Female Genital Mutilation

Definition

The World Health Organisation defines FGM/C as:

‘A procedure that involves partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons’.1

There are four types of FGM:

Type one: clitoridectomy – partial or total removal of the clitoris.

Type two: excision – partial or total removal or the clitoris and labia minora (the inner labial lips) with or without excision of the labia majora (the outer labial lips).

Type three: infibulation –partial or total removal of the clitoris, the labia minora and labia majora. The outer lips are then sewn together, leaving a small hole for urine and menstruation.

Type four: other –all other procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterising. It can be difficult to detect these once healed.

Fig.1 Image via 42nd street, with permission

Type one and type two constitutes 80% of FGM performed worldwide and type three (the most extreme form of FGM) constitutes 10-15% of FGM worldwide.

Learning bite

There are 4 main types of FGM/C – all involving altering the female genitalia and are performed for no medical reason.

Context

It has been estimated that there are 200 million women and girls living with FGM/C worldwide. It is mostly practiced in Africa, but also in some countries in the Middle East and both South and Southeast Asia.

This map is useful to identify the countries that practice FGM/C:

Fig.2 – Image via Forward, with permission

FGM/C has no health benefits and there are in fact many adverse health consequences – both in the short and long-term.

Short-term:

• Pain
• Haemorrhage
• Wound infection
• Sepsis
• Urinary retention
• Damage to other tissues
• Fracture
• Death

Long term:

• Failure to heal
• Recurrent urinary tract infections
• Menstrual difficulties
• Sexual difficulties
• Complications in childbirth
• Infertility
• Increased risk of blood-borne viruses
• Other: clitoral neuroma, keloid scars, vulval abscess, dermoid cysts

FGM/C can also have huge psychological and psychosexual consequences for its survivors.

FGM/C is illegal in the UK (Prohibition of Female Circumcision Act 1985).

The law was updated by the Female Genital Mutilation Act 2003 making it illegal to send children abroad for the purposes of FGM/C. If found guilty of an offence under this act, a person may be imprisoned for up to 14 years.

In 2015, the Female Genital Mutilation Act 2003 was updated to include a mandatory reporting duty – all health and social care professionals and teachers in England and Wales are required by law to report ‘known’ cases of FGM/C in girls under 18, which they identify in the course of their professional work, to the police.

‘Known’ cases are those where either a girl discloses FGM/C or where physical signs are apparent on examination indicating that an act of FGM/C has been carried out.

The professional who has identified FGM/C has a legal duty to report this to the police by the end of the next working day, by calling 101. 

The mandatory reporting duty is only one part of safeguarding children against FGM/C. If you identify a child with ‘known’ FGM/C, you will also need to follow your local safeguarding procedures. This may involve contacting the paediatric safeguarding team or children’s social care. Additionally, when you identify FGM/C in an adult female, you must consider if there are any children at risk of FGM/C.

Learning bites:

• FGM/C is illegal, has no health benefits, violates human rights and is child abuse.
• If you identify an adult female who has undergone FGM/C, you must consider if there are any children at risk of FGM/C.

The Royal College of Emergency Medicine recommends asking all women from a high-risk background if they have undergone FGM/C.2

This website is useful for identifying those countries deemed to be high-risk.

UK communities that are considered most at risk of FGM/C include, but are not limited to, Kenyan, Somali, Sudanese, Sierra Leonean, Egyptian, Nigerian and Eritrean.

Non-African communities that are considered most at risk of FGM/C include, but are not limited to, Yemeni, Afghani, Kurdish, Indonesian and Pakistani.

It has been estimated that there are 137,000 women and girls affected by FGM/C in the UK – including nearly 10,000 girls aged 0-14 who have undergone or who are at risk of FGM/C.3 These figures have been estimated based on the assumption that the prevalence of FGM/C in affected communities in the UK closely mirrors estimates in that of patients’ countries of origin. UK national policy has subsequently been introduced based on these estimates.4

This assumption, however, fails to account for converging evidence of changing attitudes among communities affected by FGM/C and the effect of migration. The idea that fewer girls are at risk than previously assumed is supported by the British Paediatric Surveillance Unit study.5

It does remain unclear how many UK-resident women and girls have either had, or are at risk of, FGM/C. It is therefore prudent to explore a wider context (such as migratory history, family attitudes, place of birth) than purely ‘UK community’ or ‘country of origin’ when considering risk.

