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Female Genital Mutilation (FGM)

Introduction

FGM is a serious criminal offence committed against young girls, mainly affecting families who have emigrated from West and North African countries, especially those that have not adopted UK social norms and are influenced by community and family elders. While the number of women and girls reporting FGM is lower in Reading than seen elsewhere and lower than may be expected given high levels of immigration to the area, it is difficult to know whether this reflects a true picture, or whether a large number of cases are undetected. Reading's Local Safeguarding Children's Board (LSCB) has responded to the potential of a high incidence of hidden cases by seeking to strengthen Reading's local response to FGM and, in collaboration with local partners and communities, has developed advice for professionals on reporting appropriately to Police and Children's Services, seeking medical care and assessing risks to female relatives of victims.

What do we know?

Female Genital Mutilation (FGM) refers to procedures that intentionally alter or remove part or all of the external female genital organs for non-medical reasons. The practice is medically unnecessary, has no health benefit and is extremely painful and harmful to victims, both at the time the mutilation is carried out and in later life. The practice is associated with initiation rites for young girls originating in a swath of countries across North and West Africa. In some cases, these practices have continued to be taken up by certain minority and immigrant communities living in countries in Europe and North America, including the UK. The practice was previously widely referred to as 'female circumcision', but the current term is now usually considered more appropriate as it reflects the more harmful nature of FGM compared to male circumcision.

FGM has been a criminal offence in the UK since the Prohibition of Female Circumcision Act was passed in 1985. In 2003, this was replaced by the Female Genital Mutilation Act, which also made it an offence for UK nationals, permanent or habitual UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM, even in countries where the practice is legal. The 2015 Serious Crime Act amended the FGM Act, making it illegal for responsible adults to fail to protect a girl from FGM, introducing legal powers to protect girls at risk of FGM, protecting the anonymity of victims of FGM and creating a duty of mandatory reporting for health and social care professionals in England and Wales (WHO, 2016; Reading Borough Council Safeguarding Children Board, 2016, UNICEF, 2013).

The procedures typically involved in FGM vary from case to case but are classified in the following 4 major types:

  • Type 1: clitoridectomy, - partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris)
  • Type 2: excision - partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva )
  • Type 3: infibulation- the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
  • Type 4: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

(WHO, 2016).

As well as the immediate health implications associated with the practice (including severe pain, excessive bleeding, tissue damage, fever, shock, and risk of infection or fatal haemorrhage), longer term consequences can include complications in pregnancy and childbirth, painful urination and urinary tract infection, painful menstruation, vaginal infection, and sexual and psychological problems (WHO, 2016, Reading Borough Council, 2016).

Facts, Figures, Trends

No reliable data exist to indicate the number of girls and women in a locality who have undergone or are at risk of FGM. In 2014 a national report commissioned by Trust for London and the Home Office and produced by City University London and Equality Now estimated that:

  • some 60,000 girls aged 14 or younger had been born in England and Wales to mothers who had undergone FGM;
  • approximately 103,000 women aged 15-49 and approximately 24,000 women aged 50 or older who have migrated to England and Wales were living with the consequences of FGM; and
  • approximately 10,000 girls aged under 15 who have migrated to England and Wales are considered likely to have undergone FGM.

The number of FGM cases in any given area is likely to be linked to migration patterns, prevailing trends in incidence and acceptability of FGM in the country from which women and girls have emigrated and the extent to which they integrate with other communities and are influenced by normative cultural practices. (McFarlane and Dorkenoo, 2014; UNICEF, 2013). In 2015, McFarlane and Dorkenoo went on to estimate the number of maternities to women with FGM by Local Authority area and estimated that there would be 437 maternities in an eight year period (roughly 54 per year) in Reading, but the report also highlights that these estimates may not reflect lower rates of FGM among certain populations, particularly women with secondary and higher education.

