalf; 8
Being sensitive to the intimate nature of the subject; Making no assumptions; Asking straightforward questions; Being willing to listen; Being non-judgemental (condemning the practice, but not blaming the girl/woman); Understanding how she may feel in terms of language barriers, culture shock, that she, her partner, her family are being judged; 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 9
taken overseas for the purpose of female circumcision, to aid and abet, counsel, or procure the carrying out of Female Genital Mutilation. Practice points: 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. 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 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 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 10
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: 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: 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 11
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 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. 12
Intrapartum Care 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 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 13
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 14
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 15
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) 16
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 17
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 18
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: forward@forwarduk.org.uk The NSPCC 24 hour helpline to protect children and young people affected by FGM Tel: 0800 028 3550 NESTAC Drop in groups across the Northwest for girls and women affected by FGM Tel: 01706 868993 Mobile: 07862 279289 Email: peggy@nestac.org 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) info@accmuk.com 19
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 20 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 21
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 22
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. 23
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. 24
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 At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 8.1.17 25