It may also be appropriate to ask women about FGM/C (even if they are not from a high-risk background) when they present with the following symptoms:

• Recurrent urinary tract infections or urinary incontinence
• Menstrual problems – dysmenorrhoea, menorrhagia or primary amenorrhoea
• Sexual difficulties – dyspareunia, lack of desire
• Depression/post-traumatic stress disorder symptoms
• Pregnancy – so that consideration can be given to deinfibulation (a procedure to divide the scar tissues that is narrowing the vaginal opening in type 3 FGM/C).

Learning bite:

All women from a high-risk background presenting to the Emergency Department should be asked about FGM/C.

Research has found that FGM/C safeguarding has been experienced as stigmatising, exploitative and unjustified and as “an assault on belonging and citizenship”.6 It is therefore important to ask sensitively about FGM/C and to remain non-judgemental when doing so.

The words you use are important – ‘FGM/C survivor’ is preferred to ‘FGM/C victim’ and the preferred terms for FGM/C are ‘cut’, ‘circumcised’ or even ‘FGM’ when used as an acronym. Use of the word ‘mutilation’, however, should be avoided as it can be perceived badly to some women.7 It can sometimes be useful to mirror the language of the patient when discussing FGM/C.

Examples of ways to ask include:

• Have you been cut or circumcised?
• Sometimes the symptoms you are describing can be caused by something called female circumcision – is this something that has happened to you?
• We know that female circumcision is common in [insert country]. It is important for your health for us to know, has this ever happened to you?
• We know that some communities practice cutting, does this happen in your community?

There are lots of different terms for ‘FGM/C’ and it can be helpful to have an awareness of this, for example:

• Thara/Khitan in Egypt
• Kutairai in Kenya
• Khifad in Sudan
• Guidiniin in Somalia

Learning bite:

It is important to carefully consider the words we use when asking about FGM/C.

Management of adults

Once you have identified that a patient has undergone FGM/C, it is important to document this in the patient notes.

It may be appropriate to explain that FGM/C is illegal in the UK (avoiding attributing blame and judgement) and to discuss the health consequences of FGM/C. However, if the woman has already disclosed FGM/C to a healthcare professional, a further in-depth conversation may not be required, and it is important to avoid unnecessary questioning that may result in re-traumatisation.

You need also to remember to manage the patient’s presenting medical complaint (whether or not this is related to FGM/C).

There are then two key steps in the management of an adult who has either disclosed FGM/C or it is apparent on examination – support and safeguarding:

Support

It is important to offer support to the patient. This may include offering referral to a National FGM Support Clinic. These are community-based clinics that offer a range of support services for women with FGM/C, including physical assessment and treatment, emotional support and counselling and referral to a specialist consultant if needed. To find your local National FGM Support Clinic, use this website.

Your department may also have an FGM/C patient information leaflet that you could provide your patient with, or you could signpost to local or national FGM/C charities, for example:

FORWARD is the African women-led women’s rights organisation working to end violence against women and girls.

Email: [email protected]

Call: 020 8960 4000 or 07834 168 141

Website: https://www.forwarduk.org.uk

The HALO project supports victims of honour-based violence, forced marriage and FGM/C by providing appropriate advice and support to victims.

Email: [email protected]

Call: 01642 683 045

Website: https://www.haloproject.org.uk

Daughters of Eve is a non-profit organisation that works to protect girls and young women who are at risk from FGM/C.

Text: 07983 030 488

Website: https://www.dofeve.org

Safeguarding

You then need to consider safeguarding.

Firstly, is the woman herself a vulnerable adult? If so, you may need to discuss with the adult safeguarding team.

Secondly, are there any female children or siblings at risk of FGM/C? If there are, you may need to involve the paediatric safeguarding team or children’s social care. Depending on the level of risk, you may also need to contact the police if you believe the risk of FGM/C to be imminent.

Learning bite:

There are two key steps in managing an adult female with FGM/C – support for the woman (including referral to an FGM clinic) and to think about safeguarding (both for her and any children).

Management of children

If you identify a child who has undergone FGM/C, a similar process is required to when FGM/C is identified in an adult – with a key additional step, namely the mandatory reporting duty.