Reading has a higher than average level of international migration and the 2011 census indicates populations of 465 residents born in North Africa and 2418 born in Central and Western Africa, ranking Reading 42nd and 23rd respectively amongst 348 Local Authority Districts and Unitary Authorities in England and Wales for the proportion of the population from the regions. While this suggests the likelihood of a higher number than in other areas, the difficulty in assessing the influence of the other factors mentioned above makes it difficult to make any definitive statement comparing incidence with other localities.

Since September 2014, all health and social care providers in England and Wales have been required to return monthly aggregated data about cases of FGM identified. This includes both newly identified cases and those who are currently being treated for FGM-related conditions. Data collected by providers in England are collated in the 'FGM enhanced dataset' and are publicly available via the NHS Digital website. The first annual report was published in July 2016. Caution is advised when interpreting the data as data completeness and quality is sometimes low and varies between providers.

Providers are required to record 1) newly identified cases of FGM and 2) total attendances (i.e. includes both newly identified and previously identified cases). Data are published at CCG, Local Authority and NHS Trust level.

Table 1: Number of reported new cases of FGM and total attendances of women or girls living with FGM by CCG, NHS Trust and Local Authority.

CCG, LA or Trust

Newly identified cases

Total attendances

North and West Reading CCG

5

5

South Reading CCG

25

30

Royal Berkshire NHS Trust

35

50

Reading (Local Authority)

30

40

South of England

620

1,055

Total England

5,702

8,856

Source: Health and Social Care Information Centre, 2016.

Table 2: Number of reported new cases of FGM and total attendances of women or girls living with FGM in Local Authority areas with highest incidence.

Local Authority

Newly identified cases

Total attendances

Birmingham

435

520

Bristol

385

705

Brent

325

1250

Manchester

310

350

Southwark

290

320

Source: Health and Social Care Information Centre, 2016.

Table 3: Number of reported new cases of FGM and total attendances of women or girls living with FGM in Local Authority similar to Reading.

CCG, LA or Trust

Newly identified cases

Total attendances

Southampton

25

25

Portsmouth

10

25

Slough

55

100

Swindon

>5

>5

Lambeth

175

200

Source: Health and Social Care Information Centre, 2016.

While these data cannot currently be interpreted with confidence, they indicate a higher number of cases than some similar Local Authority areas in the South, but much lower than areas in London and the Local Authority levels with the highest incidence.

National Strategy

In 2016 the Government published its updated 'Multi-Agency Statutory Guidance on Female Genital Mutilation'. The guidance seeks to provide both strategic guidance and advice and support to frontline professionals and recommends that:

  • the organisation should have a lead person whose role includes responsibility for FGM and a member of staff who has undertaken additional training to understand FGM;
  • staff understand the role in protecting children from abuse, including FGM, know how to refer and report cases, and share information appropriately;
  • there should be a policy in place to protect those who have undergone or are at risk of FGM that reflects multi-agency working arrangements;
  • the organisation takes safeguarding seriously and takes a victim-centred approach;
  • Commissioning leads should understand and make use of the data relating to their local communities and ensure that services are provided to meet the physical and mental health needs of women and girls who have undergone FGM;
  • Staff should be trained to discharge their safeguarding duties with regard to FGM; and
  • Organisations should involve local communities and community groups in discussions about how FGM can be ended and encourage reporting of FGM;

Local Strategy

Reading has a higher than average level of residents born in North and Central and Western Africa. While there are many other factors that affect the number of women and girls who have undergone FGM in a locality area, Reading's Local Safeguarding Children's Board (LSCB) has responded to a potential high incidence rate by seeking to strengthen Reading's local response to FGM. The board works with the Alliance for Cohesion and Racial Equality (ACRE), a Reading-based voluntary sector organisation working to raise awareness and prevent FGM, and facilitates access to fact sheets, assessment tools and online training for professionals. The Board's Procedures Manual sets out recommendations for assessing risk of FGM and recommending action to be taken. The board suggests that the following may indicate where a child may be at risk of FGM:

  • A female child is born to a woman who has undergone FGM or whose older sibling or cousin has undergone FGM;
  • The family belongs to a community in which FGM is practised and has a limited level of integration with UK community:
  • The family indicates that there are strong levels of influence held by elders or that elders are involved in bringing up female children;
  • If a female family elder is present, particularly if she is visiting from a country of origin, and taking a more active/influential role in the family;
  • The family makes preparation for the child to take a holiday, e.g. arranging vaccinations, planning an absence from school;
  • The child talks about a 'special procedure' or 'ceremony' that is going to take place;
  • An awareness by a midwife or obstetrician that the procedure has already been carried out on a mother, prompting concern for any daughters, girls or young women in the family;
  • Repeated failure to attend or engage with health and welfare services or the mother of a girl is very reluctant to undergo genital examination;
  • Where a girl from a practising community is withdrawn from Sex and Relationship Education they may be at risk from their parents wishing to keep them uninformed about their body and rights.

In addition, the board suggests the following may indicate that FGM has already taken place:

  • The child has changed in behaviour after a prolonged absence from school;
  • The child has health problems, particularly bladder or menstrual problems;
  • The child has difficulty walking, sitting or standing and may appear to be uncomfortable.

The Board has developed 4 pathways for referring women and girls who are at risk or have undergone FGM:

  • Girl aged under 18 years at risk or suspected of having undergone of FGM
  • Girl aged under 18 years who has undergone FGM
  • Pregnant woman who has or is suspected of having undergone FGM
  • Non-pregnant woman who has or is suspected of having undergone FGM

The pathways advise professionals about how and when police should be alerted, how and when to refer to Children's Services, how and where to seek medical care, and when to undertake risk assessments of female relatives.

A nurse led Safeguarding Service at the Royal Berkshire Hospital focuses on FGM detection and control in the West of Berkshire area and has a close working relationship with the Reading social care services. All referrals from the Hospital are screened and at-risk cases are followed up by Reading's Multi Agency Safeguarding Hub (MASH).

What is this telling us?

FGM is illegal and tends to be hidden. Processes for collecting data in NHS and other care settings have only been mandated since September 2014 and data returned is incomplete and unreliable. Initial published reports suggest that 30 women self-reporting FGM were seen in Reading in 2015-2016. This is higher than in some similar locality areas in the South East but much lower than reported elsewhere, especially in large cities and London boroughs.

What are the unmet needs/ service gaps?

While the number of women and girls reporting FGM is lower than seen elsewhere and lower than may be expected given high levels of immigration in Reading, it is difficult to know whether this reflects a true picture, or whether a large number of cases are undetected. Reading LSCB has highlighted the need to provide ongoing care to meet the physical and emotional health needs of women who have undergone FGM. An increase in provision may be effective in bringing unreported cases into contact with health and social care services.

This section links to the following sections in the JSNA:

Migration

Maternity

References

Geneva, WHO. Available online at: http://www.who.int/mediacentre/factsheets/fs241/en/ [Accessed 22nd February 2016].

HM Government (2016). Multi-Agency Statutory Guidance on Female Genital Mutilation. London, Home Office.

McFarlane, A., and Dorkenoo, E. (2015). Prevalence of Female Genital Mutilation in England and Wales: National and Local Estimates. London, City University London.

McFarlane, A., and Dorkenoo, E. (2014). Female Genital Mutilation in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk. Interim report on provisional estimates. London, City University London.

Reading Local Safeguarding Children Board (LSCB). (2016). Female Genital Mutilation. Available online at: http://www.readinglscb.org.uk/information-professionals/fgm/ [Accessed 22nd August 2016].

Unicef (2013). Female Genital Mutilation/Cutting: a statistical overview and exploration of the dynamics of change. New York. Unicef. Available online at: http://data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/FGMC_Lo_res_Final_26.pdf [Accessed 22nd February 2016].

World Health Organisation (WHO) (2016). Female Genital Mutilation Fact Sheet..

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