As for adults, documenting findings and discussions in the patient’s notes is important. You may want to explain that FGM/C is illegal in the UK and that there are numerous adverse health consequences of FGM/C. Again, it is important to remember to manage the patient’s presenting medical complaint (whether or not this is related to FGM/C).

The three key steps to remember are – the mandatory reporting duty, safeguarding and support:

The Mandatory Reporting Duty

If someone under 18 years old either discloses FGM/C or there are physical signs apparent on examination indicating that FGM/C has been carried out, then the mandatory reporting duty applies. The professional who has identified FGM/C has a legal duty to report this to the police (by calling 101) by the end of the next working day. This cannot be delegated and must be done by the same clinician. You also need to update the paediatric safeguarding team that this has been done.

Safeguarding

You must then consider safeguarding that child which may involve a discussion with children’s social care and the paediatric safeguarding team.

You also need to consider if there are any other children at risk of FGM/C in the family, for example siblings. Again, this may require a discussion with children’s social care, the paediatric safeguarding team or even the police via 999 if there is felt to be imminent risk of FGM/C for a child.

Support

It is also important to offer support to the family and the child. The child may need medical follow-up for any complications relating to the FGM/C which may be dealt with by a child-specific FGM clinic, paediatric and adolescent gynaecology teams or a Sexual Assault Referral Centre. This differs by location, so be guided by the services available in your local area.

Your department may have a patient information leaflet that could be provided to the family and you could signpost to local or national FGM/C charities (as outlined in the previous section). Additionally, the NSPCC can be a great source of support for children and they have a dedicated FGM helpline.

The leading children’s charity believing that every childhood is worth fighting for. They have a dedicated FGM helpline.

Email: [email protected]

FGM helpline: 0800 028 3550

Website: https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/female-genital-mutilation-fgm/

Learning bite:

There are three key steps in managing a child with FGM/C – the mandatory reporting duty, support for the child (including referral for medical/psychological support) and to think about safeguarding (both for that child and any other children in the family at risk of FGM/C).

There are some well-known ‘mimickers’ of FGM/C that may be difficult for a clinician without genital examination expertise to recognise.

Some common findings that have been mistaken for FGM/C in clinical practice include:

• Labial fusion
• Clitoral hood adhesions
• Genital vitiligo
• The normal appearance of prepubertal labia minora

FGM diagnosis, particularly in children, is a highly specialised skill.

Unless there is concern about an acute injury requiring urgent medical intervention, clinicians in the Emergency Department should decline the request to examine for the purpose of FGM diagnosis or opinion alone.8

If FGM/C has been ‘seen’ by a ‘non-expert’ in the absence of any disclosure or family practice of FGM/C, take advice and guidance from clinicians with additional expertise (e.g. gynaecology, the sexual assault referral centre (SARC) or community paediatrics).

Learning bite:

FGM is difficult to recognise – genital examinations in the Emergency Department should not be done solely for the purposes of identifying FGM.

1. World Health Organisation. Female Genital Mutilation. Geneva, Switzerland: World Health Organisation, 1996.
2. Fawcett R. The Royal College of Emergency Medicine Best Practice Guideline: A universal FGM flowchart and reporting tool. London: RCEM, 2017.
3. Macfarlane A, Dorkenoo E. 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, 2015.
4. Ali S, Karlsen S, et al. UK policy response to female genital mutilation needs urgent rethink. BMJ. 2023 Nov 23;383:e074751.
5. British Paediatric Surveillance Unit. British Paediatric Surveillance Unit Annual Report 2017-2018. London: Royal College of Paediatrics and Child Health (RCPCH) – Issuu, 2018
6. Karlsen S, et al. When safeguarding becomes stigmatising: A report on the impact of FGM-safeguarding procedures on people with a Somali heritage living in Bristol. University of Bristol, 2019.
7. Kavanagh J, Gardner M. Talking to your patients about female genital mutilation. InnoVAiT 2017; 10(5) 304-306.
8. Royal College of Paediatrics and Child Health (RCPCH). Requests for Female Genital Mutilation medical examination in under 18-year-olds in the emergency department. On HM Government – Multi-agency statutory guidance on Female Genital Mutilation. July 2020.

Other resources:

• e-LFH FGM e-learning modules
• Gov.uk website: Female genital mutilation
• National FGM centre: National FGM Centre – Developing excellence in response to FGM and other Harmful Practices
• Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline No53: Female Genital Mutilation and its Management. RCOG, 2015.